Discussion:
Coding of COVID-19 medical records is important in terms of assessment of the current status and decision making as well as global management of the pandemic. Moreover, this can serve as the basis for future research on the effectiveness of medications and novel therapies. Thus, accurate coding of diagnosed and suspected COVID-19 cases with or without pre-existing conditions such as diabetes and hypertension is very important.
In this study, we used social network consultation to solve COVID-19 coding problems and exchange experience between clinical coders. We also used a survey to extract the viewpoints of participants. Based on these viewpoints, coding consultations were useful and reduced coding time and increased the accuracy of COVID-19 codes.
The most frequent topics of consultation included ”Suspected or Probable cases”, ”Clinical coding instructors and diagnosis documentation” and ”Extra codes and clinical signs and symptoms”. Results of the current study revealed that using social networks is an efficient method for solving the problems faced by coders and exchange of coding instructions. An analysis of the questions raised by coders can provide health authorities with the knowledge to extract problems faced by coders and offer appropriate solutions. Based on the participants’ view, deploying social networks can reduce COVID-19 coding inconsistency caused by lack of skills. This happens by establishing an interactive communication between more experienced senior coders and junior coders, as well as those in under-privileged cities. This can potentially lead to improved problem solving and coding quality, and more accurate international reports by policy makers in light of the ongoing pandemic crisis. The trend of three most frequent consultation requests is shown in figure2. A comparison of this trend with that of COVID-19 and associated death rate indicates that in the 4th and 5th months of pandemic when death rate statistics were almost increasing coincides with the time frame when coding structures were constantly changing in line with the volatile nature of the pandemic. This is also the time period when requests about suspected cases and coding instructions increased. But, 10 months after the start of the pandemic in Iran at the start of the second wave, requests related to coding additional status increased.
New codes are regularly delivered to coders in the form of instructions. However, the un-interactive nature of instruction delivery and lack of orientation programs or other forms of educational guidelines has resulted in coding inconsistencies. The use of smartphones and social networks is becoming an increasingly popular interaction tool among health professionals, which can be used to improve the quality of coding. In light of the recent Covid-19 pandemic, the use of smartphones and social networks has drawn more attention. For instance, radiologists are using the WhatsApp platform for overseas diagnosis consultations. In a study involving a group of 11 radiologists, CT images were shared to seek consultation on possible diagnosis of COVID-1929. Online management of mental problems and monitoring of suspected COVID-19 cases are other examples of the use of internet-based technologies and social networks 19. A scoping review that investigated COVID-19 remote consultation services mentioned that health managers need to use remote consultations to improve services and provide care from a human rights perspective23. The same platform can be used for effective communication between coders, and faster and more reliable exchange of ideas and coding instructions. Moreover, this platform can be used to share the experience of more senior coders, which can be of benefit to junior coders. However, preserving the privacy of patients is an important concern, especially when dealing with images of medical records 30.
The studies on the use of social networks for professional consultation reveal that they have facilitated the decision process and reduced the time span 1,16. For example, in a study by Wani, who investigated the efficacy of communication amongst staff members in a department for plastic and reconstructive surgery, showed that consultation times can be reduced 1. According to the instructions by the health authorities in Iran, in-patient medical records should be coded online. As such, receiving a response to a consultation in one working day is acceptable. This implies that reducing the response time as well as accurate medical record coding is of high importance. Our results show that 80% of consultations reached a final decision and 47% of response times that were shorter than 10±3 min. It was seen in our study that at least three individuals participated in a given consultation, and in more complicated cases, at least one senior coder also participated in the process.
Given the limited number of reserved codes for COVID-19, coding of COVID-19 records may not seem difficult. However, a few items need to be taken into account; First, because of the novel nature of the current pandemic, the coding standards are evolving over time to account for previously unknown side effects, diagnostic methods, and associated therapeutic interventions. At the beginning of the pandemic, only a single code was assigned for COVID-19 cases. This was later complemented to include suspected cases, Covid-19 in pregnancy, specific organ damage, blood clotting effects, etc. Therefore, coding of diagnoses and procedures has also evolved over time since the onset of the pandemic. Second, COVID-19 cases were originally diagnosed as pneumonia and nothing else in many countries, and therefore the appropriate diagnostic tests were not requested for these patients 8. In addition, diagnostic kits were required for the definitive diagnosis. However, because of their unavailability, test results were not always recorded in many medical records. Because of the low sensitivity of the tests (60% to 70%) 31, the final diagnosis has sometimes been identified as COVID-19 clinically by physicians despite negative test results. Since the coder is required to comply with the clinical diagnosis and is not allowed to make changes at their own discretion, this results in a discrepancy between what they identify as the final diagnosis and the instructions provided by the health authorities. Third, CT scans gradually started to be deployed as part of the diagnosis procedure for COVID-19 cases after the start the pandemic. Accordingly, these were accounted for in the coding process for probable and suspected cases. The discrepancy between the final diagnosis by the clinician and the polymerase chain reaction (PCR) and CT test results was one of the consultation topics among coders. Using social networks can help healthcare providers to provide better services and use co-workers’ experiences 32. However, there are studies that suggest that social networks may lead to increased anxiety in healthcare workers 33 Thus, it is better that health professionals manage time spent on social networks.