Improving clinician's coded data entry through the use of an electronic patient record system: 3.5 years experience with a semiautomatic browsing and encoding tool in clinical routine

Joerg H. Hohnloser, Florian Puerner, Hooman Soltanian

Research output: Contribution to journalArticle

Abstract

This report presents data on clinicians' use of a browsing and encoding utility. Traditional and computerized discharge summaries during three 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 discharge summary are encoded manually; using a computerized browsing and encoding utility this rate may increase by 64%; when forced to encode diagnoses manually users may 'shift' as much as 84% of relevant diagnoses 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 conclude that the use of a computerized browsing and encoding tool by clinicians can increase data quality and the volume of documented data. Mechanisms bypassing the need to code can be reversed.

Original languageEnglish (US)
Pages (from-to)41-47
Number of pages7
JournalComputers and Biomedical Research
Volume29
Issue number1
DOIs
StatePublished - Feb 1996

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ASJC Scopus subject areas

  • Medicine (miscellaneous)

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