Introduction
Recording clinical information is important to the health industry
Access to previous information leads to better diagnosis and treatment in the future [1]
Paper-based record / Electronic records
[1] Movig KL, Leufkens HG, Lenderink AW, Egberts AC. Validity of hospital discharge International Classification of Diseases (ICD) codes for identifying patients with hyponatremia. J Clin Epidemiol. 2003 Jun;56(6):530-5.
Diagnosis and procedures codificationDiagnosis and procedures codification
Lacks of information of previous studies [1]
Electronic patient record (EPR) as the main method in a near future. [2]
It is important to study and to conclude if this new information organization will result in any difference from the old one.
[1] Movig KL, Leufkens HG, Lenderink AW, Egberts AC. Validity of hospital discharge International Classification of Diseases (ICD) codes for identifying patients with hyponatremia. J Clin Epidemiol. 2003 Jun;56(6):530-5.
[2] Gillies J, Holt A. Anxious about electronic health records? No need to be. N Z Med J. 2003 Sep 26;116(1182):U604.
Diagnosis and procedures codificationDiagnosis and procedures codification
Advantages and disadvantages of EPR and paper-based records. Most of the studies conclude that the electronic system is better, although some of them disagree. [1,2,3,4,5]
[1] Van der Meijden MJ, Tange HJ, Boiten J, Troost J, Hasman A. An experimental electronic patient record for stroke patients. Part 1: situation analysis. Int J Med Inform. 2000 Sep;58-59:111-25
[2] Mikkelsen G, Aasly J. Concordance of information in parallel electronic and paper based patient records. Int J Med Inform. 2001 Oct;63(3):123-31.
[3] McLendon K. Electronic medical record systems as a basis for computer-based patient records. J AHIMA. 1993 Sep;64(9):50, 52, 54-5.
[4] Nilsson G, Ahlfeldt H, Strender LE. Textual content, health problems and diagnostic codes in electronic patient records in general practice. Scand J Prim Health Care. 2003 Mar;21(1):33-6.
[5] Tange HJ. The paper-based patient record: is it really so bad? Comput Methods Programs Biomed. 1995 Sep-Oct;48(1-2):127-31.
Diagnosis and procedures codificationDiagnosis and procedures codification
[1] Mohr DN, Carpenter PC, Claus PL, Hagen PT, Karsell PR, Van Scoy RE. Implementing an EMR: paper's last hurrah. Proc Annu Symp Comput Appl Med Care. 1995;:157-61.
[2] Friedman BA. The potential role of physicians in the management of hospital information systems. Clin Lab Med. 1990 Mar;10(1):239-50
[3] Rodriguez NJ, Murillo V, Borges JA, Ortiz J, Sands DZ. A usability study of physicians interaction with a paper-based patient record system and a graphical-based electronic patient record system. Proc AMIA Symp. 2002;:667-71.
Main difficulties in the implementation of EPR. [1]
Negligent data introduction. [2]
Typing and visualization speed. [3]
Diagnosis and procedures codificationDiagnosis and procedures codification
Coding errors (ICD). [1,2]
Costs and benefits of EPR. [3,4]
Hospital’s economical survival. [5,6]
[1] Movig KL, Leufkens HG, Lenderink AW, Egberts AC. Validity of hospital discharge International Classification of Diseases (ICD) codes for identifying patients with hyponatremia. J Clin Epidemiol. 2003 Jun;56(6):530-5.
[2]Stengel D, Bauwens K, Walter M, Kopfer T, Ekkernkamp A. Comparison of handheld computer-assisted and conventional paper chart documentation of medical records. A randomized, controlled trial. J Bone Joint Surg Am. 2004 Mar;86-A(3):553-60.
[3] Ellingsen G, Monteiro E. Big is beautiful: electronic patient records in large Norwegian hospitals 1980s-2001. Methods Inf Med. 2003;42(4):366-70.
[4] Neubauer AS, Priglinger S, Ehrt O. [Electronic versus paper-based patient records: a cost-benefit analysis] Ophthalmologe. 2001 Nov;98(11):1083-8.
[5] Muller ML, Burkle T, Irps S, Roeder N, Prokosch HU. The diagnosis related groups enhanced electronic medical record. Int J Med Inform. 2003 Jul;70(2-3):221-8.
[6]Muller ML, Burkle T, Irps S, Roeder N, Prokosch HU. Optimizing coding quality: the role of the electronic medical record in the context of diagnosis related groups. Stud Health Technol Inform. 2002;90:236-40.
Diagnosis and procedures codificationDiagnosis and procedures codification
Objective
The main objective is:
Evaluate if the implementation of the EPR brought any changes in the quality or quantity of the patient data on hospital statistics.
Diagnosis and procedures codificationDiagnosis and procedures codification