Structuring clinical coding data

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appointments, blood tests, or even the GP appointment, as part of coordinating the patient’s follow up care.

• Providing access to the patient’s medical records, clinical research evidence and medical knowledge resources.

• Integration with clinical ordering systems to allow hospital doctors to request tests, or to book appointments for patients as part of completing a discharge summary.

• Alert systems that detect the presence of non-standard shortened forms, invalid dates, abnormal medication dosages, typing and grammatical mistakes and empty mandatory fields.

• Providing the functionality to import and transform the content of the patient’s medical record into a discharge summary.

• Allowing customisation of data entry based on speciality, type of patient admission and patient problems.

• Presenting “blank” field with less ambiguous “null” value flavours such as “not known”, “not applicable”, “none”.

• Supporting multiple authorships (nurse, hospital doctors, allied professionals).

• Commencing automatically when the patient is admitted to hospital.

• Supporting progressive data input.

• Reminder of incomplete data input when the planned discharge date is approaching, or if the patient has been discharged.

• Supporting mobility, for example handheld data input.

6.3. 7 Structuring clinical coding data

In current practice, clinical coding in secondary care is solely for secondary purposes using classification systems such as ICD10 and OPCS4. NPfIT

discharge report specification supports clinical coding for primary purposes. The coding data are represented as coded entries in HL7 CDA and use SNOMED CT

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as the reference clinical terminology. Based on the understanding of how the various information contained in a discharge summary is supposed to be used, this study recommends that the clinical coding data to be sub-divided into different categories to reflect the different kinds of uses. The first category is the generic coded entries, which include clinical findings (diagnosis, allergy, complication, problems, conditions, assessments), clinical interventions (procedure,

investigation, medication), and adverse events. The generic coded entries can be used as data source for decision support systems and the cross-mapping to existing classification systems. Generic coded entries embedded in the patient’s EHR will continue to be relevant for the patient’s care, as past medical history. The other categories should reflect the specific use of the coding data, which is assumed to be temporary. For example, medication reconciliation coded entries would be used to assist automatic reconciliation of patient medication record on the GP system.

Order coded entries would be used to facilitate clinical order in a discharge

summary such as requests to GPs or an outpatient appointment. This type of coded entry can be used to facilitate coordination between health professionals involved in the patient’s continuity of care. Only clinical applications that support the required functionalities will be allowed to process the non-generic coded entries.

Consequently, this study recommends that HL7 CDA adopts the features of coded entry specialisation, which is based on the specific purpose of the coded entries.

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6.4 Summary

This chapter has presented the key insights gained from this study and the implications for improving discharge summary systems, and how these insights expand the current knowledge related to discharge summaries. Overall, this study claims the following contributions to new knowledge:

• This study has identified a number of hospital practices and other factors that contribute to the problems of poor data quality and delayed discharge summaries. These include the attitude of senior doctor, lack of regulations in the area of delegation and junior doctor training, deficits in

communication and coordination between secondary and primary care providers.

• This study has demonstrated the medical orientation of current discharge summary construction and argued the need for a multidisciplinary discharge summary with multiple authorships and accountability.

• This study has demonstrated that TTOs were considered inconsequential by both hospital doctors and GPs due to the poor quality issue, and it is important to establish a greater accountability of NHS Hospital Trusts to achieve high data quality and timely discharge summaries.

• This study has proposed a formal transitional care pathway supported by innovative IT systems as the solution for safer, smoother transfer of responsibility for the patient’s care from secondary to primary care providers.

• This study has elaborated how health professionals interacts through a discharge summary in real life practice, and developed hypothetical semantic structure in order to explain these interactions.

• This study reaffirms the significant use of idiosyncratic shortened forms in discharge summaries, including abbreviations, acronyms, metonyms, numeric expressions, special characters and signs, and their potential contribution to error.

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• This study has identified a number of features of electronic data entry systems that could facilitate the creation of better discharge summaries and would support the interactions between health professionals.

• This study has recommended that clinical coding data should be structured according to their intended uses by clinical applications, including to interactions between different health professionals.

• Methodologically, this study has demonstrated how theoretical concepts, such as pragmatic, semantic, syntactic, speech act and mental frame, can be used together as conceptual framework to investigate various aspects related to the construction of discharge summaries in a holistic approach.

This approach can be replicated in researching other clinical documentation.

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