Diagnosis and procedures codification The effects of technology

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 Jun;56(6): Diagnosis 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 Jun;56(6): [2] Gillies J, Holt A. Anxious about electronic health records? No need to be. N Z Med J Sep 26;116(1182):U604. Diagnosis 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 Sep;58-59: [2] Mikkelsen G, Aasly J. Concordance of information in parallel electronic and paper based patient records. Int J Med Inform Oct;63(3): J [3] McLendon K. Electronic medical record systems as a basis for computer-based patient records. J AHIMA Sep;64(9):50, 52, [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 Mar;21(1):33-6. [5] Tange HJ. The paper-based patient record: is it really so bad? Comput Methods Programs Biomed Sep-Oct;48(1-2): Diagnosis 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;: [2] Friedman BA. The potential role of physicians in the management of hospital information systems. Clin Lab Med Mar;10(1): [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;: Main difficulties in the implementation of EPR. [1] Negligent data introduction. [2] Typing and visualization speed. [3] Diagnosis 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 Jun;56(6): [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 Mar;86-A(3): [3] Ellingsen G, Monteiro E. Big is beautiful: electronic patient records in large Norwegian hospitals 1980s Methods Inf Med. 2003;42(4): [4] Neubauer AS, Priglinger S, Ehrt O. [Electronic versus paper-based patient records: a cost-benefit analysis] Ophthalmologe Nov;98(11): [5] Muller ML, Burkle T, Irps S, Roeder N, Prokosch HU. The diagnosis related groups enhanced electronic medical record. Int J Med Inform Jul;70(2-3): [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: Diagnosis 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 codification

Linear Flow Chart Diagnosis and procedures codification

Linear Flow Chart Diagnosis and procedures codification

Linear Flow Chart Diagnosis and procedures codification

Methods Flow Chart Diagnosis and procedures codification

Methods Flow Chart Diagnosis and procedures codification

Methods Flow Chart Diagnosis and procedures codification

Gantt’s Graphic/Chart Diagnosis and procedures codification

Greetings We would like to thank the professors Ricardo Correia and Cristina Santos without whose help we would not be able to finish our work. Diagnosis and procedures codification