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.