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
Jh. Hohnloser et al., 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, Computers and biomedical research, 29(1), 1996, pp. 41-47
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.