Kortüm Karsten, Hirneiß Christoph, Müller Michael, Babenko Alexander, Kampik Anselm, Kreutzer Thomas C
University Eye Hospital, Ludwig-Maximilians-University, Mathildenstrasse, 8, D-80336, Munich, Germany.
BMC Med Inform Decis Mak. 2016 Jul 26;16:100. doi: 10.1186/s12911-016-0340-1.
A specific Electronic Health Record (EHR) for ophthalmology was introduced in an academic center in Germany. As diagnoses coding corresponding to the International Classification of Diseases Version 10 (ICD-10) is mandatory for billing reasons in Germany, we analyzed whether a change occurred in the diversity and number of diagnoses after the EHR introduction. The number of patients was also analyzed. Proper diagnoses coding is of the utmost importance for further data analysis or billing.
Graphical User Interfaces (GUIs) were created by using Advanced Business Application Programming language in EHR "i.s.h.med." Development of an EHR was conducted in close collaboration between physicians and software engineers. ICD-10 coding was implemented by using a "hit list" and a search engine for diagnoses. An observational analysis of a 6-month period prior to and after the introduction of an ophthalmological specific EHR was conducted by investigating the diversity and number of diagnoses in various ophthalmological disease categories and the number of patient consultations.
During the introduction of a specific ophthalmological EHR, we observed a significant increase in the emergency department cases (323.9 vs. 359.9 cases per week), possibly related to documentation requirements. The number of scheduled outpatients didn't change significantly (355.12 vs. 360.24 cases per week). The variety of diagnoses also changed: on average, 156.2 different diagnoses were made per week throughout our hospital before the EHR launch, compared to 186.8 different diagnoses per week thereafter (p < 0.05). Additionally, a significantly higher number of diagnoses per case and per week were observed in both emergency and subspecialty outpatient clinics (1.15 vs. 1.22 and 1.10 vs. 1.47, respectively).
An optimized EHR was created for ophthalmological needs and for simplified ICD-10 coding. The implementation of digital patient recording increased the diversity of the diagnoses used per case as well as the number of diagnoses coded per case. A general limitation to date is the suboptimal precision of ICD-10 coding in ophthalmology. Correct coding is of utmost importance for future data analysis.
德国一家学术中心引入了特定的眼科电子健康记录（EHR）。由于在德国出于计费原因，对应国际疾病分类第10版（ICD - 10）的诊断编码是强制性的，我们分析了引入EHR后诊断的多样性和数量是否发生了变化。还对患者数量进行了分析。正确的诊断编码对于进一步的数据分析或计费至关重要。
通过在EHR“i.s.h.med.”中使用高级商业应用编程语言创建图形用户界面（GUI）。EHR的开发是在医生和软件工程师密切合作下进行的。ICD - 10编码通过使用“命中列表”和诊断搜索引擎来实现。通过调查各种眼科疾病类别的诊断多样性和数量以及患者会诊次数，对引入眼科特定EHR之前和之后的6个月期间进行了观察性分析。
在引入特定的眼科EHR期间，我们观察到急诊科病例显著增加（每周323.9例对359.9例），这可能与文档要求有关。预约门诊患者数量没有显著变化（每周355.12例对360.24例）。诊断的多样性也发生了变化：在我们医院，EHR推出前每周平均做出156.2种不同诊断，之后为每周186.8种不同诊断（p < 0.05）。此外，在急诊科和专科门诊中，每例和每周观察到的诊断数量均显著增加（分别为1.15对1.22以及1.10对1.47）。
针对眼科需求和简化ICD - 10编码创建了优化的EHR。数字患者记录的实施增加了每例使用的诊断多样性以及每例编码的诊断数量。迄今为止的一个普遍限制是眼科中ICD - 10编码的精度欠佳。正确编码对于未来的数据分析至关重要。
