A Method of Assessment of Reliability of Coding Clinical terms to ICD-10 and ICPC Using ENCODE-FMΩ, a Primary Care Controlled Clinical Terminology

Abstract

Background: Data entry into electronic medical records remains a barrier to their use in primary care. One of the difficulties in data recording has been the use of terminologies unsuited to clinical data entry by physicians. Canada has chosen ICD-10 as its standard of classification of medical diagnoses and the World Organization of Family Doctors created and uses ICPC-2. In this study, we tested a clinical terminology for reliability of classification. ICD-10 is not intended to be used by clinicians as care is given, and ICPC is too small to be useful to follow patients in a clinical record. ENCODE-FMΩ is a clinical terminology specifically designed to overcome these limitations and provide both clinical specificity of health problems for patient care, and data aggregation for statistics and research. This study was intended both to test the reliability of data entry using ENCODE-FMΩ and to serve as a model methodology for testing vocabularies in general. Method: Terms for "reason for encounter" taken from a random selection of encounter forms in family practice were coded by five different physician coders using a computerised search engine for ENCODE-FMΩ. Intraclass correlations were calculated to see how well clinical data grouped to ICD-10 and ICPC. Results: Use of the ENCODE-FMΩ clinical terminology resulted in highly reliable data aggregation to the standard international classifications ICD-10 and ICPC. Intraclass correlations were .87 (p<.001) and .85 (p<.001). Interpretation: The study shows that the method of assessment is both simple and acceptable. ENCODE-FMΩ can be used reliably for data entry into an electronic medical record, and analysis of coding errors suggests that direct data entry by care providers would be more reliable than third party coding. Physician coders prefer simple partial word searches.

Keywords

• Classifications
• terminologies
• ICD-10
• ICPC
• ENCODE-FMΩ
• clinical vocabularies