title: Improving clinician's coded data entry through the use of an electronic patient record system: 3.5 years experience with a semiautomatic browsing and encoding tool in clinical routine.
abstract: This report presents data on clinicians' use of a browsing and encoding utility. Traditional and computerized discharge summaries during three phases of coding ICD-9 diagnoses were compared: phase I (no coding), phase II (manual coding), and phase III (computerized semiautomatic coding). Our data indicate that only 50% of all diagnoses in a discharge summary are encoded manually; using a computerized browsing and encoding utility this rate may increase by 64%; when forced to encode diagnoses manually users may "shift" as much as 84% of relevant diagnoses from the appropriate section to other sections, thereby "bypassing" the need to encode. This effect can be partially reversed by up to 41% with the computerized approach. Using a computerized encoding help can ensure completeness of encoding data (from 46 to 100%). We conclude that the use of a computerized browsing and encoding tool by clinicians can increase data quality and the volume of documented data. Mechanisms bypassing the need to code can be reversed.
authors.affiliation: Medizinische Klinik, Klinikum Innenstadt, Ludwig-Maximilians-Universität München, Germany.
authors.forename: J H
authors.initials: JH
authors.lastname: Hohnloser
authors.forename: F
authors.initials: F
authors.lastname: Puerner
authors.forename: H
authors.initials: H
authors.lastname: Soltanian
mesh_terms: D003933:Diagnosis; D004282:Documentation; D001330:Electronic Data Processing; D005568:Forms and Records Control / Q000379:methods*; D006751:Hospital Information Systems; D006801:Humans; D016347:Medical Records Systems, Computerized; D008838:Microcomputers; D010351:Patient Discharge; D010820:Physicians