Hohnloser J H, Kadlec P, Puerner F
Medizinische Klinik, Ludwig-Maximilians-Universtität München, Germany.
Comput Biomed Res. 1995 Oct;28(5):393-401. doi: 10.1006/cbmr.1995.1026.
We present data from a controlled experiment with computerized browsing and encoding tool. Eighteen practicing clinicians were asked to extract medical concepts from narrative exercise cases using two approaches--traditional and computer-assisted use of ICD-9. Our results indicate that completeness of coding can be improved by up to 55% using a computerized coding tool; enforcing mandatory as opposed to optional modifier codes results in lower rates of incomplete coding (0 vs 55%), higher rates of correct coding (41 to 92%), and no change in the number of incorrect codings; and manual coding takes 100% longer than coding with the help of the computerized coding tool. Furthermore, clinicians need 59% more time for processing the whole set of codes than is suggested by the sum of individual codes. We conclude that use of a computerized coding tool can save time and result in higher quality coding However, de facto time spent on coding may be underestimated when looking at individual coding times instead of looking at the whole task of processing a clinical scenario.
我们展示了一项使用计算机化浏览和编码工具的对照实验的数据。18名执业临床医生被要求使用两种方法从叙述性练习病例中提取医学概念——传统方法和计算机辅助使用ICD - 9。我们的结果表明，使用计算机化编码工具可将编码完整性提高多达55%；强制使用修饰符代码而非可选代码会导致编码不完整率降低（0%对55%）、正确编码率提高（41%至92%），且错误编码数量不变；手动编码比借助计算机化编码工具编码所需时间长100%。此外，临床医生处理整套代码所需时间比单个代码时间总和所表明的时间多59%。我们得出结论，使用计算机化编码工具可以节省时间并产生更高质量的编码。然而，在查看单个编码时间而非处理临床场景的整个任务时，实际花费在编码上的时间可能被低估。
