Subject: EPR and auto-coding
- Does your Trust have a fully or partially implemented Electronic Patient Record (EPR)?
- What is the name and supplier of the EPR?
- For inpatient / daycase activity does the EPR have an ‘auto clinical coding’ function i.e. can clinical codes (ICD-10 / OPCS) be automatically assigned / suggested without manual intervention by a clinical coder?
- Is the auto-coding based solely on structured clinical information or is free-text analysed in addition?
- If free-text is used how is this analysed to predict clinical codes?
- If based on structured clinical information which clinical classification / terminology is used to record the clinical information (e.g. SNOMED CT / ICD-10 / OPCS / local codes)?
- Does the Trust utilise the auto-coding function in any way?
- If yes then which specialties is it used for?
- Is all auto-coding validated by trained clinical coders?
- Has the auto-coding improved the Trust’s clinical coding audit results / accuracy levels?
- Has the auto-coding improved the depth of coding in anyway?
- If the auto-coding function is not used what are the reasons for not using this function.
|Please find information attached.
2018-678 – FOI Request – EPR and auto-coding [110 kb] PDF