在EHR系统中映射的ICD数据与加拿大阿尔伯塔医院的DAD数据相比如何?
Namneet Sandhu1,2, Debbie Onos3, Bing Li4,5,6,7,8
1Centre for Health Informatics, Cumming School of Medicine, University of Calgary, Cal Wenzal Precision Health Building, 3280 Hospital Drive NW, Calgary, Alberta, T2N 4Z6, Canada. namneet.sandhu@ucalgary.ca.
BMC health services research
|November 26, 2025
概括
在EHR中自动编码显示,与人类编码的诊断的一致性很低. 这突出了国际疾病分类 (ICD-10-CA) 绘制和编码过程中的显著差异,影响了医疗保健数据的准确性.
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
- 电子健康记录 (EHR) 是一种电子医疗记录.
背景情况:
- 人类对诊断的编码对医疗保健系统来说是资源密集的.
- 一个自动化解决方案将临床接口术语映射到国际疾病分类 (ICD) 代码.
- 史诗和智能医疗对象 (IMO) 在这个综合解决方案上合作.
研究的目的:
- 评估自动化ICD-10-CA代码与人为编码的ICD-10-CA代码之间的一致性.
- 这项研究评估了来自加拿大阿尔伯塔省的电子健康记录系统的代码与排放摘要数据库 (DAD) 的代码.
主要方法:
- 一个回顾性分析将急性护理医院的DAD记录与省级EHR系统联系起来.
- 数据涵盖了加拿大阿尔伯塔省从2021年4月到2024年3月的入学情况.
- 对主要诊断和任何诊断的三位数和四位数ICD代码水平进行了测量,根据各种因素分层.
主要成果:
- 分析了超过60万份医院记录.
- 三位数水平的平均同意率为主要诊断的47.5%,任何诊断的37.0%.
- 人类编码器记录的诊断比自动化解决方案更多,在复杂的专业和更长的停留时间的协议较低.
结论:
- 自动化EHR映射的ICD-10-CA代码和人类编码的DAD数据之间的一致性很低.
- 自动化术语映射和手动编码过程之间存在重大差异.
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