CODING MEDICAL CONCEPTS - A CONTROLLED EXPERIMENT WITH A COMPUTERIZEDCODING TOOL

In medicine there is a growing need to encode medical concepts with th e available standard coding systems. The coding process can be time in tensive and may significantly add to daily paperwork. We have develope d a generic computerized encoding tool-the PADS (patient archiving and documentation system) encoder-to ensure rapid, correct and complete c oding of diagnoses in daily routine. The tool is integrated into an el ectronic patient record system and takes full advantage of the user fr iendly Macintosh interface. The tool was tested in a controlled experi ment by 18 clinicians who encoded a total of 666 medical concepts in e ach protocol (study protocol versus control). We present data demonstr ating that a computerized coding tool can produce more complete data o f higher quality and save time compared with the traditional approach: (a) the number of correctly encoded medical concepts was higher (99.5 5% versus 86.1%); (b) coding errors mere lower (0% versus 10.81%); (c) more modifier codes were encoded correctly (increase by up to 43%); ( d) fewer coding errors were made (decrease by up to 43%); (e) the over all rate of correctly encoded and complete main and modifier codes was increased by 31.27% (97.29% versus 66.02%); and (f) coding time was r educed by 50%.