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The diagnosis related groups enhanced electronic medical record.

作者信息

Müller Marcel Lucas, Bürkle Thomas, Irps Sebastian, Roeder Norbert, Prokosch Hans-Ulrich

机构信息

Department of Medical Informatics and Biomathematics, University of Münster, Domagkstr. 9, 48129 Münster, Germany.

出版信息

Int J Med Inform. 2003 Jul;70(2-3):221-8. doi: 10.1016/s1386-5056(03)00050-9.

DOI:10.1016/s1386-5056(03)00050-9
PMID:12909173
Abstract

PROBLEM

The introduction of Diagnosis Related Groups as a basis for hospital payment in Germany announced essential changes in the hospital reimbursement practice. A hospital's economical survival will depend vitally on the accuracy and completeness of the documentation of DRG relevant data like diagnosis and procedure codes. In order to enhance physicians' coding compliance, an easy-to-use interface integrating coding tasks seamlessly into clinical routine had to be developed. A generic approach should access coding and clinical guidelines from different information sources.

METHODS

Within the Electronic Medical Record (EMR) a user interface ('DRG Control Center') for all DRG relevant clinical and administrative data has been built. A comprehensive DRG-related web site gives online access to DRG grouping software and an electronic coding expert. Both components are linked together using an application supporting bi-directional communication. Other web based services like a guideline search engine can be integrated as well.

RESULTS

With the proposed method, the clinician gains quick access to context sensitive clinical guidelines for appropriate treatment of his/her patient and administrative guidelines for the adequate coding of the diagnoses and procedures. This paper describes the design and current implementation and discusses our experiences.

摘要

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