Automated Procedure Code Entry Decreases Error Rates

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Automated entry of procedure codes in radiology reports reduces the percentage of errors compared to manual entry, reveals a study conducted at Massachusetts General Hospital in Boston, Massachusetts and published in the September issue of the Journal of the American College of Radiology (JACR).

In 2007, the hospital’s radiology department migrated to automated procedure code entry from manual entry and implemented a report dictation system which, when accession coding was dictated by a reporting radiologist, automatically inserted a procedure description based on that accession coding. The researchers evaluated a random sample comprising 3,948 reports prepared manually over a two-year period prior to the automation initiative and 4,598 reports created using the automated system for a two-year interval after it was deployed.

The evaluation revealed a total of 63 errors in the automated reports, equal to an error rate of 1.37%. If the radiology procedure codes had been recorded manually in the group of automated reports, the researchers hypothesize, the error rate uncovered would be comparable to the 3.95% rate for the manual group of reports, resulting in 181 errors rather than 63.

Moreover, the researchers assert that had the hospital's radiology department been audited for compliance by the Office of Inspector General (OIG) of the U.S. Department of Health and Human Services (HHS) during each of the time periods, better compliance would have been seen in the latter based on the error rates identified in the study.

In the JACR report, the researchers also concede that they did not record the type of studies that were incorrectly coded by the automated system. Had they done so, they say, the cause or causes of such erroneous coding might have been identified and corrected, increasing the coding accuracy level to nearly 98%.