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Related Experiment Videos

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

P J Porcelli1

  • 1Department of Pediatrics, Wake Forest University, School of Medicine, Winston Salem, NC, USA.

Proceedings. AMIA Symposium
|February 5, 2002
PubMed
Summary

An electronic patient documentation system (EDS) captured 31% more diagnostic codes for very low birth weight infants than the paper-based system. This electronic system improves neonatal data capture and reduces errors.

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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.

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  • 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.