The current COVID-19 pandemic situation, similar to the increased incidence of Kaposi’s sarcoma in the 1980s, exposes the relevance of surveillance of new clinical pictures, and the fact that every clinician must share the responsibility, adequately documenting consultations, and recognising that their entries will be used beyond the clinician–patient relationship.1
Clinicians’ preferred use of free text to store information is inadequate. There is a need to use clinical coding extensively, not just diagnoses, but symptoms and examination findings. Otherwise electronic health records are no more than digital papers. Processing a large amount of consultations can only be made through informatics, and software works much better with coded clinical entries.
Clinicians have been using electronic records for decades but they are still infrequent coders,2,3 there is considerable data quality variation, and furthermore it is often suboptimal.4 Additional training and improving systems design are needed,5,6 but is it time to reconsider the clinical nomenclature itself? SNOMED-CT was expected to be the solution to facilitate coding,7 but clinicians are still not engaging enough with it.6 Frontline clinicians require an effortless, easy-to-use entry system that facilitates the interaction with the patient and the computer rather than the current complex and hard-to-find code nomenclature with less-than-helpful software that, combined, fail to facilitate coding consultations adequately.
The future use of clinical coding will not improve by implementing more complex nomenclatures. Currently there is more free text than code, and information will be partial, insufficient to improve health care, detrimental for research, and inefficient to alert about increases in particular symptoms or conditions.
Future generations of patients will be better served by a profound analysis of current clinical nomenclature and software, and a resulting real change to clinicians’ use of electronic health records.
- © British Journal of General Practice 2020
