Biomedical subjects

F Puerner

Publications and source records attributed to F Puerner.

4 recordsLinked to original sources

PubMed1996

Improving clinician's coded data entry through the use of an electronic patient record system: 3.5 years experience with a semiautomatic browsing and encoding tool in clinical routine.

This report presents data on clinicians' use of a browsing and encoding utility. Traditional and computerized discharge summaries during three phases of coding ICD-9 diagnoses were compared: phase I (no coding), phase II (manual coding), and phase III (computerized semiautomatic coding). Our data indicate that only 50% of all diagnoses in a discharge summary are encoded manually; using a computerized browsing and encoding utility this rate may increase by 64%; when forced to encode diagnoses manually users may "shift" as much as 84% of relevant diagnoses from the appropriate section to other sections, thereby "bypassing" the need to encode. This effect can be partially reversed by up to 41% with the computerized approach. Using a computerized encoding help can ensure completeness of encoding data (from 46 to 100%). We conclude that the use of a computerized browsing and encoding tool by clinicians can increase data quality and the volume of documented data. Mechanisms bypassing the need to code can be reversed.

Diagnosis↗

PubMed1996

Coding clinical information: analysis of clinicians using computerized coding.

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.

Disease↗

PubMed1996

Improving coded data entry by an electronic patient record system.

Data are presented on the use of a browsing and encoding utility to improve coded data entry for an electronic patient record system. Traditional and computerized discharge summaries were compared: during three phases of coding ICD-9 diagnoses phase I, no coding; phase II, manual coding, and phase III, computerized semiautomatic coding. Our data indicate that (1) only 50% of all diagnoses in a discharge summary are encoded manually; (2) using a computerized browsing and encoding utility this percentage may increase by 64%; (3) when forced to encode manually, users may "shift" as much as 84% of relevant diagnoses from the appropriate coding section to other sections thereby "bypassing" the need to encode, this was reduced by up to 41% with the computerized approach, and (4) computerized encoding can improve completeness of data encoding, from 46 to 100%. We conclude that the use of a computerized browsing and encoding tool can increase data quality and the percentage of documented data. Mechanisms bypassing the need to code can be avoided.

Data Collection↗

PubMed1995

Experiments in coding clinical information: an analysis of clinicians using a computerized coding tool.

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.

Computers↗