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At least 19 recordsLinked to original sources
PubMed2001

[The Medical Information Systems Project clinical coding and surgeons: why should surgeons code and how?].

The clinical coding system recently instituted in France, the PMSI (Projet de Médicalisation du Système d'Information), has become an unavoidable element in funding allocations for short-term private and public hospitalization centers. Surgeons must take into serious consideration this controversial medicoeconomic instrument. Coding is a dire time-consuming task but, like the hospitalization or surgery report, is an essential part of the discharge procedure. Coding can in the long run be used to establish pricing by pathology. Surgeons should learn the rules and the logic behind this coding system: which, not being based on a medical rationale, may be somewhat difficult to understand. Choosing the right main diagnosis and the comobidity Items is crucial. Quality homogeneous coding is essential if one expects the health authorities to make good use of the system. Our medical societies have a role to play in promoting and harmonizing the coding technique.

Abstracting and Indexing↗
PubMed2002

Co-ordination between clinical coding systems and pragmatic clinical terminologies based on a core open system: the role of ISO/TC215/WG3 and CEN/TC2511/WG2 standardisation?

The article addresses the need to co-ordinate efforts to develop clinical coding systems and pragmatic clinical terminologies like SNOMED CT. In the first part, a description is given of the current context of divergent and replicated efforts. Then is presented a "reference terminology representation" approach based on a formal terminology representation as an open source available in the public domain with diversity in the linguistic expressiveness of end users let to competing developers and researchers. The last part is devoted to the contribution of the standardisation process in healthcare terminology initiated by CEN/TC251 and supported now by the work of CEN/TC215/WG3 to this new approach which can be summarised as the practical realisation of an ontology.

Forms and Records Control↗
PubMed2005

The barriers to clinical coding in general practice: a literature review.

Clinical coding is variable in UK general practice. The reasons for this remain undefined. This review explains why there are no readily available alternatives to recording structured clinical data and reviews the barriers to recording structured clinical data. Methods used included a literature review of bibliographic databases, university health informatics departments, and national and international medical informatics associations. The results show that the current state of development of computers and data processing means there is no practical alternative to coding data. The identified barriers to clinical coding are: the limitations of the coding systems and terminologies and the skill gap in their use; recording structured data in the consultation takes time and is distracting; the level of motivation of primary care professionals; and the priority within the organization. A taxonomy is proposed to describe the barriers to clinical coding. This can be used to identify barriers to coding and facilitate the development of strategies to overcome them.

Family Practice↗
PubMed2002

A dynamic problem to knowledge linking Semantic Web service based on clinical codes.

Many information needs arise during everyday clinical practice. Problem to knowledge linking aims to answer these needs by providing contextually appropriate medical knowledge in the right place and at the right time. Empirical evidence shows that well-informed physicians and patients are able to make better clinical decisions that positively affect healthcare outcomes. This paper reports on the design and development of a re-usable and flexible Semantic Web problem to knowledge linking service. The service makes use of metadata and clinical codes contextually to link disparate Electronic Patient Record clients to resources in an online medical knowledge service (HealthCyberMap). Clinical codes act as crisp knowledge hooks, providing a reliable common backbone language for communication between Electronic Patient Records and HealthCyberMap. Ideas to improve the service are also discussed. By minimizing irrelevant leads (noise) and reducing the time needed to find relevant information (the right contextually relevant knowledge is linked to real patient data in the Electronic Patient Record), the system is potentially beneficial. The actual success of the system will depend on the quality and granularity of metadata it uses and the topical coverage and quality of resources to which it points.

Databases as Topic↗
PubMed2001

Toward a model for the evaluation of clinical coding systems.

OBJECTIVE: To demonstrate an empirical method to evaluate the utility of clinical coding systems. To use this method to assess the predictive power of two codes. METHOD: Controlled trial of two coding systems. SETTING: The Read Clinical Codes, version II and the International Classification of Primary Care (ICPC). OUTCOME MEASURES: The association between codes and pharmaceuticals prescribed. RESULTS: The power of both codes to predict pharmaceuticals increased with their precision. ICPC performed better than Read at the same level of precision. CONCLUSION: ICPC may be a more efficient coding system to use than Read. Assessment of the predictive power of a code is central to assessing its utility.

Diagnosis-Related Groups↗
PubMed1998

Assessment of the reproducibility of clinical coding in routinely collected hospital activity data: a study in two hospitals.

BACKGROUND: The aim of the study was to assess the reproducibility of clinical coding in two National Health Service hospitals within North West Thames region. METHODS: A retrospective audit was carried out, of clinical coding in hospital episode statistics, involving comparison of the codes assigned by local staff with those assigned by members of an external team unaware of the locally assigned codes. Where local and external coders disagreed, the records were reviewed for a third time by a further independent coder. The subjects were a random sample of 1607 non-maternity, non-psychiatric admissions occurring between 1991 and 1993, stratified for year and type of disease (asthma, diabetes, appendicitis, fractured femur and 'general'--a random selection of any diagnoses). The main outcome measures were the levels of exact agreement between local and external teams over codes for main diagnosis and procedure, and the level of approximate agreement (over the first three characters of the ICD-9 code for diagnosis and the letter and first two digits of the OPCS-4 code for procedure). For disagreements, the outcome measure was the level of agreement between the 'third' coder and the local and external coders. RESULTS: For the main diagnosis in the 'general' group at hospital A, internal and external coders agreed exactly in 43 per cent of the admissions examined and agreed 'approximately' in 55 per cent (kappa = 0.54). For hospital B the corresponding figures were 60 per cent and 72 per cent (kappa = 0.72). Approximate agreement was higher for the specific diseases considered, particularly for asthma (A: 86 per cent; B: 91 per cent) and fractured femur (A: 84 per cent; B: 89 per cent). For the main procedure at hospital A, there was exact agreement for 58 per cent and approximate agreement for 70 per cent (kappa = 0.66). For hospital B, the corresponding figures were 76 per cent and 83 per cent (kappa = 0.80). In cases of disagreement over the first three digits of the ICD-9 code for main diagnosis, the third coder disagreed with both local and external coders in 53 per cent at hospital A and 38 per cent at hospital B. Agreement was slightly better for discharges in 1992-1993 than in 1991-1992. CONCLUSIONS: The full clinical codes in NHS hospital episode statistics (HES) data should be treated with caution. The first three characters of ICD-9 codes for diagnoses and the OPCS-4 codes for procedures were more reliable. For some specific conditions such as asthma and fractured femur, reliability of the first three characters is much higher (for example, 86 per cent and 91 per cent for asthma in the two hospitals), but for the full codes can be worse. Secondary diagnoses or comorbidities may be significantly undercoded. A higher level of agreement in 1992-1993 than in 1991-1992 suggests that coding may be improving.

Abstracting and Indexing↗
PubMed2002

HealthCyberMap: a semantic visual browser of medical Internet resources based on clinical codes and the human body metaphor.

OBJECTIVES: HealthCyberMap (HCM-http://healthcybermap.semanticweb.org) is a web-based service for healthcare professionals and librarians, patients and the public in general that aims at mapping parts of the health information resources in cyberspace in novel ways to improve their retrieval and navigation. METHODS AND SERVICE DESCRIPTION: HCM adopts a clinical metadata framework built upon a clinical coding ontology for the semantic indexing, classification and browsing of Internet health information resources. A resource metadata base holds information about selected resources. HCM then uses GIS (Geographic Information Systems) spatialization methods to generate interactive navigational cybermaps from the metadata base. These visual cybermaps are based on familiar medical metaphors. CONCLUSIONS: HCM cybermaps can be considered as semantically spatialized, ontology-based browsing views of the underlying resource metadata base. Using a clinical coding scheme as a metric for spatialization ('semantic distance') is unique to HCM and is very much suited for the semantic categorization and navigation of Internet health information resources. Clinical codes ensure reliable and unambiguous topical indexing of these resources. HCM also introduces a useful form of cyberspatial analysis for the detection of topical coverage gaps in the resource metadata base using choropleth (shaded) maps of human body systems.

Abstracting and Indexing↗
PubMed2001

A survey to identify the clinical coding and classification systems currently in use across Europe.

INTRODUCTION: This is a survey to identify what clinical coding systems are currently in use across the European Union, and the states seeking membership to it. We sought to identify what systems are currently used and to what extent they were subject to local adaptation. BACKGROUND: Clinical coding should facilitate identifying key medical events in a computerised medical record, and aggregating information across groups of records. The emerging new driver is as the enabler of the life-long computerised medical record. A prerequisite for this level of functionality is the transfer of information between different computer systems. This transfer can be facilitated either by working on the interoperability problems between disparate systems or by harmonising the underlying data. This paper examines the extent to which the latter has occurred across Europe. METHOD: Literature and Internet search. Requests for information via electronic mail to pan-European mailing lists of health informatics professionals. RESULTS: Coding systems are now a de facto part of health information systems across Europe. There are relatively few coding systems in existence across Europe. ICD9 and ICD 10, ICPC and Read were the most established. However the local adaptation of these classification systems either on a by country or by computer software manufacturer basis; significantly reduces the ability for the meaning coded with patients computer records to be easily transferred from one medical record system to another. CONCLUSIONS: There is no longer any debate as to whether a coding or classification system should be used. Convergence of different classifications systems should be encouraged. Countries and computer manufacturers within the EU should be encouraged to stop making local modifications to coding and classification systems, as this practice risks significantly slowing progress towards easy transfer of records between computer systems.

Classification↗
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↗
PubMed2005

Clinical coding. Code breakers.

--The advent of payment by results has seen the role of the clinical coder pushed to the fore in England. --Examinations for a clinical coding qualification began in 1999. In 2004, approximately 200 people took the qualification. --Trusts are attracting people to the role by offering training from scratch or through modern apprenticeships.

England↗
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↗
PubMed2003

Managers see the problems associated with coding clinical data as a technical issue whilst clinicians also see cultural barriers.

OBJECTIVE: In UK general practice, the coding of clinical data (Read Coding) is far from universal. This study set out to examine the barriers to recording structured information in computerised medical records; and to explore whether managers and clinicians had different perspectives in how these barriers should be overcome. METHOD: A qualitative study, using semi-structured interviews of general practitioners, primary care nurses and practice managers. The interviews were recorded verbatim, and then underwent thematic analysis; additional interviews were conducted until thematic saturation was achieved. RESULTS: For clinicians the recording of structured data within a consultation is not a neutral activity, they are highly aware of diagnostic uncertainty and sensitive to the potential impact of both a correct and incorrect diagnostic label on their relationship with their patient. Clinicians accept that data has to be coded if they are to demonstrate that appropriate evidence based care has been provided to populations; but alongside this they require free-text as a more powerful reminder of the individual human encounter. Managers felt that they could encourage clinicians to code data for re-use as part of population data or as quality target indicators rather than as an enabler of the next consultation. CONCLUSIONS: The primary care consultation is a complex social interaction, and coding of the medical diagnosis in itself imposes the bio-medical model, carries assumptions about certainty, and is perceived by clinicians to potentially jeopardise their relationships with their patient. Further research to elicit patients' views may help clarify the magnitude of this barrier.

Ambulatory Care Information Systems↗
PubMedDate not supplied

Phase II evaluation of clinical coding schemes: completeness, taxonomy, mapping, definitions, and clarity. CPRI Work Group on Codes and Structures.

OBJECTIVE: To compare three potential sources of controlled clinical terminology (READ codes version 3.1, SNOMED International, and Unified Medical Language System (UMLS) version 1.6) relative to attributes of completeness, clinical taxonomy, administrative mapping, term definitions and clarity (duplicate coding rate). METHODS: The authors assembled 1929 source concept records from a variety of clinical information taken from four medical centers across the United States. The source data included medical as well as ample nursing terminology. The source records were coded in each scheme by an investigator and checked by the coding scheme owner. The codings were then scored by an independent panel of clinicians for acceptability. Codes were checked for definitions provided with the scheme. Codes for a random sample of source records were analyzed by an investigator for "parent" and "child" codes within the scheme. Parent and child pairs were scored by an independent panel of medical informatics specialists for clinical acceptability. Administrative and billing code mapping from the published scheme were reviewed for all coded records and analyzed by independent reviewers for accuracy. The investigator for each scheme exhaustively searched a sample of coded records for duplications. RESULTS: SNOMED was judged to be significantly more complete in coding the source material than the other schemes (SNOMED* 70%; READ 57%; UMLS 50%; *p < .00001). SNOMED also had a richer clinical taxonomy judged by the number of acceptable first-degree relatives per coded concept (SNOMED* 4.56, UMLS 3.17; READ 2.14, *p < .005). Only the UMLS provided any definitions; these were found for 49% of records which had a coding assignment. READ and UMLS had better administrative mappings (composite score: READ* 40.6%; UMLS* 36.1%; SNOMED 20.7%, *p < .00001), and SNOMED had substantially more duplications of coding assignments (duplication rate: READ 0%; UMLS 4.2%; SNOMED* 13.9%, *p < .004) associated with a loss of clarity. CONCLUSION: No major terminology source can lay claim to being the ideal resource for a computer-based patient record. However, based upon this analysis of releases for April 1995, SNOMED International is considerably more complete, has a compositional nature and a richer taxonomy. Is suffers from less clarity, resulting from a lack of syntax and evolutionary changes in its coding scheme. READ has greater clarity and better mapping to administrative schemes (ICD-10 and OPCS-4), is rapidly changing and is less complete. UMLS is a rich lexical resource, with mappings to many source vocabularies. It provides definitions for many of its terms. However, due to the varying granularities and purposes of its source schemes, it has limitations for representation of clinical concepts within a computer-based patient record.

Abstracting and Indexing↗
PubMed2001

Differences in length of stay for Hospital in the Home patients: comparing simple clinical coding with medical record review.

AIM: To determine whether the apparently longer length of stay (LOS) reported for patients with cellulitis managed in Hospital in the Home (HITH) compared with those managed as inpatients was correct. METHODS: Data, including LOS, from the Victorian In-patient Minimum Database (VIMD) of all patients with cellulitis managed between July 1998 and June 1999 at a large metropolitan teaching hospital were analysed and compared with a retrospective medical record review of the same patients. RESULTS: In the VIMD data, there were 266 episodes of cellulitis during the study period. However, the medical record review found that six episodes were not separate, but rather a continuation of treatment for the same episode of cellulitis, and that 18 were not episodes of cellulitis, but were pilonidal sinus infections. In the VIMD data set, the mean LOS for patients treated in HITH was generally longer than that for inpatients (7.2 days vs 5.1 days, respectively, P = 0.002). However, in the retrospective medical record review, the LOS for patients treated in HITH was similar to inpatients (7.3 days versus 7.0 days, respectively, P = 0.68). CONCLUSIONS: In contrast to the VIMD data, the medical record review demonstrated that, overall, patients with cellulitis had a similar LOS irrespective of whether they were managed at home or in hospital. This study confirms that caution is required in interpreting the VIMD data, highlights the importance of carefully monitoring the introduction of new treatment modalities and indicates areas for further research.

Analysis of Variance↗