Computer-based clinical coding activity analysis for neurosurgical terms.

Area of Science:

• Medical Informatics
• Clinical Coding Systems
• Health Information Management

Background:

• Measuring the effort required for clinical coding is challenging.
• Existing methods do not accurately quantify the time and cognitive load involved in medical data coding.
• A standardized assessment for clinical coding activity is needed.

Purpose of the Study:

• To introduce and validate an assessment method for clinical coding activity.
• To measure and compare the time and accuracy of coding neurosurgical terms.
• To evaluate the performance of neurosurgical residents (NSRs) versus medical record administrators (MRAs) in clinical coding.

Main Methods:

• Developed a novel computer application to track mouse trajectories and record coding time.
• Utilized Systematized Nomenclature of Medicine - Clinical Terms (SNOMED CT) as the coding system.
• Assessed coding accuracy by a senior neurosurgeon and tested the method with 5 NSRs and 5 MRAs using 20 neurosurgical terms.

Main Results:

• NSRs achieved a mean accuracy of 89.33%, significantly higher than MRAs at 80% (p=0.024).
• NSRs completed coding in a mean duration of 158.47 seconds, substantially faster than MRAs at 271.75 seconds (p=0.003).
• The developed method accurately quantified coding time and performance differences.

Conclusions:

• The proposed method effectively analyzes the clinical coding process and quantifies time requirements.
• NSRs demonstrated superior efficiency and accuracy in coding neurosurgical terms compared to MRAs.
• This assessment provides valuable insights into the cognitive demands of clinical coding and informs training needs.