Hohnloser J H, Pürner F, Kadlec P
Medizinische Klinik, Klinikum Innenstadt, Ludwig-Maximilians-Universität, München, Germany.
Med Inform (Lond). 1996 Jul-Sep;21(3):199-206. doi: 10.3109/14639239609025357.
In medicine there is a growing need to encode medical concepts with the available standard coding systems. The coding process can be time intensive and may significantly add to daily paperwork. We have developed a generic computerized encoding tool--the PADS (patient archiving and documentation system) encoder--to ensure rapid, correct and complete coding of diagnoses in daily routine. The tool is integrated into an electronic patient record system and takes full advantage of the user friendly Macintosh interface. The tool was tested in a controlled experiment by 18 clinicians who encoded a total of 666 medical concepts in each protocol (study protocol versus control). We present data demonstrating that a computerized coding tool can produce more complete data of higher quality and save time compared with the traditional approach: (a) the number of correctly encoded medical concepts was higher (99.55% versus 86.1%); (b) coding errors were lower (0% versus 10.81%); (c) more modifier codes were encoded correctly (increase by up to 43%); (d) fewer coding errors were made (decrease by up to 43%); (e) the overall rate of correctly encoded and complete main and modifier codes was increased by 31.27% (97.29% versus 66.02%); and (f) coding time was reduced by 50%.
在医学领域，使用现有的标准编码系统对医学概念进行编码的需求日益增长。编码过程可能会耗费大量时间，并且可能会显著增加日常文书工作。我们开发了一种通用的计算机化编码工具——PADS（患者存档与文档系统）编码器，以确保在日常工作中对诊断进行快速、正确且完整的编码。该工具集成到电子病历系统中，并充分利用了用户友好的麦金塔界面。18名临床医生在一项对照实验中对该工具进行了测试，他们在每个方案（研究方案与对照）中总共编码了666个医学概念。我们展示的数据表明，与传统方法相比，计算机化编码工具能够产生质量更高、更完整的数据，并节省时间：（a）正确编码的医学概念数量更多（99.55%对86.1%）；（b）编码错误更少（0%对10.81%）；（c）正确编码的修饰码更多（最多增加43%）；（d）编码错误更少（最多减少43%）；（e）正确编码且完整的主码和修饰码的总体比例提高了31.27%（97.29%对66.02%）；（f）编码时间减少了50%。
