IMPROVING CLINICIAN CODED DATA-ENTRY THROUGH THE USE OF AN ELECTRONICPATIENT RECORD SYSTEM - 3.5 YEARS EXPERIENCE WITH A SEMIAUTOMATIC BROWSING AND ENCODING TOOL IN CLINICAL ROUTINE

This report presents data on clinicians' use of a browsing and encodin g utility. Traditional and computerized discharge summaries during thr ee phases of coding ICD-9 diagnoses were compared: phase I (no coding) , phase II (manual coding), and phase III (computerized semiautomatic coding). Our data indicate that only 50% of all diagnoses in a dischar ge summary are encoded manually; using a computerized browsing and enc oding utility this rate may increase by 64%; when forced to encode dia gnoses manually users may ''shift'' as much as 84% of relevant diagnos es from the appropriate section to other sections, thereby ''bypassing '' the need to encode. This effect can be partially reversed by up to 41% with the computerized approach. Using a computerized encoding help can ensure completeness of encoding data (from 46 to 100%). We conclu de that the use of a computerized browsing and encoding tool by clinic ians can increase data quality and the volume of documented data. Mech anisms bypassing the need to code can be reversed. (C) 1996 Academic P ress, Inc.