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Editorial
Encode to manage
Codificar para gestionar
Alfonso Manuel Soto Morenoa,
Corresponding author
, Roman Villegas Porterob
a Servicio de Endocrinología y Nutrición, Hospital Universitario Virgen del Rocío, Sevilla, Spain
b Subdirección Técnica de Gestión de la Información, Servicio Andaluz de Salud, Sevilla, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The article published in this issue of the journal by our colleagues from the Endocrinology&#44; Nutrition and Diabetes Society of Castilla - La Mancha &#40;<span class="elsevierStyleItalic">Sociedad Castellano Manchega de Endocrinolog&#237;a&#44; Nutrici&#243;n y Diabetes</span>&#41;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> highlights an unquestionable reality&#58; What goes on in our outpatient clinics is totally opaque to the different healthcare services&#44; beyond the classical and inefficient indicator represented by the relationship between first visits and follow-up visits - which is not applicable to our specialty - or the measurement of delay in referrals from primary care &#40;PC&#41;&#46; At present&#44; the greater or lesser complexity we have in our clinics cannot be measured even by ourselves&#44; and at managerial level we typically mix general consultations&#44; usually referring to the first line of care for patients referred from PC&#44; with monographic consultations of maximum complexity&#44; some of which are even recognized by the Spanish Ministry of Health through the Centers&#44; Services and Reference Units &#40;CSUR&#41; program&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">It is hardly a consolation that this situation is far from exclusive to our specialty&#44; but affects all care provided in our country in outpatient clinics&#46; However&#44; unlike other specialties&#44; the percentage of our activity dedicated to such consultations is far higher&#46; Perhaps because of this&#44; and in line with the innovation capacity characteristic of endocrinologists&#44; we should&#44; as suggested by our colleagues&#44; address this issue from other levels of the specialty at national level and propose some practical solutions&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">But let us first examine the global framework in which we move&#46; The encoding of outpatient processes is generally complex&#46; The Royal Decree regulating the Registry of Specialized Healthcare Activity in Spain limits its scope to day hospitals&#44; physicians and outpatient procedures of special complexity&#44; initially excluding outpatient clinics&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Technical reports of the Ministry indicate that the encoding of external consultations is the last objective contemplated in this Registry&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Other authors who have described the trajectory from the traditional Minimum Basic Data Set &#40;MBDS&#41; to the current situation have also emphasized the importance of having an encoding system for the activities carried out in external consultations&#44; but in turn draw attention to its complexity&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> In addition&#44; implementation of the ICD-10 as an encoding system&#44; with its 70&#44;000 diagnostic codes&#44; has implied a greater amount of information &#40;e&#46;g&#46;&#44; regarding the different types of diabetes&#41;&#44; but has also added complexity to the encoding process&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> In spite of some familiarity with automation or semi-automation strategies for encoding purposes&#44;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#8211;8</span></a> diabetes is specifically one of the scenarios in which the greatest percentage of errors or miscoding problems occur&#44; especially in reference to the outpatient setting&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> The use of Natural Language Processing &#40;NLP&#41; tools has allowed some hospital emergency departments &#40;with encoding difficulties similar to those in outpatient clinics&#41; to obtain good results&#44; with a precision of 0&#46;976 &#40;95&#37;CI&#58; 0&#46;957&#8211;0&#46;990&#41;&#44; a recall &#40;sensitivity&#41; of 0&#46;878 &#40;95&#37;CI&#58; 0&#46;844&#8211;0&#46;910&#41; and an F-score of 0&#46;925 &#40;95&#37;CI&#58; 0&#46;903&#8211;0&#46;943&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The relevance of the above-mentioned article is therefore clear&#46; The problem regarding measuring activity in outpatient clinics is real and is widespread&#46; As an alternative&#44; the authors developed a Delphi method with the participation of some fifty colleagues from their Autonomous Community&#44; reaching a fairly plausible consensus when seen from the perspective of a specialist in Endocrinology and Nutrition&#46; However&#44; there are a number of deficiencies that the authors themselves comment on in the article&#46; The number of participating specialists was small&#44; and their dedication greatly conditioned the scores awarded&#46; Moreover&#44; it is questionable whether an index of greater complexity would reflect three times the care time &#40;a variable that would determine schedule times&#41; or three times the difficulty and&#44; therefore&#44; training and study &#40;a variable that would determine the need for the selection of staff specially trained for the most complex consultations&#41;&#44; or a combination of them&#46; We agree that by securing a broader and more representative expert consensus within the Departments of Endocrinology and Nutrition throughout the country&#44; such classification could be useful for establishing comparisons among centers&#46; Without this&#44; it would only be useful for allocating resources within the Department&#44; with all the other nuances that arise at micromanagement level&#46; The authors propose that the Spanish Society of Endocrinology and Nutrition perform an analysis with this same or a similar method&#44; which could reach a consensus such as that which we suggest&#46; We think that it would be the appropriate setting for this work&#44; since the leadership and indications afforded by the scientific bodies would be that of our own peers&#44; this being essential for carrying out a project requiring the maximum implication of all members of the specialty&#44; free from personal interests and working for the benefit of all&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">If we can achieve this&#44; if we as specialists in Endocrinology and Nutrition can agree and assess&#44; compare and evaluate ourselves&#44; will this allow us to move beyond a mere comparison and rearrangement of activities&#63; Is this objective enough&#44; or do we need to be more ambitious&#63; What would be our role as coordinators of the majority of multidisciplinary teams focusing on patients with diseases in Endocrinology and Nutrition&#63; The role of endocrinologists in complex units such as the CSUR regarding complex hypothalamic-pituitary disease or innate errors of metabolism&#44; in cases of short bowel&#44; thyroid cancer&#44; and so many other conditions&#44; is essential&#46; The characteristics of our specialty refer to many diseases&#44; and our work goes beyond mere patient care in the consulting room&#46; We will try to answer this issue from the convictions of the authors of this editorial in relation to clinical management&#46; Modern medicine is built around multidisciplinary teams&#44; professionals who each contribute their specific expertise to the treatment of disease&#44; obviating the conventional hierarchical structure and working in an intermingling matrix network within the healthcare center&#46; The only way to secure quality care is through the involvement of these professionals&#44; getting them to do their work as they understand they should&#44; without obstacles or instructions that correspond more to old hierarchical structures and to small victories that do not win wars&#46; To achieve such involvement&#44; professionals need to feel important&#44; to participate and to share the responsibility of their results&#44; feeling part of the final outcome&#46; To this end&#44; it is essential for management in each center to grant terrain to professionals who want to take on roles and also responsibilities&#46; Central to this model is the role of the middle managers<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;11</span></a> as spokesmen for their colleagues&#44; as the &#8220;interpreters&#8221; between central management and the unit&#44; as the individuals their colleagues place their trust in for negotiating&#44; and which the management team trusts to delegate responsibilities&#46; The heads of service need tools to be able to negotiate with management&#44; and in this regard having the work load of the clinic well analyzed may be one of them&#46; They also need to take on their role and propose efficient alternatives in the care of our patients&#44; assuming responsibility in many cases&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">We would like to close this editorial by encouraging the Spanish Society of Endocrinology and Nutrition to accept the challenge proposed by the <span class="elsevierStyleItalic">Sociedad Castellano Manchega de Endocrinolog&#237;a</span>&#44; <span class="elsevierStyleItalic">Nutrici&#243;n y Diabetes</span>&#46; Let us expand&#44; improve and develop a tool which&#44; as mentioned earlier&#44; does not exist yet and is complex&#46; Finally&#44; once we have this tool&#44; we should use it wisely and for the good of the specialty as a whole&#44; ensuring reasonable work times that improve working conditions&#44; as this will undoubtedly benefit quality care for our patients&#44; as the ultimate purpose of our profession&#46;</p></span>"
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