Howes M H
St Vincent's Hospital, Sydney.
Aust Med Rec J. 1993 Dec;23(4):117-22. doi: 10.1177/183335839302300403.
In 1992 the Hospital recognised that the existing casemix data reporting systems were too removed from individual patients to have any meaning for clinicians, analysis of the data was difficult and the processes involved in the DRG assignment were subject to considerable error. Consequently, the Hospital approved the purchase of technology that would facilitate the coding and grouping process. The impact of automated coding and grouping technology is assessed by three methods. Firstly, by looking at by-product information systems, secondly, through subjective responses by coders to a satisfaction questionnaire and, thirdly, by objectively measuring hospital activity and identified coding elements before and after implementation of the 3M technology. It was concluded that while the 3M Coding and Grouping software should not be viewed as a panacea to all coding and documentation ills, objective evidence and subjective comment from the coders indicated an improvement in data quality and more accurate DRG assignment. Development of an in-house casemix information system and a feedback mechanism between coder and clinician had been effected. The product had been used as a training tool for coders and had also proven to be a useful auditing tool. Finally, linkage with other systems and the generation of timely reports had been realised.
1992年，该医院认识到现有的病例组合数据报告系统与个体患者脱节，对临床医生毫无意义，数据难以分析，疾病诊断相关分组（DRG）的分配过程存在大量错误。因此，医院批准购买有助于编码和分组过程的技术。通过三种方法评估自动编码和分组技术的影响。首先，查看副产品信息系统；其次，通过编码人员对满意度调查问卷的主观反馈；第三，在实施3M技术前后客观测量医院活动和确定的编码要素。得出的结论是，虽然3M编码和分组软件不应被视为解决所有编码和文档问题的万灵药，但编码人员的客观证据和主观评价表明数据质量有所提高，DRG分配更加准确。已开发出内部病例组合信息系统，并实现了编码人员与临床医生之间的反馈机制。该产品已用作编码人员的培训工具，也被证明是一种有用的审计工具。最后，实现了与其他系统的链接并生成及时的报告。
