Context-oriented coding aids for healthcare activity description

Since 1989, the French healthcare politic has introduced a national healthcare information system, based on the hospitalization description by diagnosis and procedure codes according to a standardized format derived from Disease Related Groups. The medical interest of such an information database is limited by the data quality, and the coding task remains difficult and constraining for physicians. We report the results of a preliminary study, whose objective was to measure the effects on information quality of context-oriented coding forms. In a French hospital, coding forms were elaborated for frequent and standardized clinical situations in the cardiology field during the 1998-year. The comparison of the a 3-year activity description in the concerned unit showed an improvement in the mean number of target procedure codes, the choice of the principal diagnosis, the precision of data and the abstract classification, despite a loss in diagnostic codes. Coding controls by expert confirmed the data quality improvement. The concept of context-oriented coding aid can be extended to other medical disciplines but the paper supply limits the aid content, and leads to problematic maintenance updating. The opportunity to integrate the coding forms in a unique digital library using a semantic network structure is discussed.