Predicting the influence of the electronic health record on clinical coding practice in hospitals.
The key drivers of change to clinical coding practice are identified and examined, and a major shift is predicted. The traditional purposes of the coding function have been the provision of data for research and epidemiology, in morbidity data reporting and, latterly, for casemix-based funding. It is contended that, as the development of electronic health records progresses, the need for an embedded nomenclature will force major change in clinical coding practice. Clinical coders must become expert in information technology and analysis, change their work practices, and become an integral part of the clinical team.
Robinson
Kerin
K
Department of Health Information Management, School of Public Health, Faculty of Health Sciences, La Trobe University, Bundoora, Victoria. K.Robinson@latrobe.edu.au
Shepheard
Jennie
J
D001315:Australia; D059019:Clinical Coding / Q000592:standards*; D003953:Diagnosis-Related Groups; D057286:Electronic Health Records / Q000592:standards*; D005544:Forecasting; D063025:Health Information Management / Q000639:trends*; D006761:Hospitals; D016347:Medical Records Systems, Computerized; D009626:Terminology as Topic