DEVELOPMENT AND EVALUATION OF A COMPUTERIZED ADMISSION DIAGNOSES ENCODING SYSTEM

Hospital information systems designed to support the needs of health c are professionals include patient data entered using both freetext and preceded storage schemes. A major disadvantage of freetext storage sc hemes is that data captured in this format can only be presented as is to the user for review tasks. In the view of many health care scienti sts, natural language understanding systems capable of identifying, ex tracting, and encoding information contained in freetext data may prov ide the necessary tools to overcome this weakness. This paper describe s the development and evaluation of a such a system designed to encode freetext admission diagnoses. This system combines both semantic and syntactic linguistic analysis techniques. Evaluation results demonstra te the overall performance of this system to be reasonable, accurately encoding approximately 76% of admission diagnoses. Inefficiencies are primarily due to the inability of this system to generate encodings i n roughly 15% of test cases. When encodings are produced, however, acc uracy equals that of the current manual coding method. With further mo dification, this application can partially automate the coding process . (C) 1996 Academic Press, Inc.