Towards the Development of a Web Support System for Improving Accuracy in Coding Discharge Diagnosis The practice of coding morbidity data using international standard diagnostic classifications has become increasingly important and recognized as a difficult and timeconsuming task. Clinical codersphysicians assign codes to each patient episode based on their interpretation of the available case notes or the electronic patient record systems. Therefore, accurate coding depends on the legibility of the case notes and on the codersxe2x80x98 understanding of medical terminology. Several studies have indicated poor reproducibility of clinical coding. To support physicians, in the coding of diagnoses and procedures using ICD 9th revision, Clinical Modifications (ICD9CM), and in identifying the main condition to be filled in Hospital Discharge Records, the SISCO.web service is proposed. The service has the aim of improving the accuracy of coding by using the combination of NLP algorithms, controlled vocabularies mapped to ICD9CM, as well as codingrules and a decision trees for the identification of the main condition.

Problems and Barriers during the Process of Clinical Coding: a Focus Group Study of Codersxe2x80x99 Perceptions Coded data are the basis of information systems in all countries that rely on Diagnosis Related Groups in order to reimbursefinance hospitals, including both administrative and clinical data. To identify the problems and barriers that affect the quality of the coded data is paramount to improve data quality as well as to enhance its usability and outcomes. This study aims to explore problems and possible solutions associated with the clinical coding process. Problems were identified according to the perspective of ten medical coders, as the result of four focus groups sessions. This convenience sample was sourced from four public hospitals in Portugal. Questions relating to problems with the coding process were developed from the literature and authorsxe2x80x99 expertise. Focus groups sessions were taped, transcribed and analyzed to elicit themes. Variability in the documents used for coding, illegibility of hand writing when coding on paper, increase of errors due to an extra actor in the coding process when transcribed from paper, difficulties in the diagnosesxe2x80x99 coding, coding delay and unavailability of resources and tools designed to help coders, were some of the problems identified. Some problems were identified and solutions such as the standardization of the documents used for coding an episode, the adoption of the electronic coding, the development of tools to help coding and audits, and the recognition of the importance of coding by the management were described as relevant factors for the improvement of the quality of data.