Background Reliable information which can only be derived from accurate data is crucial to the success of the health system. Since encoded data on diagnoses and procedures are put to a broad range of uses, the accuracy of coding is imperative. Accuracy of coding with the International Classification of Diseases, 10th revision (ICD-10) is impeded by a manual coding process that is dependent on the medical records officers’ level of experience/knowledge of medical terminologies. Aim statement To improve the accuracy of ICD-10 coding of morbidity/mortality data at the general hospitals in Lagos State from 78.7% to ≥95% between March 2018 and September 2018. Methods A quality improvement (QI) design using the Plan–Do–Study–Act cycle framework. The interventions comprised the introduction of an electronic diagnostic terminology software and training of 52 clinical coders from the 26 general hospitals. An end-of-training coding exercise compared the coding accuracy between the old method and the intervention. The outcome was continuously monitored and evaluated in a phased approach. Results Research conducted in the study setting yielded a baseline coding accuracy of 78.7%. The use of the difficult items (wrongly coded items) from the research for the end-of-training coding exercise accounted for a lower coding accuracy when compared with baseline. The difference in coding accuracy between manual coders (47.8%) and browser-assisted coders (54.9%) from the coding exercise was statistically significant. Overall average percentage coding accuracy at the hospitals over the 12-month monitoring and evaluation period was 91.3%. Conclusion This QI initiative introduced a stop-gap for improving data coding accuracy in the absence of automated coding and electronic health record. It provides evidence that the electronic diagnostic terminology tool does improve coding accuracy and with continuous use/practice should improve reliability and coding efficiency in resource-constrained settings.

中文翻译：

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通过在尼日利亚拉各斯的综合医院引入电子诊断术语工具，提高 ICD-10 发病率/死亡率数据编码的准确性

背景 只能从准确数据中获得的可靠信息对于卫生系统的成功至关重要。由于有关诊断和程序的编码数据被广泛使用，因此编码的准确性势在必行。国际疾病分类第 10 版 (ICD-10) 编码的准确性受到手动编码过程的阻碍，该过程取决于病历官员的医学术语经验/知识水平。目标声明 将 2018 年 3 月至 2018 年 9 月拉各斯州综合医院的发病率/死亡率数据的 ICD-10 编码准确性从 78.7% 提高到≥95%。 方法 使用 Plan-Do 的质量改进 (QI) 设计– 研究 – 行动周期框架。干预包括引入电子诊断术语软件和培训来自 26 家综合医院的 52 名临床编码员。训练结束时的编码练习比较了旧方法和干预之间的编码准确性。以分阶段的方式持续监测和评估结果。结果 在研究环境中进行的研究产生了 78.7% 的基线编码准确度。与基线相比，在训练结束编码练习中使用研究中的困难项目（错误编码的项目）导致编码准确性较低。编码练习中手动编码器 (47.8%) 和浏览器辅助编码器 (54.9%) 之间的编码准确性差异具有统计学意义。在 12 个月的监测和评估期间，医院的总体平均编码准确率为 91.3%。结论 在缺乏自动编码和电子健康记录的情况下，这项 QI 计划为提高数据编码的准确性提供了一个权宜之计。它提供的证据表明，电子诊断术语工具确实提高了编码准确性，并且随着持续使用/实践应该提高资源受限环境中的可靠性和编码效率。