SEARCH · PubMed Health

Results for “Clinical Coding”

Explore indexed PubMed citations for clinical trials, systematic reviews and public health research. Read source abstracts and follow each citation to its original PubMed record.

Quote a phrase for an exact phrase match. Source license links do not imply unrestricted reuse.

At least 613 records · Page 34Linked to original sources

PubMed1989

Immunoreactivity of tissue plasminogen activator and of its inhibitor complexes. Biochemical and multicenter validation of a two site immunosorbent assay.

An enzyme linked immunosorbent assay (ELISA) based on goat polyclonal antibodies against human tissue plasminogen activator (tPA) was evaluated. The relative immunoreactivity of tPA in free form and tPA in complex with inhibitors was estimated by ELISA and found to be 100, 74, 94, 92 and 81% for free tPA and tPA in complex with PAI-1, PAI-2, alpha 2-antiplasmin and C1-inhibitor, respectively. Addition of tPA to PAI-1 rich plasma resulted in rapid and total loss of tPA activity without detectable loss of ELISA response, indicating an immunoreactivity of tPA in tPA/PAI-1 complex of about 100%. Three different treatments of citrated plasma samples (acidification/reneutralization, addition of 5 mM EDTA or of 0.5 M lysine) prior to determination by ELISA all resulted in increased tPA levels. The fact that the increase was equally large in all three cases along with good analytical recovery of tPA added to plasma, supported the notion that all tPA antigen present in plasma samples is measured by the ELISA. Analysis by ELISA of fractions obtained by gel filtration of plasma from a patient undergoing tPA treatment identified tPA/inhibitor complexes and free tPA but no low molecular weight degradation products of tPA. Determinations of tPA antigen were made at seven French clinical laboratories on coded and randomized plasma samples with known tPA antigen content. For undiluted samples there was no significant difference between the tPA levels found and those known to be present. The between-assay coefficient of variation was 7 to 10%. In conclusion, the ELISA appeared suited for determination of total tPA antigen in human plasma samples.

Antigen-Antibody Reactions↗

PubMed2001

Computerized assessment of complications after colorectal surgery: is it valid?

PURPOSE: Historically, complication rates after colorectal surgery have been stratified by disease process, type of operation, or anesthesia risk derived after an intensive review of the medical record. Newer computer applications purport to shorten this process and predict the probability of postoperative complications by distinguishing them from comorbidities that are commingled on uniform discharge codes. We analyzed CaduCIS software, which uses discharge codes, to determine whether its predictions of comorbidity and complications were comparable to what was interpreted on the medical record. METHODS: Two-hundred seventy patients were analyzed according to the principal and secondary diagnoses coded on discharge. Coding inaccuracies of clinical occurrences were identified by physician review of each medical record. The actual incidences of 17 common preoperative comorbidities and 11 postoperative complications were compared with those predicted by CaduCIS. RESULTS: The CaduCIS-predicted distribution of comorbidities was similar to the actual occurrences in 15 of 17 categories. The overall incidence of complications obtained by physician (actual) review was 47 percent, compared with 46 percent predicted by CaduCIS. However, there was a statistical difference between the CaduCIS-predicted and the actual complication rates in 5 of the 11 categories. The most common preoperative comorbidity and complication was cardiopulmonary (47 percent and 28 percent, respectively). CONCLUSION: The overall complication rate interpreted from the medical record (47 percent) was accurately predicted by CaduCIS (46 percent). Predictions of 5 of 11 individual complications were underestimated because of charting and coding inaccuracies, not because of computerized errors. Because uniform discharge coding of commingled comorbidity and complications is increasingly used to rapidly compute surgical outcomes, colon and rectal surgeons need to ensure compatibility of the actual and coded medical records.

Comorbidity↗

PubMedDate not supplied

Surgical treatment of papillary and follicular thyroid carcinoma.

There is limited clinical information about the prognostic factors in survival and distant metastasis for well differentiated thyroid cancer in Chinese patients. Pitfalls were noted when applying the results of published studies to another population. In order to realize the differences of these factors between different areas, we retrospectively analyzed the data of 569 papillary or follicular thyroid carcinoma patients who received their primary treatment at the Chang Gung Memorial Hospital during the period from January 1979 to June 1994. Actuarial survival rates were calculated by the Kaplan-Meier method. For the analysis of prognostic variables, 14 clinical parameters were coded into the computer for the univariate and multivariate analyses. Multivariate analysis was performed to assess the independent effect of these variables using the Cox model. Among these cases, there were 466 papillary thyroid carcinoma (81.9%), 103 cases of follicular thyroid carcinoma (18.1%). The subjects included 440 female patients with mean age of 38.8 +/- 14.4 years and 129 male patients with the mean age of 44.7 +/- 14.4 years (p = 0.0001). Most of the cases received total thyroidectomy treatment after the diagnosis was confirmed by a frozen section during the operation. In the follow-up period, 30 (5.3%) patients died of metastatic thyroid cancer. The one year Greenwood survival probability after the disease diagnosed in papillary and follicular thyroid carcinomas was 0.986 and 0.909 respectively. Using a log-rank univariate analysis, survival was significantly associated with the histological type of primary tumors, age, clinical staging, post-operative 131I pattern, tumor size, postoperative serum thyroglobulin (Tg) level and post-operative X-ray findings. Tumor size larger than 2.5 centimeters could influence both the survival and distant metastases of these well differentiated thyroid cancer patients. In the Cox multivariate regression analysis, the combination factors that gave the best prognostic values were the association of distant metastasis (0.005), age (p = 0.027), and one month postoperative serum Tg level (p = 0.042). Well differentiated thyroid cancer is not an unusual disease in Taiwan. In this limited period of follow-up study, distant metastasis at the time of surgery, the patients' age and one month post-operative serum Tg level may serve as the prognostic factors for the well differentiated thyroid cancer patients.

Adenocarcinoma, Follicular↗

PubMed1990

[Imaging of penile vascular anastomoses using color-coded Doppler ultrasound: comparison with CW Doppler ultrasound and clinical aspects].

In fourteen patients undergoing surgical revascularization (11 with Hauri's, three with Virag's anastomosis) because of erectile dysfunction, the patency of vascular anastomosis was evaluated and visualized by color-coded-Doppler sonography (CCDS). Results were compared with continuous-wave Doppler (CWD) and clinical data. CCDS proved to be superior to CWD with regard to assessment of flow in the penile vessels and to applicability. Strength and direction of flow can be judged visually. Therefore, the nature of the imaged vessel (artery or vein, deep or dorsal artery) can be differentiated. There is a good correlation of CCDS and CWD in their evaluation of the patency of the anastomosis. CCDS showed higher accuracy in detecting deep cavernosal arteries.

Adult↗

PubMed2003

Quality improvement and tissue-type plasminogen activator for acute ischemic stroke: a Cleveland update.

BACKGROUND AND PURPOSE: A systematic audit of intravenous tissue-type plasminogen activator (tPA) use and stroke outcomes in Cleveland, Ohio, during 1997-1998 demonstrated higher rates of symptomatic intracranial hemorrhage (ICH) than reported in the National Institute of Neurological Disorders and Stroke (NINDS) trial. We now report updated results of intravenous tPA use in the Cleveland Clinic Health System (CCHS). METHODS: A stroke quality improvement program was initiated in the 9-hospital CCHS in 1999. A retrospective chart review for all stroke patients with primary International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes 434 and 436 admitted to the 9 hospitals from June 1999 to June 2000 was used to determine outcomes of patients treated with intravenous tPA. RESULTS: Intravenous tPA was given to 18.8% of patients arriving within 3 hours of symptom onset. Protocol deviations occurred in 19.1% of patients given intravenous tPA. The symptomatic ICH rate was 6.4%. CONCLUSIONS: Since 1997, intravenous tPA use has increased, while the rates of symptomatic ICH and protocol deviations have decreased in the CCHS. The CCHS symptomatic ICH rate is now similar to that reported in the NINDS trial. These improvements occurred after initiation of a stroke quality improvement program.

Acute Disease↗

PubMedDate not supplied

Automated mapping of observation codes using extensional definitions.

OBJECTIVE: To create "extensional definitions" of laboratory codes from derived characteristics of coded values in a clinical database and then use these definitions in the automated mapping of codes between disparate facilities. DESIGN: Repository data for two laboratory facilities in the Intermountain Health Care system were analyzed to create extensional definitions for the local codes of each facility. These definitions were then matched using automated matching software to create mappings between the shared local codes. The results were compared with the mappings of the vocabulary developers. MEASUREMENTS: The number of correct matches and the size of the match group were recorded. A match was considered correct if the corresponding codes from each facility were included in the group. The group size was defined as the total number of codes in the match group (e.g., a one-to-one mapping is a group size of two). RESULTS: Of the matches generated by the automated matching software, 81 percent were correct. The average group size was 2.4. There were a total of 328 possible matches in the data set, and 75 percent of these were correctly identified. CONCLUSIONS: Extensional definitions for local codes created from repository data can be utilized to automatically map codes from disparate systems. This approach, if generalized to other systems, can reduce the effort required to map one system to another while increasing mapping consistency.

Algorithms↗

PubMed2003

Laparoscopic vs open colectomy: outcomes comparison based on large nationwide databases.

HYPOTHESIS: Laparoscopic colectomy has significant advantages over open colectomy in the treatment of diverticular disease with respect to the length of hospital stay, routine hospital discharge, and postoperative morbidity and mortality. DESIGN: Retrospective secondary data analysis. PATIENTS AND SETTING: Patients with primary International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes for laparoscopic (709 patients [3.8%]) and open sigmoid resection (17 735 patients [96.2%]) were selected from the 1998, 1999, and 2000 Nationwide Inpatient Samples. These databases represent 20% stratified probability samples of all US community hospital discharges. Sampling weights were used to allow generalization of the study findings to the overall US population. Multiple linear and logistic regression analyses were performed to assess the risk-adjusted association between the surgery type and patient outcomes. MAIN OUTCOME MEASURES: Length of hospital stay, in-hospital complications, in-hospital mortality, and the rate of routine discharge. RESULTS: The patients had a mean age of 59.8 years; they were preponderantly white (89.1%) and female (54.0%). After adjusting for other covariates, laparoscopic sigmoidectomy was associated with a shorter mean hospital stay (laparoscopic sigmoidectomy vs open sigmoidectomy, 7.47 vs 9.37 days; P<.001), fewer gastrointestinal tract complications (odds ratio, 0.57; 95% confidence interval, 0.35-0.93; P =.03), a lower overall complication rate (odds ratio, 0.64; 95% confidence interval, 0.47-0.88; P =.007), and a higher routine hospital discharge rate (odds ratio, 2.21; 95% confidence interval, 1.51-3.21; P<.001). CONCLUSION: Laparoscopic sigmoid resection in patients with diverticular disease has statistically and clinically significant advantages over open sigmoid resection with respect to the length of hospital stay, rate of routine hospital discharge, and postoperative in-hospital morbidity.

Age Distribution↗

PubMed1996

Detection of genes coding for extended-spectrum SHV beta-lactamases in clinical isolates by a molecular genetic method, and comparison with the E test.

A highly sensitive and specific method, termed PCR/NheI, for the detection of genes coding for SHV extended-spectrum beta-lactamases (ESBL) in clinical isolates is presented. It is based on polymerase chain reaction (PCR) amplification of the blaSHV genes, followed by restriction with NheI. Due to the glycine (positive 238) (SHV-non-ESBL)-->serine (position 238) (SHV-ESBL) mutation, only PCR fragments from the genes coding for SHV-ESBLs were cleaved. A commercially available test for ESBLs, the E test ESBL, identified 52% of our 29 clinical isolates carrying blaSHV-ESBL genes as ESBL producers.

Base Sequence↗

PubMed2002

The effect of zanamivir treatment on influenza complications: a retrospective cohort study.

BACKGROUND: Complications of influenza are a major cause of morbidity and mortality during the influenza season. Clinical trials of zanamivir have reported a reduced incidence of influenza complications among high-risk patients. OBJECTIVES: This retrospective study sought to determine whether the use of zanamivir lowers the risk of acute influenza complications in a broader population, based on an analysis of claims data from a large managed care organization. METHODS: Medical and pharmacy health insurance claims data from October 1, 1999, through April 30, 2000, were compiled for UnitedHealthcare members in 19 states. All patients with a diagnosis of influenza (International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic code 487.xx) associated with a physician visit were identified. From these, all patients were selected who had received zanamivir on the same day as the diagnosis of influenza. The propensity score matching technique was used to identify a comparison group with similar health service utilization and comorbidities who received a diagnosis of influenza but no antiviral therapy. Follow-up started the day after the influenza diagnosis and continued for 21 days. RESULTS: From the 43,741 patients originally identified, 2341 were selected who received a simultaneous diagnosis of influenza and a prescription for zanamivir. The untreated comparator group numbered 2337. Fewer zanamivir patients than untreated patients were hospitalized for complications, and the absolute risks were low (0.6% and 1.0%, respectively; risk ratio [RR], 0.58; 95% CI, 0.30-1.12). Zanamivir-treated patients had an excess of outpatient visits (16.9% vs 14.5%; RR, 1.16; 95% CI, 1.02-1.33) and antibiotic use (16.3% vs 14.8%; RR, 1.10; 95% CI, 0.97-1.26), although the RRs were modest. CONCLUSIONS: In the setting of a large managed care plan, patterns of influenza complications were similar in zanamivir-treated and untreated patients with a diagnosis of influenza. The results of this study are in contrast to those of published clinical trials reporting a reduction in the risk of influenza complications in zanamivir-treated patients.

Adolescent↗

PubMed2003

Identifying acute myocardial infarction: effects on treatment and mortality, and implications for National Service Framework audit.

BACKGROUND: The National Service Framework (NSF) for Coronary Heart Disease requires annual clinical audit of the care of patients with myocardial infarction, with little guidance on how to achieve these standards and monitor practice. AIM: To assess which method of identification of acute myocardial infarction (AMI) cases is most suitable for NSF audit, and to determine the effect of the definition of AMI on the assessment of quality of care. DESIGN: Observational study. METHODS: Over a 3-month period, 2153 consecutive patients from 20 hospitals across the Yorkshire region, with confirmed AMI, were identified from coronary care registers, biochemistry records and hospital coding systems. The sensitivity and positive predictive value of AMI patient identification using clinical coding, biochemistry and coronary care registers were compared to a 'gold standard' (the combination of all three methods). RESULTS: Of 3685 possible cases of AMI singled out by one or more methods, 2153 patients were identified as having a final diagnosis of AMI. Hospital coding revealed 1668 (77.5%) cases, with a demographic profile similar to that of the total cohort. Secondary preventative measures required for inclusion in NSF were also of broadly similar distribution. The sensitivities and positive predictive values for patient identification were substantially less in the cohorts identified through biochemistry and coronary care unit register. Patients fulfilling WHO criteria (n=1391) had a 30-day mortality of 15.9%, vs. 24.2% for the total cohort. DISCUSSION: Hospital coding misses a substantial proportion (22.5%) of AMI cases, but without any apparent systematic bias, and thus provides a suitably representative and robust basis for NSF-related audit. Better still would be the routine use of multiple methods of case identification.

Aged↗

PubMed2004

Identification and recall of children with chronic medical conditions for influenza vaccination.

OBJECTIVES: Despite long-standing recommendations to provide annual influenza vaccination to children with chronic medical conditions, immunization rates are <10% in most primary care settings. Many obstacles impede implementation of these recommendations, including the challenge of identifying targeted children and the need to immunize yearly in a short time interval. The objective of this study was to assess the accuracy of billing data for identifying children who have high-risk conditions (HRCs) and need influenza vaccination and 2) to evaluate the efficacy of reminder/recall for children with HRCs. METHODS: The study was conducted in 4 private pediatric practices in metropolitan Denver, Colorado, that share a computerized billing system and also participate in an immunization registry. For all children aged 6 to 72 months, registry records were linked with the billing database. Patients with >or=1 encounters for an HRC in the previous 24 months were selected, with HRCs identified from International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic codes. Using medical records as the "gold standard," we reviewed 327 randomly selected records to determine the sensitivity, specificity, and accuracy of billing data for identifying HRCs. For children with an HRC, we then conducted a randomized, controlled trial of reminder/recall for influenza vaccination. The primary outcome of the recall trial was receipt of influenza vaccine. RESULTS: Billing data had a sensitivity of 72% (95% confidence interval [CI]: 48%-95%), specificity of 95% (95% CI: 90%-100%), and overall accuracy of 90% (95% CI: 84%-96%) in determining which children had an HRC. Of the 17,273 patients aged 6 to 72 months, 2007 had >or=1 HRCs (12% overall; range: 9%-14% per practice). Asthma/reactive airways disease accounted for 87% of all HRCs. Reminder/recall significantly increased influenza immunization in children with HRCs, with a vaccination rate of 42% in those recalled, compared with 25% in control subjects. Recalled subjects were more likely to have an office visit (68% vs 60%) and less likely to have a missed opportunity to immunize (28% vs 37%) compared with control subjects. CONCLUSIONS: Diagnosis-based billing data accurately identified children who had HRCs and needed annual influenza vaccination, and registry-driven reminder/recall significantly increased influenza immunization in targeted children.

Child↗

PubMed1995

Code status decision-making in a nursing home population: processes and outcomes.

OBJECTIVES: To examine the clinical utility of prehospital code status discussions in a nursing home (NH) setting and the health care outcomes of the decisions made. Also to identify patient factors and other variables associated with these decisions. DESIGN: Retrospective uncontrolled observational study carried out through record review. SETTING: A single skilled-level teaching NH and its affiliated university hospital. PATIENTS: All of the 350 individuals who resided at the NH during a 2-year period. MAIN RESULTS: Code status decisions were routinely sought through discussion involving primary care physician/social worker teams and residents or surrogates of demented patients. Choices were made for 80% of the NH residents, most (73%) by surrogates and most (80%) for do-not-resuscitate (DNR) orders, usually within 10 weeks of NH admission. Neither short-term measures of NH care intensity nor hospital use changed after a DNR decision. Most (80%) hospital transfer records included code status documentation. At the NH, both the likelihood of decisions and their directions were associated with involvement by specific physician/social worker teams. Additionally, a dementia diagnosis, white race, and older age were associated with a nursing home DNR decision. At the hospital, a DNR order was associated with white race, the presence of nursing home DNR documentation in the transfer records, hospital attending care by certain NH physicians, and a terminal hospital stay. Hospital inpatient medical and surgical therapy use, except for intensive care procedures, was similar for DNR and non-DNR inpatients. Residents with DNR orders had a higher mortality rate, yet most survived at least 1 year after the order. In the short term, a DNR order had no impact on measured health care resource consumption, but, for those in the final months of life, in-patient hospital use was less for the DNR group, and most of these died at the nursing home. CONCLUSIONS: Prehospital code status decisions can be made effectively within the NH setting. Outside of medical intensive care, DNR orders have no impact on NH and hospital care intensity in the short term. In the final 6 months of life, however, hospital use is less for the DNR subgroup.

Advance Directives↗

PubMed2004

Increased survival among severe trauma patients: the impact of a national trauma system.

HYPOTHESIS: The survival of severe trauma patients is affected by the implementation of a national trauma system, which brought about developments both at the hospital and prehospital levels during the past decade. DESIGN: A retrospective cohort study of all severely injured patients (Injury Severity Score >16) recorded in the Israeli National Trauma Registry at all level I trauma centers in Israel from January 1, 1997, to December 31, 2001. Inpatient death rates were examined overall and by subgroups. SETTING: The National Trauma Registry includes trauma (International Statistical Classification of Diseases, 9th Revision, Clinical Modification diagnosis codes 800-959) hospitalizations, patients who were transferred to or from other hospitals, and those who died in the emergency department. It excludes patients who were dead on arrival, discharged following treatment in the emergency department, and patients who do not fall into the definition of trauma. Main Outcome Measure Inpatient death. RESULTS: Seven thousand four hundred twenty-three severe trauma patients were recorded. Inpatient death rates decreased significantly from 21.6% in 1997 to 14.7% in 2001. The odds ratios of mortality in 1998 through 2001 vs 1997, adjusted for year, age, sex, penetrating injury, and severity of injury (Injury Severity Score >25), were 0.92, 0.89, 0.70, and 0.65, respectively, confirming the downward trend. CONCLUSIONS: A steady significant reduction in the inpatient death rate of severe trauma patients hospitalized at all level I trauma centers in Israel between 1997 and 2001 was observed. Although a single factor that explains the reduction was not identified, it is evident that the establishment of the trauma system brought about a significant decrease in mortality. We believe that integrated cooperation of various components of the national trauma system in Israel across the years may explain the reduction.

Adolescent↗

PubMed1990

Pneumococcal vaccine. Efficacy and associated cost savings.

We evaluated the efficacy and cost savings of the pneumococcal pneumonia vaccine in a retrospective cohort study of 762 vaccinated and 1161 randomly selected unvaccinated age-sex matched persons in Blue Cross/Blue Shield of Minnesota using medical and pharmaceutical claims. The pneumonia incidence and the ratio of incidence in the postvaccination to prevaccination periods (rate ratio) were examined in the vaccine group by sex and risk factors. Vaccination significantly reduced pneumonia incidence, with overall efficacy of 69% and higher efficacy in women (86%) than in men (33%). We assigned persons to risk categories based on disease conditions as recorded in the claims by the ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification) diagnostic codes. In the risk categories, efficacy varied from 50% to 75% and was confounded by sex. Immunocompromised and immunocompetent women had high efficacy (83% to 88%), while immunocompetent and immunocompromised men had lower efficacy (33%). Persons with a precondition of pneumonia exhibited similar vaccine efficacy to the overall cohort relative to the comparison group. Projected costs of pneumonia cases are 3.6 times the observed costs of vaccination and postvaccination pneumonia costs. We conclude that the pneumococcal pneumonia vaccine is efficacious in persons having had pneumonia, persons "at risk" of developing pneumonia, or persons over 50 years of age, and it corresponds to overall savings of $141 per person.

Aged↗

PubMed1981

Behavioral assessment of peer interaction and social functioning in institutional and structured settings.

Observed 18 children in a short-term psychiatric facility over a 5-month period using a peer interaction coding system. The direct behavioral observation method was adapted and revised from existing scales to increase reliability and efficiency for use by institutional staff. Response codes included Adaptive Peer Interaction, Maladaptive Peer Interaction, Solitary Independent Play, and Response to Staff. Reliability was assessed on 35% of the total coded intervals, which yielded an overall reliability coefficient of 94.3%. In addition, reliability coefficients were calculated for each individual component behavior, an extremely important but often ignored statistic, and all yielded reliabilities greater than 90%. Normative rates for children on the psychiatric unit also are presented, and discussion is provided concerning the application of this coding system in clinics, schools, and institutional settings.

Adolescent↗

PubMed1990

Nonverbal behavior and client state changes during psychotherapy.

In an intensive videotape analysis of 10 psychotherapy sessions, the body positions and gesticulation patterns of the client were examined in relation to changes in her verbal behavior. Verbal ratings were obtained on the Experiencing Scale (Klein, Mathieu, Gendlin, & Kiesler, 1970), and nonverbal ratings were obtained on the Davis Nonverbal States Scales (Davis, 1986). Results revealed that the position "accessibility" ratings were related significantly to levels of self-disclosure and involvement as determined by the verbal ratings. The client's gesticulation ratings were not related significantly to the Experiencing Scale ratings, but clinically interesting relationships between gesticulation patterns and verbal content were noted. While body movement long has been recognized as an important source of clinical information, replicable coding of complex patterns of position and gesture has been very difficult to develop. This study presents data that support a promising, replicable method for coding nonverbal behavior in psychotherapy process research.

Adult↗

PubMed2001

Predicting the functional consequences of non-synonymous single nucleotide polymorphisms: structure-based assessment of amino acid variation.

We have developed a formalism and a computational method for analyzing the potential functional consequences of non-synonymous single nucleotide polymorphisms. Our approach uses a structural model and phylogenetic information to derive a selection of structure and sequence-based features serving as indicators of an amino acid polymorphim's effect on function. The feature values can be integrated into a probabilistic assessment of whether an amino acid polymorphism will affect the function or stability of a target protein. The method has been validated with data sets of unbiased mutations in the lac repressor and lysoyzyme. Applying our methodology to recent surveys of genetic variation in the coding regions of clinically important genes, we estimate that approximately 26-32 % of the natural non-synonymous single nucleotide polymorphisms have effects on function. This estimate suggests that a typical person will have about 6240-12,800 heterozygous loci that encode proteins with functional variation due to natural amino acid polymorphism.

Amino Acids↗

PubMed1994

Data quality in computerized patient records. Analysis of a haematology biopsy report database.

This paper addresses the problem of data quality in electronic patient records using a computerized haematology biopsy report system as an example. Physicians extracted five parameters from a traditional free text cytology report and encoded these parameters thus producing a computer processable report. The parameters were 1) the organ biopsied, 2) quality of specimen, 3) cytological diagnosis including 4) a modifier code for the main diagnosis code (i.e. status post chemotherapy, Y-code) and 5) an additional key describing the degree of remission obtained after chemotherapy of acute leukemias. From the various steps involved in generating the electronic record we selected two critical ones: encoding of free text terms by physician staff; entering of the coded terms into a computer by lab staff. We analyzed the rates of correct, incorrect and missing codes for each of the five parameters. Our findings indicate that in this model of an electronic patient record: 1) there is significant inaccuracy of physicians during the process of encoding the free text report with error rates between 3.2 and 28% and omission rates up to 64%. 2) lab staff entering these coded data into the computer introduce additional errors (0-7.8%) but rarely miss correctly encoded data (0-0.9%). 3) introducing a revised coding system data quality improved significantly (p < or = 0.001) with a fivefold increase of correct and a 75% reduction of missing codes. 4) the clinical relevance of the diagnoses encoded as perceived by clinicians is a significant factor affecting error and omission rates.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗