A new publication led by members of the Asthma UK Centre for Applied Research explores the usage of allergy codes in primary care electronic health records in Scotland. Read on for an overview of the study from author, Mome Mukherjee.
Will a more comprehensive coding system improve the quality of coding in primary care?
Medical coding is the translation of clinical terminology (e.g. diagnoses, treatments, procedures) to an alphanumeric code which allows analysis of healthcare provision and for epidemiological purposes. Improvements to coding ensures better quality data are collected to inform decisions on healthcare provision and policy.
Our study suggests that a more detailed coding system, in isolation, will not improve coding quality and that other initiatives should also be implemented to improve coding quality.
Why this study was done?
- The Read code system used in primary care is to be replaced with the Systematised Nomenclature of Medicine – Clinical Terms (SNOMED-CT), to allow for more detailed coding of conditions and associated factors. SNOMED-CT will eventually be rolled out across the whole of the NHS.
- We wanted to study current coding practice and identify any lessons for future migration to SNOMED-CT and so we analysed Read codes in Scotland, with allergy as an exemplar condition.
What we analysed
- 11 potentially allergic diseases (e.g. anaphylaxis, asthma, eczema)
- >2 million primary care consultation records
- >100,000 patients in Scotland
- Between 2003 – 2010
This is the first national investigation of use of Read codes in primary care for allergic disorders.
What we found
- Of the 352 allergy Read codes, only 10% (32) of the codes were used 95% of the time.
- 21% (73) codes were never used.
What we recommend
- Training for clinicians so they code to the most appropriate term.
- A data entry system that aids clinicians to code terms appropriately, e.g. terminology browsers, prompts for suggested codes/terms, code/term definition, logical structure for codes.
How to cite
Mukherjee M, Wyatt JC, Simpson CR, Sheikh A. Usage of allergy codes in primary care electronic health records: a national evaluation in Scotland. Allergy 2016; 71: 1594–1602
Author contact details
Ms Mome Mukherjee, The University of Edinburgh. Tel: +44 (0)131 650 3813. Email: mome.mukherjee@ed.ac.uk