Coding

The easiest way to distinguish between efficiency and effectiveness is applying the rule of the American management guru Peter Drucker: efficiency is doing the job right, effectiveness is doing the right job.

The only thing you need to know about ineffectiveness, on the other hand, is looking at the canonical example of demanding complete diagnostic coding in hospital patient discharge summary.

The truth is that doctors are supposed to code the diagnosis, besides writing a summary of what happened after a patient was discharged from hospital. Writing a summary deserves significant attention - even if it isn't easy - to let subsequent doctors carry on with the care. No one questions why we need to write good summary, but it is intriguing to conceive how diagnosis coding is linked with patient care. If writing patient discharge summary is like painting a picture, coding means naming each and every colour that has been used.

So let me repeat, once more: diagnosis coding has nothing to do with patient care.

There's an expectation now among our hospital administrators that the diagnostic coding should be as meticulous as forensic examination. Their rules are pretty strict. Writing the code 487.8 indicative of influenza is okay; it isn't when the auditor finds out the patient suffered from influenza A. I just received a letter telling me to change the code to 487.1, supposed to be more specific for influenza A (and not the influenza B virus). Disagreement about my original coding can take on the feel of a Supreme Court decision that will discipline me. I sheepishly ticked the box literally meaning "Pleaded Guilty" on the audit form, amended the coding and returned two copies of the summary acknowledging my mistakes. I felt how woefully the auditors had wasted their time parsing voluminous charts and combing through the laboratory results in this exercise, and wondered what purposes they serve. There is no evidence of real patient risk being infinitesimally reduced by such meticulous diagnostic coding. Obsession with such paperwork can override actual patient care - impersonal at best, distraction at worst.

In fact, I could offer dozens, indeed hundreds, of examples in which doctors are pushed to come up with as many codes as we can.

I really don't have much of a temper, but audits like these put me over the top.