Abstract
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.
Keywords
Free Text - Coding - ICD-9 - Computerized Patient Record - Database Browsing - Encoding
Tools - Medical Concepts
