‘‘There Are Too Many, but Never Enough’’: Qualitative Case Study Investigating Routine Coding of Clinical Information in Depression Kathrin Cresswell1*, Zoe Morrison 1 , Aziz Sheikh 1 , Dipak Kalra2 1 eHealth Research Group, Centre for Population Health Sciences, The University of Edinburgh, Edinburgh, United Kingdom, 2 Centre for Health Informatics and Multi- professional Education, University College London, London, United Kingdom Abstract Background: We sought to understand how clinical information relating to the management of depression is routinely coded in different clinical settings and the perspectives of and implications for different stakeholders with a view to understanding how these may be aligned. Materials and Methods: Qualitative investigation exploring the views of a purposefully selected range of healthcare professionals, managers, and clinical coders spanning primary and secondary care. Results: Our dataset comprised 28 semi-structured interviews, a focus group, documents relating to clinical coding standards and participant observation of clinical coding activities. We identified a range of approaches to coding clinical information including templates and order entry systems. The challenges inherent in clearly establishing a diagnosis, identifying appropriate clinical codes and possible implications of diagnoses for patients were particularly prominent in primary care. Although a range of managerial and research benefits were identified, there were no direct benefits from coded clinical data for patients or professionals. Secondary care staff emphasized the role of clinical coders in ensuring data quality, which was at odds with the policy drive to increase real-time clinical coding. Conclusions: There was overall no evidence of clear-cut direct patient care benefits to inform immediate care decisions, even in primary care where data on patients with depression were more extensively coded. A number of important secondary uses were recognized by healthcare staff, but the coding of clinical data to serve these ends was often poorly aligned with clinical practice and patient-centered considerations. The current international drive to encourage clinical coding by healthcare professionals during the clinical encounter may need to be critically examined. Citation: Cresswell K, Morrison Z, Sheikh A, Kalra D (2012) ‘‘There Are Too Many, but Never Enough’’: Qualitative Case Study Investigating Routine Coding of Clinical Information in Depression. PLoS ONE 7(8): e43831. doi:10.1371/journal.pone.0043831 Editor: James Coyne, University of Pennsylvania, United States of America Received April 27, 2012; Accepted July 30, 2012; Published August 24, 2012 Copyright: 2012 Cresswell et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: This report is independent research commissioned by the National Health Service (NHS) Connecting for Health Evaluation Programme. The views expressed in this publication are those of the authors and not necessarily those of the NHS, the NHS Connecting for Health Evaluation Programme, or the Department of Health. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing Interests: The authors have declared that no competing interests exist. * E-mail: kathrin.beyer@ed.ac.uk Introduction Information technology is increasingly used to facilitate the safety and efficiency of healthcare [1]. Systems rely upon real-time structured electronic data capture, often using coding (the activity of assigning a code to information in order to classify it), to process information in relation to, for example, performance measures, resource allocation, medical research, and billing [2–4]. In doing so, clinical statements (these may include medical diagnoses) within a classification system are assigned numerical values or clinical codes. There is therefore currently an increasing drive to achieve clinical coding by healthcare professionals at the point of care [5]. However, structured data entry systems also need to satisfy the clinical needs of users (often referred to as ‘clinical utility’) [6–9] and facilitate information exchange between different care settings in increasingly fragmented healthcare systems [4,7,10,11]. Although in many countries coding of clinical information is used primarily for billing purposes (e.g. Canada and the United States of America (USA)), this is less common in the United Kingdom (UK) which has a publicly-funded national health service. Here, the coding of clinical information is focused on demographic details, diagnoses, reasons for encounters, numeric results, prescriptions, assessment scales and chronic disease monitoring datasets. The primary aims are to support care management, clinical decision making, adherence to guidelines, contributions to reimbursement, and less commonly, research. UK secondary care depression services use the ICD-10 (International Classification of Diseases 10th Revision) classification system for coding diagnoses, whilst GPs use Read Codes (a clinical coding system purchased by the UK government and used in primary care). Across countries, clinical coding is often carried out at the end of the consultation, after the healthcare professional has collected and recorded all relevant historical and examination data PLOS ONE | www.plosone.org 1 August 2012 | Volume 7 | Issue 8 | e43831