IMPROVING CLINICIAN ACCEPTANCE AND USE OF COMPUTERIZED DOCUMENTATION OF CODED DIAGNOSIS

After the Northwest Division of Kaiser Permanente implemented EpicCare , a comprehensive electronic medical record, clinicians were required to directly document orders and diagnoses on this computerized system, a task they found difficult and time consuming. We analyzed the sourc es of this problem to improve the process and increase its acceptance by clinicians. One problem was the use of the International Classifica tion of Diseases (ICD-9) as our coding scheme, even though ICD-9 is no t a complete nomenclature of diseases and using it as such creates dif ficulties. In addition, the synonym list we used had some inaccurate a ssociations, contributing to clinician frustration. Furthermore, the i nitial software program contained no adequate mechanism for adding qua lifying comments or preferred terminology. We sought to address all th ese issues. Strategies included adjusting the available coding choices and descriptions and modifying the medical record software. In additi on, the software vendor developed a utility that allows clinicians to replace the ICD-9 description with their own preferred terminology whi le preserving the ICD-9 code. We present an evaluation of this utility .