Hohnloser J H, Kadlec P, Puerner F
Medizinische Klinik, Klinikum Innenstadt, Ludwig-Maximilians-University, Munich, Germany.
Methods Inf Med. 1996 Jun;35(2):104-7.
Data are presented of a controlled experiment with a computerized browsing and encoding tool. Eighteen practicing clinicians extracted medical concepts from two narrative exercise cases using two approaches, traditional and computer-assisted use of ICD-9. Our results indicate that by using a computerized coding tool the completeness of coding can be improved by up to 55%, that by enforcing mandatory as opposed to optional modifier codes results in lower rates of incomplete coding (0 and 55%, respectively), higher rates of correct coding (41 to 92%) and no change in incorrect code, and that manual coding takes twice as long than coding with the help of the computerized coding tool. Clinicians need 59% more time for processing the whole set of codes than is suggested by the sum of individual codes. We conclude that the use of a computerized coding tool can save time and result in higher quality codes. However, the real time spent on coding may be underestimated when looking at individual coding times, instead of the whole task of processing a clinical scenario.
本文展示了一项关于计算机化浏览和编码工具的对照实验数据。18名执业临床医生使用两种方法（传统方法和计算机辅助使用ICD-9）从两个叙述性练习病例中提取医学概念。我们的结果表明，通过使用计算机化编码工具，编码的完整性可提高多达55%；强制使用修饰符代码而非可选代码，可降低不完整编码率（分别为0和55%），提高正确编码率（41%至92%），且错误编码无变化；手动编码所需时间是借助计算机化编码工具编码的两倍。临床医生处理整套代码所需时间比各个代码处理时间之和所建议的时间多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代码。然而，查看单个编码时间而非处理临床场景的整个任务时，实际编码时间可能被低估。
