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A patient data storage and retrieval system has been developed for a microcomputer used in a nuclear medicine department. The advantages of coding clinical information and the problems encountered in coding are highlighted. The application of the stored patient data is briefly discussed.
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The Clinical Care Costing Method (CCCM for the Home Health Care Classification (HHCC) System provides an innovative way to determine the cost of clinical nursing practice. This costing methodology consists of three major nursing indicators--Care Components, Actions and Outcomes. These three indicators require Clinical Care Pathways (CCP) to document, track, and code clinical care using the HHCC System. The clinical care costs and/or resources are derived from the time and frequencies of the Action Types for the specific nursing interventions performed by the different type of health care providers to achieve the Outcomes and resolve the Care Component that are used to classify nursing diagnoses/patient problems. This method can also be used to deter-mine the reimbursement for nursing care services retrospectively and once validated prospectively. The Clinical Pathway data provide the evidence that the nursing interventions achieve the desired outcomes.
PURPOSE: To compare a template-driven medical documentation system to undirected handwritten documentation and determine whether the template (1) decreases physician evaluation time, (2) increases gross billing, and (3) increases physician satisfaction with the documentation process. METHODS: A prospective randomized trial of documentation with a template system (T-System for Primary Care, Dallas, TX) versus undirected handwritten documentation was conducted in 2 separate teams of a single family medicine residency program. After training, one team used the template system and the other team used undirected written documentation. Clinic visit duration was recorded. Medical records were evaluated by a blinded professional coder to assign an evaluation/management code. Clinic visit duration and coding level differences were evaluated using an independent t test. At the conclusion of the study, residents completed a questionnaire to determine physician satisfaction with the documentation tool. Survey responses were on a -2 to + 2 Likert scale. Means and standard deviations are reported. RESULTS: A total of 1339 patients were included in the analysis of patient visits. There was no significant difference in clinic time between the template system and the written documentation visits. The mean visit time was 1.75 hours for both teams. For the analysis of gross billing, 1237 charts were included. The mean billing amount for written documentation was USD $150 and for the template system it was USD $163--a statistically significant difference. The physicians' surveys favored continuing to use the template documentation method. CONCLUSIONS: The template medical documentation system compared with undirected written documentation produced a significantly higher bill for the visit, yielding no differences in evaluation time, and was overall positively received by the residents and faculty.
OBJECTIVES: To assess the feasibility of coding with MedDRA, the Medical Dictionary for Regulatory Activities, not only serious adverse events required for notification but also all other events usually reported in HIV clinical trials. To develop an approach for MedDRA implementation within an institutional research unit that contributes to an efficient, concise and reproducible event coding. To evaluate the impact of the maintenance and the versioning of this new medical terminology. METHODS: MedDRA versions 3.0 and 5.0 were used for coding hundreds of events reported through two HIV clinical trials. The implementation of MedDRA consisted in the setup of a training program, guidelines to clinical investigators, coding rules and medical validation process. MedDRA version 6.1 was applied to the coding made with the MedDRA version 5.0 in order to identify the assignments affected by the new version and to determine the impact of versioning. RESULTS: Coding with MedDRA all types of events in HIV clinical trials was feasible even though coders experienced some difficulties due mainly to the lack of precision in the investigator verbatim and the high specificity and sensitivity of MedDRA. The addition of appropriate tools to support the use of MedDRA improved significantly the coding of all types of events in HIV clinical trials. The impact of MedDRA versioning was limited and did not result in significant issues. The global implementation process of MedDRA required important resources in terms of qualified personnel, organisation and maintenance. CONCLUSIONS: Guidelines for investigators, coding rules and medical validation appeared to be mandatory for a successful implementation of MedDRA. The use of MedDRA, with the addition of the mentioned support tools, should ensure coding consistency and facilitate the clinical and tolerance analyses and meta-analyses in clinical trials.
BACKGROUND: Clinical pathways are commonly developed for homogenous patient groups. We were wondering if the traditional patient classification systems could be used for classifying clinical pathways. METHODOLOGY: To examine the utility of patient classification systems for clinical pathways, a sample of 13 clinical pathways was analyzed, involving a total of 412 patients. Three classification systems were tested: International Classification of Diseases, Ninth Revision (ICD9-CM), Clinical Coding System (CCS) data and All-Patient Redefined Diagnosis Related Groups (APR-DRG). RESULTS: Categorization with ICD9-CM and CCS shows rather wide variation. However, when restricting for the principal codes, CCS classification shows an almost homogeneous relationship with clinical pathways. APR-DRG's are already corrected for secondary procedures and are difficult to assess. Categorization with the Risk Of Mortality (ROM) is more homogeneous than with the Severity Of Illness (SOI). CONCLUSION: Patient groups in clinical pathways are rather heterogeneous. When restricting for the principal procedures, the strongest relationship seems to exist between clinical pathways and CCS. Further research is needed to refine this relationship.
A major topic of concern for the health information management (HIM) professional today is the quality of health care data. Although the coding professional within the HIM department has responsibility for assigning accurate clinical codes, often there are discrepancies or areas that need improvement. What ways are in place now to ensure quality clinical data? Quality programs and projects that can lead us into the next millennium are important to the HIM profession, administrators, health care payers, and state agencies. The challenges that we face are not without solutions. Sharing information and solutions is important for the individual and the profession as a whole. The article discusses four current but different ways in which data quality is looked at and addressed.
Radical changes planned in the New Zealand health system aim to improve its cost effectiveness, quality and consumer responsiveness. These changes will take place despite a paucity of data on the use of resources and outcomes. Data collection systems are to be introduced into hospitals and primary care with the use of the Read clinical codes (RCC) in addition to ICD-9-CM (International classification of disease--clinical modification) and ICPC (International classification of primary care). This paper discusses the proposed changes to the New Zealand health care system and describes their effect on the present and future data collection methods in general practice.
BACKGROUND: An independent health care evaluating organization reported on the Internet that the 1996-1998 mortality rate for simple pneumonia (one of the diagnoses in diagnosis-related group [DRG] 89) was 11.06% (expected rate, 7.69%)--a rate much higher than suggested by the medical center's prospective quality surveillance. Chart review was undertaken to explain this reported higher mortality rate. METHODS: Two-hundred forty-six charts of patients (123 expired, and 123 alive at discharge) were reviewed; each chart concluded with a principal diagnosis. The differences between the originally coded principal diagnosis and the recoded principal diagnoses were examined. RESULTS: Application of Coding Clinic guidelines revealed that a principal diagnosis of simple pneumonia should have been coded in only 85 (34.6%) of the charts. The remaining charts should have been coded as respiratory failure (13.8%), congestive heart failure (11.4%), respiratory infections and inflammations (7.7%), and other diagnoses (32.5%). Coding occurred prior to discharge summary dictation in 48.4% of the cases. On the basis of the findings, the actual calculated mortality rate of simple pneumonia was 6.6%. DISCUSSION: Coding in advance of discharge summary completion and nonexplicit documentation of the principal diagnoses occurred frequently. Reasons for miscoding included failure to distinguish between principal and final diagnoses, delay in discharge summary dictation, and inadequate documentation.
BACKGROUND AND OBJECTIVES: Transfusion laboratories with transfusion committees have a responsibility to monitor transfusion practice and generate improvements in clinical decision-making and red cell usage. However, this can be problematic and expensive because data cannot be readily extracted from most laboratory information systems. To overcome this problem, we developed and introduced a system to electronically extract and collate extensive amounts of data from two laboratory information systems and to link it with ICD10 clinical codes in a new database using standard information technology. MATERIALS AND METHODS: Three data files were generated from two laboratory information systems, ULTRA (version 3.2) and TM, using standard information technology scripts. These were patient pre- and post-transfusion haemoglobin, blood group and antibody screen, and cross match and transfusion data. These data together with ICD10 codes for surgical cases were imported into an MS ACCESS database and linked by means of a unique laboratory number. Queries were then run to extract the relevant information and processed in Microsoft Excel for graphical presentation. We assessed the utility of this data extraction system to audit transfusion practice in a 600-bed adult tertiary hospital over an 18-month period. RESULTS: A total of 52 MB of data were extracted from the two laboratory information systems for the 18-month period and together with 2.0 MB theatre ICD10 data enabled case-specific transfusion information to be generated. The audit evaluated 15,992 blood group and antibody screens, 25,344 cross-matched red cell units and 15,455 transfused red cell units. Data evaluated included cross-matched to transfusion ratios and pre- and post-transfusion haemoglobin levels for a range of clinical diagnoses. Data showed significant differences between clinical units and by ICD10 code. CONCLUSION: This method to electronically extract large amounts of data and linkage with clinical databases has provided a powerful and sustainable tool for monitoring transfusion practice. It has been successfully used to identify areas requiring education, training and clinical guidance and allows for comparison with national haemoglobin-based transfusion guidelines.
OBJECTIVE: To assess the validity of clinical information held on a regional maternity database, the St Mary's Maternity Information System (SMMIS). DESIGN: A retrospective review of 892 maternity case notes and matched SMMIS records, by a midwife trained in clinical coding techniques. SETTING: Three maternity units in the North West Thames Region. MAIN OUTCOME MEASURES: Percentage agreement for 17 directly recorded SMMIS data items and equivalent data abstracted from the notes. Frequencies of diagnosis codes abstracted from case notes, as compared with those generated by SMMIS on the basis of directly recorded data. RESULTS: A generally high level of agreement was observed between the abstracts of the notes and the SMMIS records. Of the 17 data items examined, 10 showed 95% agreement or better, and all but two exceeded 80% agreement. Little difference was found between the levels of agreement observed at the three sites. A greater number and range of diagnosis codes were abstracted from the notes than were generated by SMMIS. CONCLUSIONS: The directly recorded clinical data held on the SMMIS regional database is largely accurate and consistently recorded across a variety of units. The database can therefore be considered a valuable resource for the comparative audit of maternity practice. The SMMIS technique for deriving, on a semi-automatic basis, diagnosis codes from the directly recorded fields, appears to work moderately well. We suggest that the direct method of data collection used in SMMIS could provide a model for other specialties in the National Health Service.
Twelve laboratories collaborated in formulating and testing a standardized plaque reduction assay for cytomegalovirus (CMV) cell-associated clinical isolates. Four characterized and plaque-purified CMV strains, as well as six coded clinical isolates obtained after antiviral therapy, were distributed and tested. Good agreement was obtained for four of the clinical isolates, but a broad distribution of results was obtained for two isolates. Analysis of these results indicates the problems associated with clinical isolates, including the large genetic variability and the highly cell-associated phenotype. This collaborative effort, by addressing these problems, represents a significant step toward the development of a standardized assay.
A modified dye pour-plate auxanographic (DPPA) method for the presumptive identification of medically important yeasts was evaluated, in a comparative study with a conventional procedure, the API 20C clinical yeast system (Analytab Products Inc.), and the Uni-Yeast-Tek (UYT) system. The 174 coded clinical isolates were members of the genera Candida, Cryptococcus, Rhodotorula, Saccharomyces, Torulopsis, and Trichosporon. The identification accuracies with DPPA, API, and UYT were 95%, 93%, and 99% respectively. DPPA and API required more time to inoculate but gave rapid identification profiles. UYT was simple to inoculate and both UYT and DPPA were easy to read. Cost analysis of the three rapid methods demonstrated DPPA to be the most economical making it a feasible alternative for small clinical laboratories as well as large laboratories possessing the facilities to make their own media.
OBJECTIVE: To determine whether there was a relationship between coded diseases at the time of hospital discharge, a pattern of ordering investigations, and hospital readmission in a major teaching hospital. DESIGN: Systematic review of data relating to emergency medical patients admitted to St James' Hospital Dublin between 1 January and 31 December 2002. DATA SOURCES AND METHODS: Data on discharges from hospital recorded in the Hospital In-Patient Enquiry (HIPE) system. The value of HIPE data in describing the relationship between the pattern of resource utilisation, diagnostic related groups, and hospital readmission has not previously been examined. RESULTS: Of 5038 episodes recorded among 4050 patients admitted, the number of readmissions was up to 15. Age and male gender were factors associated with readmission, and readmitted patients remained in hospital for longer. No particular test request predicted readmission, but computed tomography of the brain was associated with a reduced readmission rate. Discharge diagnostic related group coding at first discharge predicted readmission-codes related to heart failure, respiratory system, alcohol, malignancy, and anaemia. CONCLUSIONS: It was found that clinical coding using the HIPE database strongly predicted hospital readmission. It may be argued that early hospital readmission reflects unsatisfactory patient care, alternatively that many readmissions are not preventable, representing either new events in elderly patients with chronic illnesses and frequent co-morbidity or related to social factors. The utility of specific interventions, in patients at high risk for hospital readmission, could be explored.
Data on discharges from acute public hospitals in Ireland is recorded in the hospital in-patient enquiry (HIPE) system; its value in describing the casemix and pattern of resource utilization following emergency medical admissions has not been examined. We wished to determine whether there was a relationship between coded diseases at the time of discharge, patterns of investigation, and length of hospital stay (LOS) in a major teaching hospital. Data relating to emergency medical patients admitted to St James' Hospital Dublin between 1st January and 31st December 2002 was recorded. Of 5038 episodes evaluated, the median LOS was 6 days (IQR 3-13); this was significantly shorter when the patient was admitted under a general medical service (p<0.0001). There was also a positive correlation between patient age and LOS (r = 0.32; p<0.0001). No test request was associated with a shortened LOS. Prolonged LOS was associated with oesophago-gastro-duodenoscopy, echocardiography, computerised tomography, magnetic resonance imaging, and abdominal ultrasonography testing. Furthermore, prolonged LOS was associated with the following disease related groups (DRG) at discharge; codes related to heart failure, respiratory system, malignancy, stroke, diabetes, psychiatry, and anaemia. We found that clinical coding using the HIPE database strongly predicted hospital LOS for acute general medical admissions. Spare bed capacity is essential if an acute hospital is to operate efficiently and at a level of risk acceptable to patients. Therefore, determining major influences on hospital LOS is valuable, to develop potential strategies to optimise efficient utilization of acute bed capacity.
The introduction of casemix funding systems has focused attention on the reliability and validity of coded health data. Defining and classifying medical and health related terms are the core activities of the National Centre for Classification in Health (NCCH), which has recently published the Australian modification of the International statistical classification of diseases and health related problems, 10th revision (ICD-10-AM). An important feature is a classification of procedures (MBS-E) based on the Commonwealth Medical Benefits Schedule. Clinicians have made major contributions to the new classification through a network of 21 Clinical Coding and Classification Groups, which advise the NCCH. Major advantages of ICD-10-AM for clinicians include the ability to update the classification within Australia with continued clinical consultation, the familiarity of the procedure codes based on MBS, and the possibility of having one classification for use in public and private healthcare facilities.
Single-parent families have been identified as using more coercion and aggression to elicit compliance than intact families. The present study compared 9 mother-only and 15 intact families from a referred clinical sample to 9 mother-only and 16 intact nonreferred "normal" families using a family behavioral observation code. Clinical families emitted higher rates of aggressive behavior than normals, and mother-only emitted higher rates than intact. However, mother-only normals had lower rates than intact clinical families. The intact versus mother-only factor appears to be less important in understanding aggression than do the specific interactional patterns of family members.