Automated coded ambulatory problem lists: evaluation of a vocabulary and a data entry tool
Background: Problem lists are fundamental to electronic medical records (EMRs). However, obtaining an appropriate problem list dictionary is difficult, and getting users to code their problems at the time of data entry can be challenging. Objective: To develop a problem list dictionary and search al...
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| Veröffentlicht in: | International journal of medical informatics (Shannon, Ireland) Ireland), 2003-12, Vol.72 (1), p.17-28 |
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| container_title | International journal of medical informatics (Shannon, Ireland) |
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| creator | Wang, Samuel J Bates, David W Chueh, Henry C Karson, Andrew S Maviglia, Saverio M Greim, Julie A Frost, Jennifer P Kuperman, Gilad J |
| description | Background: Problem lists are fundamental to electronic medical records (EMRs). However, obtaining an appropriate problem list dictionary is difficult, and getting users to code their problems at the time of data entry can be challenging.
Objective: To develop a problem list dictionary and search algorithm for an EMR system and evaluate its use.
Methods: We developed a problem list dictionary and lookup tool and implemented it in several EMR systems. A sample of 10,000 problem entries was reviewed from each system to assess overall coding rates. We also performed a manual review of a subset of entries to determine the appropriateness of coded entries, and to assess the reasons other entries were left uncoded.
Results: The overall coding rate varied significantly between different EMR implementations (63–79%). Coded entries were virtually always appropriate (99%). The most frequent reasons for uncoded entries were due to user interface failures (44–45%), insufficient dictionary coverage (20–32%), and non-problem entries (10–12%).
Conclusion: The problem list dictionary and search algorithm has achieved a good coding rate, but the rate is dependent on the specific user interface implementation. Problem coding is essential for providing clinical decision support, and improving usability should result in better coding rates. |
| doi_str_mv | 10.1016/j.ijmedinf.2003.08.002 |
| format | Article |
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Objective: To develop a problem list dictionary and search algorithm for an EMR system and evaluate its use.
Methods: We developed a problem list dictionary and lookup tool and implemented it in several EMR systems. A sample of 10,000 problem entries was reviewed from each system to assess overall coding rates. We also performed a manual review of a subset of entries to determine the appropriateness of coded entries, and to assess the reasons other entries were left uncoded.
Results: The overall coding rate varied significantly between different EMR implementations (63–79%). Coded entries were virtually always appropriate (99%). The most frequent reasons for uncoded entries were due to user interface failures (44–45%), insufficient dictionary coverage (20–32%), and non-problem entries (10–12%).
Conclusion: The problem list dictionary and search algorithm has achieved a good coding rate, but the rate is dependent on the specific user interface implementation. Problem coding is essential for providing clinical decision support, and improving usability should result in better coding rates.</description><identifier>ISSN: 1386-5056</identifier><identifier>EISSN: 1872-8243</identifier><identifier>DOI: 10.1016/j.ijmedinf.2003.08.002</identifier><identifier>PMID: 14644303</identifier><language>eng</language><publisher>Shannon: Elsevier Ireland Ltd</publisher><subject>Algorithms ; Biological and medical sciences ; Boston ; Efficiency, Organizational ; Forms and Records Control ; Health Services Research ; Humans ; Medical record systems, computerized ; Medical Records Systems, Computerized - organization & administration ; Medical records, problem-orientated ; Medical Records, Problem-Oriented ; Medical sciences ; Multi-Institutional Systems ; Quality Assurance, Health Care ; Radiotherapy. Instrumental treatment. Physiotherapy. Reeducation. Rehabilitation, orthophony, crenotherapy. Diet therapy and various other treatments (general aspects) ; Technology. Biomaterials. Equipments. Material. Instrumentation ; User-Computer Interface ; Vocabulary, Controlled</subject><ispartof>International journal of medical informatics (Shannon, Ireland), 2003-12, Vol.72 (1), p.17-28</ispartof><rights>2003 Elsevier Ireland Ltd</rights><rights>2004 INIST-CNRS</rights><lds50>peer_reviewed</lds50><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-c425t-ae69e723a7c4b292e2196b1a74c34549553d6403ea43e3f7ccf07cf827f871593</citedby><cites>FETCH-LOGICAL-c425t-ae69e723a7c4b292e2196b1a74c34549553d6403ea43e3f7ccf07cf827f871593</cites></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktohtml>$$Uhttps://dx.doi.org/10.1016/j.ijmedinf.2003.08.002$$EHTML$$P50$$Gelsevier$$H</linktohtml><link.rule.ids>314,780,784,3550,27924,27925,45995</link.rule.ids><backlink>$$Uhttp://pascal-francis.inist.fr/vibad/index.php?action=getRecordDetail&idt=15328698$$DView record in Pascal Francis$$Hfree_for_read</backlink><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/14644303$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Wang, Samuel J</creatorcontrib><creatorcontrib>Bates, David W</creatorcontrib><creatorcontrib>Chueh, Henry C</creatorcontrib><creatorcontrib>Karson, Andrew S</creatorcontrib><creatorcontrib>Maviglia, Saverio M</creatorcontrib><creatorcontrib>Greim, Julie A</creatorcontrib><creatorcontrib>Frost, Jennifer P</creatorcontrib><creatorcontrib>Kuperman, Gilad J</creatorcontrib><title>Automated coded ambulatory problem lists: evaluation of a vocabulary and a data entry tool</title><title>International journal of medical informatics (Shannon, Ireland)</title><addtitle>Int J Med Inform</addtitle><description>Background: Problem lists are fundamental to electronic medical records (EMRs). However, obtaining an appropriate problem list dictionary is difficult, and getting users to code their problems at the time of data entry can be challenging.
Objective: To develop a problem list dictionary and search algorithm for an EMR system and evaluate its use.
Methods: We developed a problem list dictionary and lookup tool and implemented it in several EMR systems. A sample of 10,000 problem entries was reviewed from each system to assess overall coding rates. We also performed a manual review of a subset of entries to determine the appropriateness of coded entries, and to assess the reasons other entries were left uncoded.
Results: The overall coding rate varied significantly between different EMR implementations (63–79%). Coded entries were virtually always appropriate (99%). The most frequent reasons for uncoded entries were due to user interface failures (44–45%), insufficient dictionary coverage (20–32%), and non-problem entries (10–12%).
Conclusion: The problem list dictionary and search algorithm has achieved a good coding rate, but the rate is dependent on the specific user interface implementation. Problem coding is essential for providing clinical decision support, and improving usability should result in better coding rates.</description><subject>Algorithms</subject><subject>Biological and medical sciences</subject><subject>Boston</subject><subject>Efficiency, Organizational</subject><subject>Forms and Records Control</subject><subject>Health Services Research</subject><subject>Humans</subject><subject>Medical record systems, computerized</subject><subject>Medical Records Systems, Computerized - organization & administration</subject><subject>Medical records, problem-orientated</subject><subject>Medical Records, Problem-Oriented</subject><subject>Medical sciences</subject><subject>Multi-Institutional Systems</subject><subject>Quality Assurance, Health Care</subject><subject>Radiotherapy. Instrumental treatment. Physiotherapy. Reeducation. Rehabilitation, orthophony, crenotherapy. Diet therapy and various other treatments (general aspects)</subject><subject>Technology. Biomaterials. Equipments. Material. Instrumentation</subject><subject>User-Computer Interface</subject><subject>Vocabulary, Controlled</subject><issn>1386-5056</issn><issn>1872-8243</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2003</creationdate><recordtype>article</recordtype><sourceid>EIF</sourceid><recordid>eNqFkE1v3CAQhlHVqEnT_oWIS3uzy5cB99QoaptIkXpJLrmgMR4kVrZJDV6p_z6sdqsccwEEzzszPIRccdZyxvW3XRt3M45xCa1gTLbMtoyJd-SCWyMaK5R8X8_S6qZjnT4nH3PeMcYN69QHcs6VVkoyeUGerreSZig4Up_GusI8bBOUtP6jz2saJpzpFHPJ3ynuYdqgxLTQFCjQffJwYCsJSw3SEQpQXEq9KClNn8hZgCnj59N-SR5__Xy4uW3u__y-u7m-b7wSXWkAdY9GSDBeDaIXKHivBw5Geak61XedHLViEkFJlMF4H5jxwQoTrOFdLy_J12PdOu_fDXNxc8wepwkWTFt2hismpBZvgrwX3Bh-APUR9GvKecXgntc41486ztxBv9u5__rdQb9j1lX9NXh16rAN9fk1dvJdgS8nALKHKayw-JhfuU4Kq3tbuR9HDqu4fcTVZR9x8bXlir64McW3ZnkBVC-mPw</recordid><startdate>20031201</startdate><enddate>20031201</enddate><creator>Wang, Samuel J</creator><creator>Bates, David W</creator><creator>Chueh, Henry C</creator><creator>Karson, Andrew S</creator><creator>Maviglia, Saverio M</creator><creator>Greim, Julie A</creator><creator>Frost, Jennifer P</creator><creator>Kuperman, Gilad J</creator><general>Elsevier Ireland Ltd</general><general>Elsevier</general><scope>IQODW</scope><scope>CGR</scope><scope>CUY</scope><scope>CVF</scope><scope>ECM</scope><scope>EIF</scope><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>7QO</scope><scope>8FD</scope><scope>FR3</scope><scope>P64</scope><scope>7X8</scope></search><sort><creationdate>20031201</creationdate><title>Automated coded ambulatory problem lists: evaluation of a vocabulary and a data entry tool</title><author>Wang, Samuel J ; Bates, David W ; Chueh, Henry C ; Karson, Andrew S ; Maviglia, Saverio M ; Greim, Julie A ; Frost, Jennifer P ; Kuperman, Gilad J</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c425t-ae69e723a7c4b292e2196b1a74c34549553d6403ea43e3f7ccf07cf827f871593</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2003</creationdate><topic>Algorithms</topic><topic>Biological and medical sciences</topic><topic>Boston</topic><topic>Efficiency, Organizational</topic><topic>Forms and Records Control</topic><topic>Health Services Research</topic><topic>Humans</topic><topic>Medical record systems, computerized</topic><topic>Medical Records Systems, Computerized - organization & administration</topic><topic>Medical records, problem-orientated</topic><topic>Medical Records, Problem-Oriented</topic><topic>Medical sciences</topic><topic>Multi-Institutional Systems</topic><topic>Quality Assurance, Health Care</topic><topic>Radiotherapy. Instrumental treatment. Physiotherapy. Reeducation. Rehabilitation, orthophony, crenotherapy. Diet therapy and various other treatments (general aspects)</topic><topic>Technology. Biomaterials. Equipments. Material. Instrumentation</topic><topic>User-Computer Interface</topic><topic>Vocabulary, Controlled</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Wang, Samuel J</creatorcontrib><creatorcontrib>Bates, David W</creatorcontrib><creatorcontrib>Chueh, Henry C</creatorcontrib><creatorcontrib>Karson, Andrew S</creatorcontrib><creatorcontrib>Maviglia, Saverio M</creatorcontrib><creatorcontrib>Greim, Julie A</creatorcontrib><creatorcontrib>Frost, Jennifer P</creatorcontrib><creatorcontrib>Kuperman, Gilad J</creatorcontrib><collection>Pascal-Francis</collection><collection>Medline</collection><collection>MEDLINE</collection><collection>MEDLINE (Ovid)</collection><collection>MEDLINE</collection><collection>MEDLINE</collection><collection>PubMed</collection><collection>CrossRef</collection><collection>Biotechnology Research Abstracts</collection><collection>Technology Research Database</collection><collection>Engineering Research Database</collection><collection>Biotechnology and BioEngineering Abstracts</collection><collection>MEDLINE - Academic</collection><jtitle>International journal of medical informatics (Shannon, Ireland)</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Wang, Samuel J</au><au>Bates, David W</au><au>Chueh, Henry C</au><au>Karson, Andrew S</au><au>Maviglia, Saverio M</au><au>Greim, Julie A</au><au>Frost, Jennifer P</au><au>Kuperman, Gilad J</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Automated coded ambulatory problem lists: evaluation of a vocabulary and a data entry tool</atitle><jtitle>International journal of medical informatics (Shannon, Ireland)</jtitle><addtitle>Int J Med Inform</addtitle><date>2003-12-01</date><risdate>2003</risdate><volume>72</volume><issue>1</issue><spage>17</spage><epage>28</epage><pages>17-28</pages><issn>1386-5056</issn><eissn>1872-8243</eissn><abstract>Background: Problem lists are fundamental to electronic medical records (EMRs). However, obtaining an appropriate problem list dictionary is difficult, and getting users to code their problems at the time of data entry can be challenging.
Objective: To develop a problem list dictionary and search algorithm for an EMR system and evaluate its use.
Methods: We developed a problem list dictionary and lookup tool and implemented it in several EMR systems. A sample of 10,000 problem entries was reviewed from each system to assess overall coding rates. We also performed a manual review of a subset of entries to determine the appropriateness of coded entries, and to assess the reasons other entries were left uncoded.
Results: The overall coding rate varied significantly between different EMR implementations (63–79%). Coded entries were virtually always appropriate (99%). The most frequent reasons for uncoded entries were due to user interface failures (44–45%), insufficient dictionary coverage (20–32%), and non-problem entries (10–12%).
Conclusion: The problem list dictionary and search algorithm has achieved a good coding rate, but the rate is dependent on the specific user interface implementation. Problem coding is essential for providing clinical decision support, and improving usability should result in better coding rates.</abstract><cop>Shannon</cop><pub>Elsevier Ireland Ltd</pub><pmid>14644303</pmid><doi>10.1016/j.ijmedinf.2003.08.002</doi><tpages>12</tpages></addata></record> |
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| ispartof | International journal of medical informatics (Shannon, Ireland), 2003-12, Vol.72 (1), p.17-28 |
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| subjects | Algorithms Biological and medical sciences Boston Efficiency, Organizational Forms and Records Control Health Services Research Humans Medical record systems, computerized Medical Records Systems, Computerized - organization & administration Medical records, problem-orientated Medical Records, Problem-Oriented Medical sciences Multi-Institutional Systems Quality Assurance, Health Care Radiotherapy. Instrumental treatment. Physiotherapy. Reeducation. Rehabilitation, orthophony, crenotherapy. Diet therapy and various other treatments (general aspects) Technology. Biomaterials. Equipments. Material. Instrumentation User-Computer Interface Vocabulary, Controlled |
| title | Automated coded ambulatory problem lists: evaluation of a vocabulary and a data entry tool |
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