Abstract
Data are presented on the use of a browsing and encoding utility to improve coded
data entry for an electronic patient record system. Traditional and computerized discharge
summaries were compared: during three phases of coding ICD-9 diagnoses phase I, no
coding; phase II, manual coding, and phase III, computerized semiautomatic coding.
Our data indicate that (1) only 50% of all diagnoses in a discharge summary are encoded
manually; (2) using a computerized browsing and encoding utility this percentage may
increase by 64%; (3) when forced to encode manually, users may “shift” as much as
84% of relevant diagnoses from the appropriate coding section to other sections thereby
“bypassing” the need to encode, this was reduced by up to 41 % with the computerized
approach, and (4) computerized encoding can improve completeness of data encoding,
from 46 to 100%. We conclude that the use of a computerized browsing and encoding
tool can increase data quality and the percentage of documented data. Mechanisms bypassing
the need to code can be avoided.
Keywords
Browser - ICD-9 - Computerized - Encoding - Electronic Patient Record - Natural Language
Processing
