Are central hospitals ready for national health insurance? ICD coding quality from an electronic patient discharge record for clinicians

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dc.contributor.authorDyers, Robin E.en_ZA
dc.contributor.authorEvans, Julieten_ZA
dc.contributor.authorWard, Grant Alexen_ZA
dc.contributor.authorDu Plooy, Shaneen_ZA
dc.contributor.authorMahomed, Hassanen_ZA
dc.date.accessioned2017-02-10T09:08:16Z
dc.date.available2017-02-10T09:08:16Z
dc.date.issued2016-02
dc.descriptionCITATION: Dyers, R. E. et al. 2016. Are central hospitals ready for national health insurance? ICD coding quality from an electronic patient discharge record for clinicians. South African Medical Journal, 106(2):181-185, doi:10.7196/SAMJ.2016.v106i2.10079.
dc.descriptionThe original publication is available at http://www.samj.org.za
dc.description.abstractENGLISH SUMMARY : Background. South Africa (SA)’s planned National Health Insurance reforms require the use of International Statistical Classification of Diseases (ICD) codes for hospitals to purchase services from the proposed National Health Authority. However, compliance with coding at public hospitals in the Western Cape Province has been challenging. A computer application was developed to aid clinicians in integrating ICD coding into the patient hospital discharge process.Objective. To evaluate the quality of ICD codes captured using the application and predictors thereof in a single hospital department.Methods. After 6 months, the quality of ICD codes was determined by comparing ICD code descriptors with medical concepts in a random sample of original patient records selected over a 6-week period. Patient and personnel characteristics influencing quality of coding, derived from a theoretical framework, were collected.Results. Of 223 patient records, 45.3% (95% confidence interval (CI) 38.8 - 51.9) had complete ICD codes. Primary ICD code accuracy was 74.0% (95% CI 67.8 - 79.5). Patient characteristics such as female gender, younger age group and fewer comorbidities, as well as seniority of clinician rank, were significantly associated with ICD coding being complete on adjusted analysis.Conclusion. The results of this study describe ICD coding quality at a central hospital in SA supported by a computer application and the factors influencing this. More interventions are required to achieve reliable coding data, such as additional ICD coding validation tools, training and oversight of junior clinicians.en_ZA
dc.description.urihttp://www.samj.org.za/index.php/samj/article/view/10079
dc.description.versionPublisher's version
dc.format.extent5 pages
dc.identifier.citationDyers, R. E. et al. 2016. Are central hospitals ready for national health insurance? ICD coding quality from an electronic patient discharge record for clinicians. South African Medical Journal, 106(2):181-185, doi:10.7196/SAMJ.2016.v106i2.10079.
dc.identifier.issn2078-5135 (online)
dc.identifier.issn0256-9574 (print)
dc.identifier.otherdoi:10.7196/SAMJ.2016.v106i2.10079
dc.identifier.urihttp://hdl.handle.net/10019.1/100618
dc.language.isoen_ZAen_ZA
dc.publisherHealth & Medical Publishing Group
dc.rights.holderAuthors retain copyright
dc.subjectHospitals -- Western Cape (South Africa)en_ZA
dc.subjectNational health insurance -- South Africaen_ZA
dc.subjectNosology -- Code numbers.en_ZA
dc.subjectInternational Classification of Diseases (ICD) codingen_ZA
dc.titleAre central hospitals ready for national health insurance? ICD coding quality from an electronic patient discharge record for cliniciansen_ZA
dc.typeArticleen_ZA
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