The diagnosis related groups enhanced electronic medical record.
OBJECTIVE
The introduction of Diagnosis Related Groups as a basis for hospital payment in Germany announced essential changes in the hospital reimbursement practice. A hospital's economical survival will depend vitally on the accuracy and completeness of the documentation of DRG relevant data like diagnosis and procedure codes. In order to enhance physicians' coding compliance, an easy-to-use interface integrating coding tasks seamlessly into clinical routine had to be developed. A generic approach should access coding and clinical guidelines from different information sources.


METHODS
Within the Electronic Medical Record (EMR) a user interface ('DRG Control Center') for all DRG relevant clinical and administrative data has been built. A comprehensive DRG-related web site gives online access to DRG grouping software and an electronic coding expert. Both components are linked together using an application supporting bi-directional communication. Other web based services like a guideline search engine can be integrated as well.


RESULTS
With the proposed method, the clinician gains quick access to context sensitive clinical guidelines for appropriate treatment of his/her patient and administrative guidelines for the adequate coding of the diagnoses and procedures. This paper describes the design and current implementation and discusses our experiences.
Müller
Marcel Lucas
ML
Department of Medical Informatics and Biomathematics, University of Münster, Domagkstr. 9, 48129 Münster, Germany. marcel.mueller@uni-muenster.de
Bürkle
Thomas
T
Irps
Sebastian
S
Roeder
Norbert
N
Prokosch
Hans-Ulrich
HU
D003953:Diagnosis-Related Groups; D005858:Germany; D017722:Hospital Charges; D006801:Humans; D016247:Information Storage and Retrieval; D007349:Insurance, Health, Reimbursement; D020407:Internet; D016347:Medical Records Systems, Computerized; D017410:Practice Guidelines as Topic