An electronic documentation system increases diagnostic code capture for very low birth weight infants

Area of Science:

• Neonatal intensive care
• Medical informatics
• Healthcare quality evaluation

Background:

• Evaluating healthcare quality for very low birth weight (VLBW) infants requires comprehensive patient outcome data.
• A paper-based documentation system (PDS) was previously used for VLBW infant data.
• An electronic patient documentation system (EDS), PCode, was developed to improve diagnostic code capture.

Purpose of the Study:

• To compare the diagnostic code capture rate of the new electronic patient documentation system (EDS) against the traditional paper-based documentation system (PDS).
• To test the hypothesis that the EDS would capture more patient diagnostic codes than the PDS.

Main Methods:

• The study compared a paper-based system (PDS) with an electronic system (EDS) for coding neonatal diagnoses.
• Data were collected from VLBW infants, with PDS used from 11/1997-3/1999 and EDS from 3/1999-8/2000.
• The primary outcome was the number of diagnostic (DX) codes captured per patient, analyzed using independent t-test and linear regression.

Main Results:

• The electronic system (EDS) captured 31% more diagnostic codes per patient compared to the paper system (PDS) after controlling for birth weight.
• A trend towards fewer erroneous codes was observed with the EDS.
• Common diagnoses included hyaline membrane disease, sepsis evaluation, and hyperbilirubinemia.

Conclusions:

• The electronic patient documentation system (EDS) significantly increased the capture of diagnostic codes for VLBW infants.
• These findings support the adoption of electronic documentation in neonatal care.
• Linking the PCode system to patient databases is expected to further reduce manual coding errors.