Clinical Review

Free Clinic Diagnosis Data Improvement Project Using International Classification of Diseases and Electronic Health Record


 

References

A starting report was pulled March 22, 2021, covering encounters between September 6, 2017, and March 22, 2021, for the 20 most common diagnoses. Another report was pulled at the completion of the implementation phase, on June 15, 2021, covering March 22, 2021, to June 15, 2021. Willing providers and staff members were surveyed after implementation completion. The providers were asked whether they use the ICD codes, whether they would do so in the future, and whether they found it helpful when other providers had entered diagnoses. If they answered no to any of the questions, there were asked why, and whether they had any suggestions for improvements. The 4 staff members were asked whether they thought the data were helpful for their role and, if so, how they would use it.

Surveys

Surveys were conducted after the project was completed with willing and available providers and staff members in order to assess the utility of the project as well as to ensure future improvements and sustainability of the system.

Provider surveys

Do you currently input mapped ICD-10 codes when you chart for each encounter?

Yes No

If yes, do you intend to continue inputting the ICD codes in your encounters in the future?

Yes No

If no to either question above, please explain:

Do you have any recommendations for making it easier to input ICD codes or another way to track patients’ diagnoses?

Staff surveys

Is this data helpful for your role?

Yes No

If yes, how will you use this data?

Results

During the implementation phase, hypertension was the most common diagnosis seen at TOFC, accounting for 35 of 131 (27%) top 20 diagnoses entered. Depression was second, accounting for about 20% of diagnoses. Posttraumatic stress disorder was the third most common, making up 18% of diagnoses. There were 157 encounters during the implementation phase and 128 ICD diagnoses entered into the chart during this time period, suggesting that most encounters had a corresponding diagnosis code entered. See the Table for more details.

Pages

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