Future of clinical codingBMJ 2016; 353 doi: https://doi.org/10.1136/bmj.i2875 (Published 26 May 2016) Cite this as: BMJ 2016;353:i2875
- Stephen Andrew Spencer, deputy director of admissions
Clinical coding is used to classify the diagnosis and treatment of every inpatient for entry into a national data repository. The data are used for various purposes, mostly administrative. The system relies on the expertise of clinical coders, who extract data from largely unstructured notes using complex rules and a book of codes. The classification systems used in the UK are the international classification of diseases (ICD-10) for symptoms and diagnoses1 and the OPCS classification (OPCS-4) for procedures.2
This system has served the health service well since 1989, but the implementation of electronic patient records will require a radical change.3 Clinicians using electronic records will enter clinical data at the time of patient contact and are therefore in a good position to undertake clinical coding. In fact, it will become a professional responsibility because the data will be needed not just for administrative purposes but also for revalidation and to show patient safety and quality of care. Clinicians cannot be expected to record data using a disease classification system such as ICD-10; they need to be able to use terms which are familiar and more clinically relevant. These terms have to be suitable not only for the patient record but also for communicating with other health professionals and with patients, who will have access to their electronic records. Efficiency demands that information is recorded once and used many times.
Learning a new language
The NHS has been going through the process of adopting a suitable language called SNOMED CT.4 It is not a disease classification but a terminology that allows every disease concept to be recorded in a standardised way. SNOMED CT has been developed over many years from an amalgamation of an American pathology database and Read codes (developed in the UK for general practice by James Read).5 Each disease concept has a unique identification number, a fully specified name, and a preferred term. Any number of synonyms can be added, including foreign language terms, making the terminology truly international.
SNOMED CT has a hierarchical structure so that more general terms are “parents” to more specific children—for example, bacterial pneumonia is a child of pneumonia and a parent of pneumococcal pneumonia. To facilitate analysis, a disease can be part of more than one hierarchy (pneumococcal pneumonia is both a respiratory disorder and an infection, for example). Online resources6 and an online SNOMED CT browser7 are available to enable clinicians to prepare to use the system.
In England, migration of general practice systems from Read codes to SNOMED CT is already underway. Some specialties have worked with expert terminologists to refine the content of SNOMED CT for secondary care to ensure that all commonly required terms are present and correctly positioned in the heirarchy.8 This has led to the publication of subsets of terms that will give clinicians in each of these specialties quick access to their favoured terms.9
It is vital that clinicians take responsibility for ensuring the content of SNOMED CT permits accurate recording of symptoms, diagnoses and treatments. This is best achieved through medical colleges and specialty groups. Previously, clinicians had to use data collected primarily for administrative purposes to drive service development and improvements in clinical care.10 Engagement was poor because many viewed the data as inadequate for this purpose.11 In future clinicians will be empowered by data designed to support clinical research, national audit, service development, and quality improvement. These benefits have already been realised in paediatric neurodisability, where clinicians using SNOMED CT were able to show for the first time the complexity of outpatient care, leading to service redesign and considerable expansion in the consultant workforce.12
To meet the challenges of personalised medicine, linking phenotypes with genome research, and to reduce the considerable variation in healthcare across the UK, clinicians need to embrace this new technology with enthusiasm. SNOMED CT can provide the means to record routine data accurately and in real time, but clinicians working at the doctor-patient interface are the only ones who can ensure it happens. Clinical data must be recorded with the same precision as data required for research or submitted to a national audit or disease register. Only then, will patients fully benefit from the development of electronic patient records.
Competing interests: I have read and understood BMJ policy on declaration of interests and declare I am seconded to the Health and Social Care Information Centre for one day a week in a clinical advisory role.
Provenance and peer review: Not commissioned; externally peer reviewed.