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Computer-based clinical coding activity analysis for neurosurgical terms

Yeungnam University Journal of Medicine 2019년 36권 3호 p.225 ~ 230
 ( Lee Jong-Hyuk ) - Pusan National University Hospital Convergence Medical Institute of Technology

 ( Lee Jung-Hwan ) - Pusan National University Hospital Department of Neurosurgery
 ( Ryu Woo-Seok ) - Catholic University of Pusan Department of Healthcare Information Management
 ( Choi Byung-Kwan ) - Pusan National University Hospital Department of Neurosurgery
 ( Han In-Ho ) - Pusan National University Hospital Department of Neurosurgery
 ( Lee Chang-Min ) - Pusan National University Hospital Convergence Medical Institute of Technology

Abstract


Background: It is not possible to measure how much activity is required to understand and code a medical data. We introduce an assessment method in clinical coding, and applied this method to neurosurgical terms.

Methods: Coding activity consists of two stages. At first, the coders need to understand a presented medical term (informational activity). The second coding stage is about a navigating terminology browser to find a code that matches the concept (code-matching activity). Systematized Nomenclature of Medicine ? Clinical Terms (SNOMED CT) was used for the coding system. A new computer application to record the trajectory of the computer mouse and record the usage time was programmed. Using this application, we measured the time that was spent. A senior neurosurgeon who has studied SNOMED CT has analyzed the accuracy of the input coding. This method was tested by five neurosurgical residents (NSRs) and five medical record administrators (MRAs), and 20 neurosurgical terms were used.

Results: The mean accuracy of the NSR group was 89.33%, and the mean accuracy of the MRA group was 80% (p=0.024). The mean duration for total coding of the NSR group was 158.47 seconds, and the mean duration for total coding of the MRA group was 271.75 seconds (p=0.003).

Conclusion: We proposed a method to analyze the clinical coding process. Through this method, it was possible to accurately calculate the time required for the coding. In neurosurgical terms, NSRs had shorter time to complete the coding and higher accuracy than MRAs.

키워드

Clinical coding; Medical informatics; Systematized nomenclature of medicine
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