Caring for the patient, caring for the record: an ethnographic study of 'back office' work in upholding quality of care in general practice
The quality of information recorded about patient care is considered key to improving the overall quality, safety and efficiency of patient care. Assigning codes (e.g. Read codes) to patients' records is an important aspect of recording this information. However, despite current interest in large datasets which seek to collate locally generated individual patient data (such as the NHS care.data project), little attention has been paid to the details of how patient ‘data' get onto the record in the first place. This paper explores the work of summarising and coding patients' medical records, focusing on ‘back office' practices, identifying contributors and barriers to quality of care.
We undertook 187 hours (over approximately 8 months) ethnographic observation of clinical, management and administrative staff in two UK general practices with contrasting organisational characteristics. This approach involved observation of working practices, including: shadowing; recording detailed field notes; naturalistic interviews; analysis of key documents relating to summarising and coding. Ethnographic analysis drew on key sensitizing concepts to build a ‘thick description' of coding practices, drawing these together in a narrative synthesis.
Coding and summarising electronic patient records is complex work. It depends crucially on nuanced judgements made by administrators who combine their understanding of: clinical diagnostics; classification systems; how health care is organised; particular working practices of individual colleagues; current health policy. Working with imperfect classification systems, diagnostic uncertainty and a range of local practical constraints, they manage a moral tension between their idealised aspiration of a ‘gold standard' record and a pragmatic recognition that this is rarely achievable in practice. Adopting a range of practical workarounds, administrators position themselves as both formally accountable to their employers (general practitioners), and informally accountability to individual patients, in a coding process which is shaped not only by the ‘facts' of the case, but by ongoing working relationships which are co-constructed alongside the patient's summary.
Data coding is usually conceptualised as either a technical task, or as mundane, routine work, and is a form of work which usually remains ‘invisible'. This ethnographic study offers a characterisation of coding as a socially complex site of moral work through which new lines of accountability are enacted in the workplace, and it challenges taken-for-granted assumptions about the status and meaning of coded data as usually conceptualised in the ‘quality of care' discourse. It highlights not only the limits of what can be understood from reliance on ‘codes' alone, but also the value of ethnographic approaches as a means to illuminate complex ‘real world' primary care practices.
- Deborah Swinglehurst, University of Oxford, Oxford, UK
- Trisha Greenhalgh