对临床编码的变革性创新,以获得更好的数据和更少的负担
Michael Pine1, Kathy Giannangelo2, Charles Hobson3
1Managing Director MJP Healthcare Innovations, LLC.
Advances in health information science and practice
|September 22, 2025
概括
增强的国际疾病分类-11临床组件库 (ICD-11-CCL) 提供比标准ICD-11-MMS和ICD-10-CM更详细的临床数据. 这种先进的编码系统可以改善二次数据应用,并减少手动编码负担.
科学领域:
- 医疗信息学 医疗信息学
- 医疗编码系统 医学编码系统
- 临床数据表示
背景情况:
- 国际疾病分类 (ICD) 对于记录医疗保健概念至关重要,从统计需求发展到各种临床应用.
- 世界卫生组织 (WHO) 的第11次修订,ICD-11,正在评估其在临床质量,决策和二次数据使用方面的适用性.
研究的目的:
- 评估ICD-10-CM,ICD-11标准的死亡率和发病率统计 (ICD-11-MMS) 和一个增强的ICD-11-MMS原型 (ICD-11-CCL) 的功能.
- 评估它们在代表自然临床语言场景的临床患者个人资料方面的有效性.
- 为了比较基于细节性,全面性,准确性,精度,相关性和用户友好的编码支持的系统.
主要方法:
- 编码系统的比较:ICD-10-CM,标准ICD-11-MMS,以及ICD-11-CCL.
- 使用两个自然临床语言场景进行评估.
- 评估标准包括细节性,全面性,准确性,精确性,相关性和编码支持的可用性.
主要成果:
- 标准和增强的ICD-11-MMS都提供了比ICD-10-CM更详细的临床细节.
- 与ICD-10-CM和标准ICD-11-MMS不同,ICD-11-CCL表现出卓越的全面性,并允许临床医生直接输入.
- 在ICD-11-CCL中,每个场景生成了独特的代码集群,避免了ICD-11-MMS中看到的同名集群.
结论:
- 一个增强的ICD-11-MMS,就像ICD-11-CCL一样,可以比标准的ICD-11-MMS更有效地为二次应用提供细微的临床数据.
- 它保留了国际比较统计的能力,同时可能减少自动化工具的手动编码工作.
- ICD-11-CCL代表了与ICD-10修改相比的重大进步,并为未来的采用提供了进一步的发展.
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