Reference 2018-678

REF:           2018-678

Subject:       EPR and auto-coding



  1. Does your Trust have a fully or partially implemented Electronic Patient Record (EPR)?

If yes:

  1. What is the name and supplier of the EPR?
  2. 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?

If yes:

  1. Is the auto-coding based solely on structured clinical information or is free-text analysed in addition?
  2. If free-text is used how is this analysed to predict clinical codes?
  3. 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)?
  4. Does the Trust utilise the auto-coding function in any way?
  5. If yes then which specialties is it used for?
  6. Is all auto-coding validated by trained clinical coders?
  7. Has the auto-coding improved the Trust’s clinical coding audit results / accuracy levels?
  8. Has the auto-coding improved the depth of coding in anyway?
  9. 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