The diagnosis related groups enhanced electronic medical record

Problem. The introduction of Diagnosis Related Groups as a basis for hospital payment in Germany announced essential changes in the hospital reimbursement practice. A hospital's economical survival will depend vitally on the accuracy and completeness of the documentation of DRG relevant data li...

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Bibliographic Details
Published in:International journal of medical informatics (Shannon, Ireland) Ireland), 2003-07, Vol.70 (2), p.221-228
Main Authors: Müller, Marcel Lucas, Bürkle, Thomas, Irps, Sebastian, Roeder, Norbert, Prokosch, Hans-Ulrich
Format: Article
Language:English
Subjects:
Biological and medical sciences
Computerized hospital information systems
Diagnosis-Related Groups
electronic medical records
Expert systems
Germany
Hospital Charges
Humans
Information Storage and Retrieval
Insurance, Health, Reimbursement
Internet
Medical informatics applications
Medical record linkage
Medical records systems
Medical Records Systems, Computerized
Medical sciences
Practice Guidelines as Topic
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Summary:Problem. The introduction of Diagnosis Related Groups as a basis for hospital payment in Germany announced essential changes in the hospital reimbursement practice. A hospital's economical survival will depend vitally on the accuracy and completeness of the documentation of DRG relevant data like diagnosis and procedure codes. In order to enhance physicians’ coding compliance, an easy-to-use interface integrating coding tasks seamlessly into clinical routine had to be developed. A generic approach should access coding and clinical guidelines from different information sources. Methods. Within the Electronic Medical Record (EMR) a user interface (‘DRG Control Center’) for all DRG relevant clinical and administrative data has been built. A comprehensive DRG-related web site gives online access to DRG grouping software and an electronic coding expert. Both components are linked together using an application supporting bi-directional communication. Other web based services like a guideline search engine can be integrated as well. Results. With the proposed method, the clinician gains quick access to context sensitive clinical guidelines for appropriate treatment of his/her patient and administrative guidelines for the adequate coding of the diagnoses and procedures. This paper describes the design and current implementation and discusses our experiences.
ISSN:1386-5056
1872-8243
DOI:10.1016/S1386-5056(03)00050-9