‘‘There Are Too Many, but Never Enough’’ Table 4. Summary of main themes and sub-themes. Varying contexts and practices surrounding the coding of clinical information in depression. – Wide variations in care pathways resulting in the need for free-text entries in addition to coded clinical information. – Differences in type and methods of coding clinical information between primary and secondary care settings. – Differences in information technology systems and implications for associated clinical coding practices surrounding degrees of autonomy in selecting and tailoring clinical codes. – Lack of unified clinical coding system between primary and secondary care settings. Lack of direct patient care benefits and a number of risks surrounding the coding clinical data in depression. – Drawing on coded clinical information for management and research purposes. – Lack of contribution of coded clinical information to clinical decision-making and direct patient care. – Lack of understanding amongst healthcare professionals surrounding the value and use of coded clinical data. – Retrospective coding of clinical information. – Loss of contextual information and the value of free text. – Diagnostic rigor and uncertainty in complex mental health conditions. – Tensions surrounding the number and meaningful arrangement of clinical codes. Strategies employed to align clinical value with managerial demands. – Motivations and incentives to code clinical information. – Tailoring of systems versus standardization and the role of templates. – The role of clinical coders in secondary care settings – consistency of interpretation. doi:10.1371/journal.pone.0043831.t004 activity levels in relation to certain conditions to commissioners in order to get paid. Secondary care clinical coding included: NInterventions/activities (e.g. assessment of mental state, cognitive testing) – nurses and allied health professions; NAdmission diagnoses/review and discharge diagnoses - doctors for inpatients only; NClustering adult mental health users to diagnostic pathways – nurses and allied health professions. We found the use of computer systems and associated clinical coding practices to be well established in UK primary, but regarded as a relatively recent development in secondary care. Perhaps as a result of this, GPs did some clinical coding during the clinical encounter, whilst in our secondary care site doctors’ diagnoses were coded by a designated clinical coding team (although some clinical intervention and cluster coding was done by other healthcare professionals). The fact that secondary care depression services and GPs used different coding and classifica- tion systems, was attributed to differing patient needs. Whilst the majority of depression is diagnosed and treated in primary care, secondary care tends to manage the more severe spectrum of depressive disorders and may therefore need more granular diagnostic classification: ‘‘I mean psychiatrists have always had lots of codes…the fine grained detail in my opinion of diagnosis at that level is more relevant than it is in primary care.’’ (Interview 1, Academic GP). Differences in systems and associated clinical coding practices were apparent in both primary and secondary care settings. Such systems variations made it more difficult to obtain comparable data sets for research purposes: ‘‘…that’s another problem that we’re encountering with our research cos we’re getting information from…sort of twenty odd GP surgeries in South London and there’s striking differences between [name of a primary care computer system] which is by far and away the best and these other systems which are chaotic in terms of how they organi- ze…information.’’ (Interview 7, Academic GP). In some systems, users could ignore requests to code clinical information and focus only on free text. This was commonly the case in primary care, facilitating greater user autonomy. Our main secondary care research site had implemented a ‘‘home-grown’’ computer system which mandated some clinical coding by nurses and allied health professions preventing the user progressing to a different screen unless a clinical code had been picked. The ‘‘home-grown’’ nature was in many ways perceived to be an advantage, as it was relatively easy to tailor associated clinical codes. ‘‘…we can develop the system to capture what we need very quickly, it’s quite responsive and that’s kind of put us streets ahead of the other Trusts in that respect.’’ (Interview 19, Research Nurse, Secondary Care). At the time of data collection, there was no unified clinical coding system between primary and secondary care and no software to map between clinical codes. Upon transfer between care settings, patient information had to be re-coded, which was viewed as a duplication of effort. ‘‘They [GPs] all use different [clinical codes] and their computer system doesn’t link up with ours so none of the codes match across primary and secondary…’’ PLOS ONE | www.plosone.org 5 August 2012 | Volume 7 | Issue 8 | e43831