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Improving coded data entry by an electronic patient record system
J H Hohnloser1, F Puerner, H Soltanian
1Med. Klinik, Klinikum Innenstadt, Ludwig-Maximilians-Universität, München, Germany.
Methods of Information in Medicine
|June 1, 1996
Summary
A new computerized tool significantly improves the coding of diagnoses in electronic patient records. This browsing and encoding utility enhances data completeness and reduces manual coding bypasses, boosting overall data quality.
Area of Science:
- Health Informatics
- Medical Record Systems
- Data Management
Background:
- Manual coding of diagnoses in electronic patient records is often incomplete.
- Traditional discharge summaries present challenges for accurate data capture.
- Existing methods can lead to diagnoses being overlooked or improperly categorized.
Purpose of the Study:
- To evaluate the effectiveness of a computerized browsing and encoding utility.
- To assess improvements in coded data entry for electronic patient record systems.
- To compare manual versus computerized coding of International Classification of Diseases, Ninth Revision (ICD-9) diagnoses.
Main Methods:
- A comparative study across three phases: no coding, manual coding, and computerized semi-automatic coding.
- Utilized a browsing and encoding utility to assist in coding diagnoses from discharge summaries.
- Analyzed the percentage of encoded diagnoses and instances of bypassing the coding process.
Main Results:
- Manual coding captured only 50% of diagnoses; the utility increased this by 64%.
- Manual coding bypasses were reduced by up to 41% with the computerized approach.
- Computerized encoding improved data completeness from 46% to 100%.
Conclusions:
- Computerized browsing and encoding tools enhance the quality and completeness of documented data.
- These tools effectively minimize mechanisms that bypass the need for accurate coding.
- Implementing such utilities is crucial for improving electronic patient record data integrity.