[Real-time intracardiac bloodflow imaging with color-coded two-dimensional Doppler technique: clinical significance of "2-D Doppler"].
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Adult↗
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Results for “Clinical Coding”
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On educating about medical data management - the other side of the electronic health record.
OBJECTIVES: To summarize background, challenges, objectives, and methods for the usability of patient data, in particular with respect to their multiple use, and to point out how to lecture medical data management. METHODS: Analyzing the literature, providing an example based on Simpson's paradox and summarizing research and education in the field of medical data management, respectively health information management (in German: Medizinische Dokumentation). RESULTS: For the multiple use of patient data, three main categories of use can be identified: patient-oriented (or casuistic) analysis, patient-group reporting, and analysis for clinical studies. A so-called documentation protocol, related to study plans in clinical trials, supports the multiple use of data from the electronic health record in order to obtain valid, interpretable results. Lectures on medical data management may contain modules on introduction, basic concepts of clinical data management and coding systems, important medical coding systems (e.g. ICD, SNOMED, TNM, UMLS), typical medical documentation systems (e.g. on patient records, clinical and epidemiological registers), utilization of clinical data management systems, planning of medical coding systems and of clinical data management systems, hospital information systems and the electronic patient record, and on data management in clinical studies. CONCLUSION: Usability, the ultimate goal of recording and managing patient data, requires, besides technical considerations, in addition appropriate methodology on medical data management, especially if data is intended to be used for multiple purposes, e.g. for patient care and quality management and clinical research. Medical data management should be taught in health and biomedical informatics programs.
Curriculum↗
Automated encoding of clinical documents based on natural language processing.
OBJECTIVE: The aim of this study was to develop a method based on natural language processing (NLP) that automatically maps an entire clinical document to codes with modifiers and to quantitatively evaluate the method. METHODS: An existing NLP system, MedLEE, was adapted to automatically generate codes. The method involves matching of structured output generated by MedLEE consisting of findings and modifiers to obtain the most specific code. Recall and precision applied to Unified Medical Language System (UMLS) coding were evaluated in two separate studies. Recall was measured using a test set of 150 randomly selected sentences, which were processed using MedLEE. Results were compared with a reference standard determined manually by seven experts. Precision was measured using a second test set of 150 randomly selected sentences from which UMLS codes were automatically generated by the method and then validated by experts. RESULTS: Recall of the system for UMLS coding of all terms was .77 (95% CI.72-.81), and for coding terms that had corresponding UMLS codes recall was .83 (.79-.87). Recall of the system for extracting all terms was .84 (.81-.88). Recall of the experts ranged from .69 to .91 for extracting terms. The precision of the system was .89 (.87-.91), and precision of the experts ranged from .61 to .91. CONCLUSION: Extraction of relevant clinical information and UMLS coding were accomplished using a method based on NLP. The method appeared to be comparable to or better than six experts. The advantage of the method is that it maps text to codes along with other related information, rendering the coded output suitable for effective retrieval.
Abstracting and Indexing↗
Variations in the myocilin gene in patients with open-angle glaucoma.
OBJECTIVE: To determine the prevalence and associated phenotype of myocilin (MYOC) coding sequence variations and a specific promoter polymorphism (MYOC.mt1) in patients with glaucoma and glaucoma suspects. METHODS: A consecutive, unselected series of 779 patients (652 with open-angle glaucoma and 127 glaucoma suspects) were recruited from a university medical center and clinically characterized. The coding sequences of the MYOC gene and the MYOC.mt1 locus in the promoter region were screened for sequence variations. We determined the prevalence of MYOC coding sequence mutations and the MYOC.mt1 promoter polymorphism. We also compared the clinical features of individuals with and without mutations and the MYOC.mt1 promoter polymorphism. RESULTS: Plausible disease-causing sequence variations (DCVs) in the MYOC gene were found in 3.0% of the entire group. Such variations were found in patients with most forms of open-angle glaucoma studied. Patients with primary open-angle glaucoma (POAG) who harbored coding sequence DCVs were clinically similar to patients without them. Patients who harbored the rarer allele of the MYOC.mt1 promoter polymorphism were no different in any measure of disease severity from those who harbored the more common allele. CONCLUSIONS: MYOC DCVs were found in approximately 3% of patients with glaucoma and glaucoma suspects. The 2 alleles of the MYOC.mt1 promoter polymorphism were equally distributed among patients with POAG and healthy control subjects. Patients with POAG who harbored the rarer allele of the MYOC.mt1 promoter polymorphism were no different from those with the more common variant in any measure of disease severity. CLINICAL RELEVANCE: Testing for the MYOC.mt1 promoter polymorphism appears to be of no value in the evaluation of patients with glaucoma.
Adult↗
SNOMED CT in multidisciplinary clinical practice--evaluation of usefulness for classification and coding of care-planning procedures.
Studies of the usefulness of SNOMED CT in everyday clinical practice have received little attention. The purpose of this study was to evaluate the usefulness of SNOMED CT in a multidisciplinary clinical setting. Another aim was to examine how well the terminology of care-planning procedures in a local development project could be mapped to SNOMED CT, and to explore the terminological surroundings in terms of superordinate concepts, subordinate concepts and coordinate concepts. A term list of 66 non-analysed types of procedures, considered necessary in the documentation of care planning, had been compiled in a local development project. The Clue-browser, version 5.5, was used to browse for matching concepts in SNOMED CT, and the degree of correspondence was assessed for each item. Of the 66 procedures, 72% corresponded completely and 22% corresponded partly to concepts in SNOMED CT. No match was found for 6% of the procedures. More subordinate concepts) were lacking in 30% of the concepts. The study showed that SNOMED CT could be mapped fairly well to care-planning procedures in a multidisciplinary setting such as advanced home health care. The terminological surroundings were extensive and stable for superordinate concepts (stem concepts), but unstable regarding subordinate concepts. SNOMED CT and the Clue-browser were feasible for choosing terminology with machine-readable codes for a specific area where there is no terminology in Swedish.
Humans↗
Rapid diagnosis of tuberculous meningitis by frequency-pulsed electron-capture gas-liquid chromatography detection of carboxylic acids in cerebrospinal fluid.
The frequency-pulsed electron-capture gas-liquid chromatography technique described previously by Brooks et al. was modified and applied to the studies of coded and routine clinical specimens. Uncentrifuged cerebrospinal fluid (2 ml) was extracted under acidic conditions, derivatized, and analyzed by frequency-pulsed electron-capture gas-liquid chromatography on large-bore fused silica polar and nonpolar capillary columns. The frequency-pulsed electron-capture gas-liquid chromatography profile of carboxylic acids (C2 through C22) along with identification of tuberculostearic acid, established by retention time comparison of derivatized tuberculostearic acid and derivatized sample extract, strongly suggests the presence of Mycobacterium tuberculosis in patients with lymphocytic meningitis. Results from 41 coded cases and 75 clinical cases showed that the frequency-pulsed electron-capture gas-liquid chromatography test had a specificity of 91% and a sensitivity of 95%.
Carboxylic Acids↗
Medicare coverage of new clinical diagnostic laboratory tests: the need for coding and payment reforms.
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Centers for Medicare and Medicaid Services, U.S.↗
Coding and reimbursement for weight loss surgery: best practice recommendations.
OBJECTIVE: To review the use and usefulness of billing codes for services related to weight loss surgery (WLS) and to examine third party reimbursement policies for these services. RESEARCH METHODS AND PROCEDURES: The Task Group carried out a systematic search of MEDLINE, the Internet, and the trade press for publications on WLS, coding, reimbursement, and coding and reimbursement policy. Twenty-eight articles were each reviewed and graded using a system based on established evidence-based models. The Massachusetts Dietetics Association provided reimbursement data for nutrition services. Three suppliers of laparoscopic WLS equipment provided summaries of coding and reimbursement information. WLS program directors were surveyed for information on use of procedure codes related to WLS. RESULTS: Recommendations focused on correcting or improving on the current lack of congruity among coding practices, reimbursement policies, and accepted clinical practice; lack of uniform coding and reimbursement data across institutions; inconsistent and/or inaccurate diagnostic and billing codes; inconsistent insurance reimbursement criteria; and inability to leverage reimbursement and coding data to track outcomes, identify best practices, and perform accurate risk-benefit analyses. DISCUSSION: Rapid changes in the prevalence of obesity, our understanding of its clinical impact, and the technologies for surgical treatment have yet to be adequately reflected in coding, coverage, and reimbursement policies. Issues identified as key to effective change include improved characterization of the risks, benefits, and costs of WLS; anticipation and monitoring of technological advances; encouragement of consistent patterns of insurance coverage; and promotion of billing codes for WLS procedures that facilitate accurate tracking of clinical use and outcomes.
Costs and Cost Analysis↗
The financial impact of an endoluminal stenting procedure.
This paper reports on a study that examined the financial impact of an endoluminal grafting procedure for an abdominal aortic aneurysm using the Mialhe Endoluminal Aortic Stentor. Clinical outcomes were not a focus of this study. The results of the study suggest that financial impacts of new clinical procedures can be understood and addressed through planning and greater liaison between clinicians, coding professionals and clinical costing staff.
Aortic Aneurysm, Abdominal↗
Standards for the electronic transfer of clinical data: progress and promises.
Data exchange standards have two components: the message format or syntax and the dictionary of codes (semantics). For many applications, message standards already have been developed. For a few kinds of clinical entities, such as drugs, these code systems (e.g., the National Drug Code) are virtually complete, but a few gaps must be filled and an agreement must be reached about the level of granularity needed. The available codes for clinical descriptors are inadequate but the National Library of Medicine's Universal Medical Language (UML) project will do much to redress this deficiency. Codes for clinical variables such as blood pressure and blood glucose which have methods, units, normal ranges, and physiologic correlates are very inadequate. CPT4 provides some of the needed codes but has huge gaps. An early effort to extend CPT4 is included in ASTM 1238. Work being done by ASTM E31.12 and the Euclides project will offer robust codes for clinical laboratory measurements. If we want to pool data from different institutions for clinical and policy research, universal codes for observations are prerequisite. And agreement of an international coding system for observation-bearing variables should be a major agenda item for standards groups in the next year. Our goal has been to standardize the communication of clinical data between clinical systems, not the systems themselves or their internal operation. In fact, standardizing the internals of clinical application could be counterproductive at the present. It would deflect energy from, and delay the spread of, CDI standards. Moreover, it gives undue attention to computer systems, rather than the data they contain. The data are the most expensive part of any data system. They are the raison d'être for such systems. Computer systems come and go. The data last forever. Yet we have been mesmerized by the computer system while ignoring its contents. As a result, most computer-stored clinical data must live like the tragic boy in the bubble. They cannot "live" outside of the computer system in which they were born. So, we find at every hospital the bizarre rituals of humans reading computer-generated reports so they can type this information in another computer. Electronic (e.g., stored clinical) data should not depend upon the internals of a particular program, language, or machine for its interpretation. The clinical data entered into one computer system should be directly available to any other computer system that now receives them through manual transcription. Data interchange standards give life to our data--independent of the source system.
Abstracting and Indexing↗
Severity of illness measures derived from the Uniform Clinical Data Set (UCDSS).
The Health Care Financing Administration (HCFA) plans to use the Uniform Clinical Data Set System (UCDSS) to collect data on hospitalized Medicare patients. This study examined the value of UCDSS data for creating severity of illness measures. UCDSS data were obtained from a study hospital and from a national data set for patients with pneumonia (n = 528) and stroke (n = 565). Models to predict length of stay or an adverse event were derived for each condition using HCFA claims data alone, UCDSS data alone, and UCDSS data supplemented with additional information also abstracted from charts. The models were derived from one set of patients and validated on another. The R2 for predicting length of stay in the validation data for the UCDSS model was 0.29 for pneumonia and 0.19 for stroke compared to R2 values from the claims model of 0.09 for stroke and 0.06 for pneumonia. UCDSS models also were better than claims models for predicting adverse events. The best UCDSS models included International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes and other information requiring clinical judgment, and were improved by adding more information on patient functional status. Some findings were more strongly associated with outcome for the study hospital than for the national data. These results suggest that UCDSS models will predict outcome much better than the claims based models currently used by HCFA for the analysis of hospitalization-related mortality; more functional status information should be added to UCDSS; and despite an extensive objective database, the most predictive UCDSS models require clinician-assigned diagnostic codes.
Aged↗
Just-in-time coding of the problem list in a clinical environment.
Clinically useful problem lists are essential to the CPR. Providing a terminology that is standardized and understood by all clinicians is a major challenge. UNMC has developed a lexicon to support their problem list. Using a just-in-time coding strategy, the lexicon is maintained and extended prospectively in a dynamic clinical environment. The terms in the lexicon are mapped to ICD-9-CM, NANDA, and SNOMED International classification schemes. Currently, the lexicon contains 12,000 terms. This process of development and maintenance of the lexicon is described.
Diagnosis-Related Groups↗
Review paper: coding systems in health care.
Computer-based patient data which are represented in a coded form have a variety of uses, including direct patient care, statistical reporting, automated decision support, and clinical research. No standard exists which supports all of these functions. Abstracting coding systems, such as ICD, CPT, DRGs and MeSH fail to provide adequate detail, forcing application developers to create their own coding schemes for systems. Some of these schemes have been put forward as possible standards, but they have not been widely accepted. This paper reviews existing schemes used for abstracting, electronic record systems, and comprehensive coding. It also discusses the remaining impediments to acceptance of standards and the current efforts to overcome them, including SNOMED, the Gabrieli Medical Nomenclature, the Read Clinical Codes, GALEN, and the Unified Medical Language System (UMLS).
Abstracting and Indexing↗
MMPI and MMPI-2 profile and code type congruence in a brain-injured sample.
Examined the comparability of the Minnesota Multiphasic Personality Inventory (MMPI) and Minnesota Multiphasic Personality Inventory-2 (MMPI-2) in a sample of brain-injured patients. There were 53 patients (36 males, 17 females; M age = 27.25, SD = 11.45), the majority of whom had suffered a closed-head injury. The MMPI-2 and MMPI items were administered in the context of an extensive neuropsychological examination. Results revealed a lack of congruence between the MMPI and MMPI-2 when the entire profile was compared using profile analysis. Analyses of code types found congruence to be high for single point elevations but modest for 2-point code types. The degree of congruence appears related to the nature of analysis, and for clinical purposes, code-type interpretation may be most relevant. These results provide some support for the congruence of the MMPI and MMPI-2 for brain-injured patients, but particular caution should be exercised in the interpretation of 2-point code types.
Adult↗
Cancers of the upper aerodigestive tract in Ontario, Canada, and the United States.
BACKGROUND: Squamous cancers of the upper aerodigestive tract (UADT) are related to the use of tobacco and/or alcohol, and in North America they are more common among the poor. They are usually locoregionally confined at diagnosis, and local treatment with surgery and/or radiation therapy is often curative. This study compares the incidence and survival of this group of diseases in Canada and the U.S., two North American neighbors with many cultural similarities but significant differences in their health care and social programs. METHODS: To describe and compare the case mix, incidence, and outcome of squamous cancers of the UADT in Ontario, Canada, and the U.S., we used the Ontario Cancer Registry (OCR) and the Surveillance, Epidemiology, and End Results (SEER) registries in the U.S. to identify all cases of cancer with International Classification of Disease (ICD) codes 141, 143-9, 160-1, and a subset of 140, which were diagnosed between 1982 and 1994. ICD-O histology codes were placed into clinically relevant groupings, and ICD-9 site codes were grouped into sites as defined by the International Union Against Cancer and the American Joint Committee on Cancer. Age-adjusted incidence rates were calculated for each site. For the SEER registry, race specific incidence rates were also calculated. Observed and expected survival were plotted by site and registry, and from these, relative survival was calculated. Survival was compared during the first 5 years after diagnosis and during the next 5 years among patients who had survived the first 5 years. RESULTS: Of the 16,577 and 42,990 cases identified in the OCR and SEER registries, respectively, squamous cancer was by far the most common histology (94.1% in OCR, 94.6% in SEER) and will form the main subject of this report. The distribution of squamous cancers by site, subsite, age, and gender were remarkably similar in the two populations. Overall, the incidence was about 17% higher in the U.S. than in Ontario, and this difference was seen for all sites except the nasopharynx, which was more common in Ontario. The higher incidence in the U.S. in part reflects the much higher rate for African Americans than for Americans of other ethnic backgrounds. During the first 5 years after diagnosis, when most deaths from UADT cancer occur, there was a significant relative survival difference in favor of the U.S. for cancer of the supraglottis, and in favor of Ontario for cancer of the oral cavity. There was a nonsignificant trend in favor of Ontario for cancer of the nasopharynx. Within the SEER population, for all sites except the nasopharynx, 5-year relative survival was considerably worse for African Americans than for Americans of other ethnic backgrounds. Examination of survival beyond 5 years after diagnosis for patients who had survived the first 5 years revealed that for all sites, the observed survival continued to diverge markedly from the expected survival. The excess mortality ranged from less than 20% for glottic and nasopharyngeal cancers to about 30-40% for oropharyngeal and supraglottic cancers. CONCLUSIONS: Despite remarkable similarities in case mix between the two countries, UADT cancers were more frequent in the SEER population of the U.S. than in Ontario, and this was partly attributable to the much higher incidence among African Americans. Significant differences between the registries in 5-year survival were seen for several sites. African Americans with UADT cancers had much worse prognoses than did Americans of other ethnic backgrounds. Patients who survive their UADT cancer remain at a higher-than-expected risk of death even after they have been cured.
Disease-Free Survival↗
Using an information warehouse to screen patients for clinical trials: a prototype.
Success of a clinical trial recruitment process for drug discovery and new treatments depends on screening and identifying eligible patients in a timely manner. This can be a complex and tedious process that in many instances requires a research nurse to manually track patients that may be eligible. At the Ohio State University Medical Center (OSUMC) we have developed a web-based functional prototype that uses the data stored in the Information Warehouse (IW) to screen patients that meet the eligibility criteria for clinical trials. Using this prototype, a researcher can apply a set of inclusion/exclusion criteria pertinent to a research protocol and instantly find patients that may qualify for the clinical trial without revealing their identity. A researcher has access to all detailed historical clinical information such as lab results, diagnosis codes, pathology reports and clinical notes.
Clinical Protocols↗
Comparison of coding of heart failure and comorbidities in administrative and clinical data for use in outcomes research.
BACKGROUND: Despite the potential usefulness of administrative databases for evaluating outcomes, coding of heart failure and associated comorbidities have not been definitively compared with clinical data. OBJECTIVE: To compare the predictive value of heart failure diagnoses and secondary conditions identified in a large administrative database with chart-based records. METHODS: The authors studied 1808 patient records sampled from 14 acute care hospitals and compared clinically recorded data with administrative records from the Canadian Institute for Health Information. The impact of comorbidity coding in the administrative data set according to the Charlson classification was examined in models of 30-day mortality. RESULTS: The positive predictive value (PPV) of a primary diagnosis ICD-9 428 was 94.3% using the Framingham criteria and 88.6% using criteria previously validated with pulmonary capillary wedge pressure. There was reduced prevalence of secondary comorbid conditions in administrative data in comparison with clinical chart data. The specificities and PPV/negative predictive values of administratively identified index comorbidities were high. The sensitivities of index comorbidities were low, but were enhanced by examination of hospitalizations within 1 year prior to the index heart failure admission. Using information from prior hospitalizations modestly enhanced 30-day mortality model performance; however, the odds ratio point estimates of the index and enhanced administrative data sets were consistent with the clinical model. CONCLUSION: The ICD-9 428 primary diagnosis is highly predictive of heart failure using clinical criteria. Examination of hospitalization data up to 1 year prior to the index admission improves comorbidity detection and may provide enhancements to future studies of heart failure mortality.
Aged↗
Ill-defined and multiple causes on death certificates--a study of misclassification in mortality statistics.
Biases can distort, limit or inhibit the value of mortality data as an epidemiological re source. From 9500 deaths occurring in Naples (Italy during 1994, a random sample of 372 death certificates reporting ill-defined causes and multiple causes of death was extracted. The code for the underlying cause on the death certificate (assigned code) was compared with the cause reattributed with the aid of interview of the certifying physician or clinical records (modified code). The aim was to investigate the extent of misclassification of 'underlying cause' in deaths attributed to ill-defined and/or multiple causes and the shortcomings in the ICD-IX. Ill-defined underlying causes of death (7.0% of death certificates) were cardiovascular diseases, tumours with no specified site or nature, symptoms, signs, ill-defined conditions and senility. There was disagreement between the initially assigned code and the modified code in 53.8% of ill-defined underlying causes; discordance was high for the certificates filled in by the family physician. Multiple causes of death were observed in 23.6% of certificates; of these 59.2% concerned subjects aged 75 years and over at death. Diabetes was always listed in association with other pathologies but neoplasms and traumas were generally listed alone. Disagreement between codes occurred in 48 (54.5%) certificates indicating multiple causes. In 10 of them, death was established as due to a concurrence of causes. As regards ill-defined causes of death, the authors concluded that specific training on certifying procedures would be insufficient on their own; the physician should be made aware that certification is a fundamental requirement for building up epidemiological data. Evidence-based educational interventions are needed. As regards multiple causes of death, multicausal analysis may be indicated for deaths due to a concurrence of causes.
Age Factors↗