Improving coded data entry by an electronic patient record system.
Data are presented on the use of a browsing and encoding utility to improve coded data entry for an electronic patient record system. Traditional and computerized discharge summaries were compared: during three phases of coding ICD-9 diagnoses phase I, no coding; phase II, manual coding, and phase III, computerized semiautomatic coding. Our data indicate that (1) only 50% of all diagnoses in a discharge summary are encoded manually; (2) using a computerized browsing and encoding utility this percentage may increase by 64%; (3) when forced to encode manually, users may "shift" as much as 84% of relevant diagnoses from the appropriate coding section to other sections thereby "bypassing" the need to encode, this was reduced by up to 41% with the computerized approach, and (4) computerized encoding can improve completeness of data encoding, from 46 to 100%. We conclude that the use of a computerized browsing and encoding tool can increase data quality and the percentage of documented data. Mechanisms bypassing the need to code can be avoided.
Hohnloser
J H
JH
Med. Klinik, Klinikum Innenstadt, Ludwig-Maximilians-Universität, München, Germany.
Puerner
F
F
Soltanian
H
H
D003625:Data Collection; D004194:Disease / Q000145:classification; D004282:Documentation / Q000379:methods*; D001330:Electronic Data Processing; D006801:Humans; D008487:Medical History Taking; D016347:Medical Records Systems, Computerized; D010351:Patient Discharge; D011785:Quality Assurance, Health Care; D012984:Software