Clinical Archive Department, American British Cowdray Medical Center, CDMX, Mexico.
Quallity Control Department, American British Cowdray Medical Center, CDMX, Mexico.
Int J Med Inform. 2019 Sep;129:248-252. doi: 10.1016/j.ijmedinf.2019.06.019. Epub 2019 Jun 22.
The American British Cowdray Medical Center is a private healthcare institution in Mexico City. One of the many tools that we use and help us to achieve a high standard of quality and recognition worldwide is the clinical coding and Diagnosis Related Groups (DRG). To help the readers to improve the process of clinical coding, we will share the challenges, changes and different applications of the generation of DRG in the private healthcare institution.
A retrospective, descriptive study to demonstrate the changes on the process of coding and measure the outcome of clinical coding, precision of data and better quality in the generations of DRGs. Initially, less than 2 diagnoses and 1 procedure were coded per discharge, using partial medical records. By the second half of 2007, a different coding procedure was implemented, and the complete medical records started being used; also, comorbid conditions were included in coding. Nowadays, the average number of coded diagnoses is 5.4 and the average number of coded procedures is 4.2, with a coding error rate of 0.68% and a DRG outliers' rate of 0.45%.
While many countries use DRG for reimbursement, we exploit the clinical data registration and the DRGs for the economic and organizational. Through more efficient and accurate coding, DRGs are useful within the institution to generate indicators on resources, cost, length of stay and goals for each service. Having better quality clinical data has allowed for improved service line management, which has translated into patient-oriented services. Prospective studies are necessary to keep evaluating in a objective way the utilities of the DRG in healthcare private institutions.
美国英联邦考德雷医学中心是墨西哥城的一家私立医疗机构。我们使用的众多工具之一，帮助我们在全球范围内达到高标准的质量和认可，是临床编码和诊断相关组 (DRG)。为了帮助读者提高临床编码过程，我们将分享在私立医疗机构中生成 DRG 的挑战、变化和不同应用。
一项回顾性、描述性研究，旨在展示编码过程的变化，并衡量临床编码、数据精度和生成 DRGs 质量的结果。最初，每次出院时编码的诊断和手术不到 2 个，仅使用部分病历。到 2007 年下半年，实施了不同的编码程序，开始使用完整的病历；同时，也将合并症纳入编码。如今，平均编码诊断数为 5.4，平均编码手术数为 4.2，编码错误率为 0.68%，DRG 异常值率为 0.45%。
虽然许多国家将 DRG 用于报销，但我们利用临床数据登记和 DRG 进行经济和组织方面的管理。通过更高效和准确的编码，DRG 在机构内对于生成资源、成本、住院时间和每个服务目标的指标非常有用。更好的临床数据质量使得服务线管理得到改善，从而转化为以患者为中心的服务。需要进行前瞻性研究，以客观地评估 DRG 在私立医疗机构中的效用。
