------- Forwarded Message Follows -------
Date: Tue, 1 Oct 1996 19:00:46 +0100
To: [log in to unmask]
From: Professor David Barer <[log in to unmask]>
Subject: Re: Read codes
Cc: [log in to unmask]
Reply-to: Professor David Barer <[log in to unmask]>
At 10:03 27/09/96 -0500, you wrote:
>Sometimes, I think advocates of evidence-based medicine are not being
>realistic about what can be accomplished in the real world.
>
>Medical records and charts, computerized or not, at least in the US, are
>bound to be DELIBERATELY inaccurate, for at least two reasons:
>
>1) FEAR of doctors concerning what insurers or others with access to
>medical records will do with sensitive information about their patients -
>which leads to omissions, if not downright lies, within the records, and
>
>2) the physician's desire to get services paid for by insurance that
>would not normally be covered. For example, insurers will always cover
>an ultrasound to determine gestational age of a fetus, so if a pregnant
>woman wants an ultrasound, physicians justify the procedure to
>insurers by coding gestational age as the reason, even if gestational age
>was known.
These are salutary warnings - our NHS system is not yet so distorted by
financial incentives and fear of litigation that medical records are
sytematically falsified, but the pressures of the "internal market" are fast
moving it in that direction. If medical records are being increasingly
computerised and coding is becoming part of everyday clinical life, though,
wouldnt it be nice to have a system which reflects the uncertainties of
clinical practice rather than the unrealistic tidiness of the manager's
business plan or the insurer's/purchaser's contract? If clinicians are
forced to make arbitrary choices between diagnostic codes, why shouldnt they
go one step further and record false ones?
The Read coding system is a comprehensive thesaurus of medical diagnoses and
other terms agreed and officially adopted within the British NHS, and
increasingly used by management. It has many potential advantages over
previous more limited systems, but I'm sure it would encourage greater
honesty and ultimately be more useful to both clinicians and managers if
uncertainty was acknowledged and catered for within the system.
>With these kinds of things going on ROUTINELY, it would appear that
>there is very little hope of using medical records and charts with any
>validity for research, without adjusting for all this maneuvering.
I don't think "proper" research was ever suggested as the main aim, but one
of the advantages of formalising the recording of uncertainty would be to
encourage clinicians to develop a more questioning attitude, treating each
patient as a diagnostic challenge and auditing their performance against the
final answers!
David Barer Tel (0)191 273 0175
Dept of Medicine of the Elderly Fax (0)191 272 2689
Newcastle General Hospital
Newcastle upon Tyne
NE4 6BE
UK
-----------------------Sheila Teasdale---------------------------
Editor - Informatics - The Journal of Informatics in Primary Care
http://www.ncl.ac.uk/~nphcare/PHCSG/Journal/index.htm
---------------Fax 01529 460589 / 01522 569874-------------------
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