Bridging the Gap Between Patient-Reported Health Events and Clinical Coding in Primary Care

Primary care, being the frontline of the healthcare system, plays a crucial role in diagnosing and managing a broad spectrum of health conditions. The effective translation of patient-reported outcome measures (PROMs) into clinical codes is vital to ensure accurate diagnosis and treatment plans. However, the extent to which clinicians capture and utilise PROMs data, despite policy initiatives, remains uncertain.

A study by Paul J Barr and colleagues, published in the Journal of Patient-Reported Outcomes, explored the association between patient-reported health events and their subsequent clinical coding.

Unravelling the Disconnect between PROMs and Clinical Coding

The research scrutinised the reporting of fall risk and urinary incontinence (UI) on PROMs and their subsequent documentation in electronic medical records (EMR). The study further sought to assess whether the provision of PROMs data to clinicians prior to a patient visit increased the likelihood of its documentation in the EMR.

The Study and Findings

The study involved a cross-sectional patient-reported risk assessment survey and semi-structured interviews with clinicians across fourteen primary care clinics in the US. Older adult patients (≥66 years) took part, completing a 46-item health risk assessment, which included PROMs for fall risk and UI.

Results revealed that while patient reports of fall risk and UI were readily captured by PROMs, this data only found its way into the EMR between 3% – 14% of the time, showing poor agreement.

Clinician interviews revealed several barriers to using PROMs data, including poor access to data, excessive data volume, interruption to workflow, and lack of training on PROMs. Even when PROMs data was provided prior to clinic visits, it did not significantly improve the likelihood of the data being captured in the EMR.

Towards a More Effective Utilisation of PROMs

These findings highlight the need for improved systems of presenting PROMs data and better clinician training on the importance and use of PROMs. If effectively leveraged, PROMs have the potential to enhance patient engagement, facilitate shared decision-making, and contribute to improved health outcomes. However, to ensure this, we need to bridge the current gap between patient-reported health events and their subsequent translation into clinical coding in primary care.

Barr PJ, Berry SA, Gozansky WS, et al. No date for the PROM: the association between patient-reported health events and clinical coding in primary care. J Patient Rep Outcomes. 2020;4(1):19. doi:10.1186/s41687-020-0183-5

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