Accuracy and Completeness of Clinical Coding Using ICD-10 for Ambulatory Visits.

This study describes a simulation of diagnostic coding using an EHR. Twenty-three ambulatory clinicians were asked to enter appropriate codes for six standardized scenarios with two different EHRs. Their interactions with the query interface were analyzed for patterns and variations in search strategies and the resulting sets of entered codes for accuracy and completeness.

Higher accuracy of complex medication reconciliation through improved design of electronic tools.

Objective: Investigate the accuracy of 2 different medication reconciliation tools integrated into electronic health record systems (EHRs) using a cognitively demanding scenario and complex medication history.

Materials And Methods: Seventeen physicians reconciled medication lists for a polypharmacy patient using 2 EHRs in a simulation study. The lists contained 3 types of discrepancy and were transmitted between the systems via a Continuity of Care Document.

Small pulmonary nodules: detection at chest CT and outcome.

Purpose: To determine the outcome of pulmonary nodules less than 1 cm in diameter detected at chest computed tomography (CT).

Materials And Methods: Reports of chest CT performed during 6 months were reviewed to find patients with pulmonary nodules smaller than 1 cm in long axis for which repeat CT was recommended. Records were studied to determine whether follow-up had been performed, the initial nodules had changed in size, or nodules had been resected.