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Biomedical subjects

F Pürner

Publications and source records attributed to F Pürner.

4 recordsLinked to original sources

Coding medical concepts: a controlled experiment with a computerised coding tool.

In clinical routine there is a growing need to encode medical concepts with available standard coding systems. The coding process can be time consuming and may significantly add to daily paperwork, particularly regarding patients with multiple diagnoses and in busy clinical environments with a high turnover of patients. We have developed a generic computerised encoding tool--the PADS encoder--to ensure rapid, correct and complete coding of diagnoses in daily routine. The tool is integrated into an electronic patient record system (PADS, Patient Archiving & Documentation System) and takes full advantage of the user friendly Macintosh interface. The tool was tested in a controlled experiment by 18 clinicians who encoded a total of 666 medical concepts in each protocol (study protocol vs. control). The following positive findings were significantly associated with the use of the computerised coding tool: the number of correctly encoded medical concepts was higher (99.55% vs. 86.1%), coding errors were lower (0% vs. 10.81%), more modifier codes were encoded correctly (increase by up to 43%), less coding errors were made (decrease by up to 43%), the overall rate of correctly encoded and complete main and modifier codes was increased by 31.27% (97.29% vs. 66.02%), coding time was reduced by 50%. This paper presents data to suggest that a computerised coding tool can produce more complete data of higher quality and can save time compared with the traditional approach to encode medical concepts.

Computer Communication Networks↗

4.5 years of experience with an electronic patient record system at the University of Munich: PADS (Patient Archiving & Documentation System).

We demonstrate an Ethernet based local area network (LAN) with clinical workstations (Apple Macintosh). The patient archiving and documentation system (PADS) represents a computerized patient record system presently used in a university hospital's ICU, CCU, and oncology unit [1]. Since 1990, over 100 users have documented more than 6,000 patient admissions, equaling 30% of all inpatient admission in our hospital. Taking full advantage of the macintosh based graphical user interface (GUI), our system enables nurses and doctors to perform the following tasks: admission, medical history taking, physical examination, generation of problem lists and follow up notes, access to laboratory data and reports, and the semiautomatic generation of a discharge summary including full word processor capabilities. Furthermore, the system offers rapid, consistent, and complete automatic encoding of diagnoses following the International Classification of Disease (ICD - 9 CM; WHO). The system has links to other educational programs such as cardiac auscultation and image analysis. A MEDLINE literature search through a CD-ROM based system can be performed from within the system. CD-ROM based medical textbooks can be accessed as well. Users can customize their working environment and use any commercially available macintosh programs from within the main application. Additional options include: automatic background monitoring of users learning behavior, analyses and graphical display of numerous epidemiological, and healthcare related problems. Furthermore, sound and digital video can be recorded in our system. E had initially developed a relational database 4GL development tool in the rapid prototyping phase, and have since completed the next step of development: rewriting the complete application using C++ and Oracle. The user interface has hardly changed, maintaining the "look & feel" of the initial application and introducing the performance of a professional relational database management system (RDBMS). This system represents one in a line of modular departmental models which are being integrated to form a decentralized hospital information system (HIS) at the University of Munich. The proposed theater-style demonstration will walk the audience through the system simulating a true patient admission and work up.

Germany↗

PADS (Patient Archiving and Documentation System): a computerized patient record with educational aspects.

Rapid acquisition and analysis of information in an Intensive Care Unit (ICU) setting is essential, even more so the documentation of the decision making process which has vital consequences for the lives of ICU patients. We describe an Ethernet based local area network (LAN) with clinical workstations (Macintosh fx, ci). Our Patient Archiving and Documentation System (PADS) represents a computerized patient record presently used in a university hospitals' ICU. Taking full advantage of the Macintosh based graphical user interface (GUI) our system enables nurses and doctors to perform the following tasks: admission, medical history taking, physical examination, generation of problem lists and follow up notes, access to laboratory data and reports, semiautomatic generation of a discharge summary including full word processor capabilities. Furthermore, the system offers rapid, consistent and complete automatic encoding of diagnoses following the International Classification of Disease (ICD; WHO, [1]). For educational purposes the user can also view disease entities or complications related to the diagnoses she/he encoded. The system has links to other educational programs such as cardiac auscultation. A MEDLINE literature search through a CD-ROM based system can be performed without exiting the system; also, CD-ROM based medical textbooks can be accessed as well. Commercially available Macintosh programs can be integrated in the system without existing the main program thus enabling users to customize their working environment. Additional options include automatic background monitoring of users learning behavior, analyses and graphical display of numerous epidemiological and health care related problems. Furthermore, we are in the process of integrating sound and digital video in our system. This system represents one in a line of modular departmental models which will eventually be integrated to form a decentralized Hospital Information System (HIS).

Computer User Training↗

Coding medical concepts: a controlled experiment with a computerized coding tool.

In medicine there is a growing need to encode medical concepts with the available standard coding systems. The coding process can be time intensive and may significantly add to daily paperwork. We have developed a generic computerized encoding tool--the PADS (patient archiving and documentation system) encoder--to ensure rapid, correct and complete coding of diagnoses in daily routine. The tool is integrated into an electronic patient record system and takes full advantage of the user friendly Macintosh interface. The tool was tested in a controlled experiment by 18 clinicians who encoded a total of 666 medical concepts in each protocol (study protocol versus control). We present data demonstrating that a computerized coding tool can produce more complete data of higher quality and save time compared with the traditional approach: (a) the number of correctly encoded medical concepts was higher (99.55% versus 86.1%); (b) coding errors were lower (0% versus 10.81%); (c) more modifier codes were encoded correctly (increase by up to 43%); (d) fewer coding errors were made (decrease by up to 43%); (e) the overall rate of correctly encoded and complete main and modifier codes was increased by 31.27% (97.29% versus 66.02%); and (f) coding time was reduced by 50%.

Abstracting and Indexing↗