Development of Construction Model of Disease Classification on Clinical Diagnosis in Ophthalmology

Suh, Jin-Sook; Shin, Hee-Young; Kee, Chang-Won

Journal of Korean Society Quality Assurance Health Care 2003;10(2): 204.
Published online December 30, 2003.

임상진단명에 따른 질병분류체계 구축모형 개발 - 안과를 대상으로 -

서진숙¹, 신희영¹, 기창원²

¹삼성서울병원 의무기록파트
²성균관대학교 의과대학 안과

Development of Construction Model of Disease Classification on Clinical Diagnosis in Ophthalmology

Jin-Sook Suh¹, Hee-Young Shin¹, Chang-Won Kee²

¹Department of Medical Record, Samsung Medical Center
²Department of Ophthalmology, Samsung Medical Center, Sungkyunkwan University School of Medicine

Abstract

Background
ICD-10 Classification, which is used domestically as well as internationally, has limited use in the clinical practice since it is developed for at disease statistics and epidemiology. Therefore, the purposes of this study were to improve the quality of diagnosis by constructing a new disease classification based on the diagnoses doctors currently make in the clinical setting and connecting this classification with OCS and EMR, and to meet the demands of doctors for high quality medical study data in medical research.
Methods
The specialists in each ophthalmic subfield collected clinical diagnoses and abbreviations based on the ophthalmology textbooks and confirmed the classifications. Total number of clinical diagnoses collected was totaled 672, for which ideal diagnoses had been selected and a new model of disease classification model in connection with ICD-10 was constructed. The constructed classification of clinical diagnoses consisted of six steps: the first step was the classification by ophthalmic subspecialty field; the second to fifth steps were the detailed classification by each specialty field; the sixth step was the classification by site.
Results
After introducing the new disease classification, research on the use and a pre-post comparison was conducted. The result from the research on the use of the clinical diagnoses in inpatient and outpatient care has shown a gradually increasing tendency. From the pre-post comparison of EMR discharge summary diagnoses, the result demonstrated that the diagnosis was stated correctly and in detail. Since the diagnosis was stated correctly, code classification became correct as well, which makes it possible to construct high quality medical DB.
Conclusion
This construction of clinical diagnoses provides the medical team with high quality medical information. It is also expected to increase the accuracy and efficiency of service in the department of medical record and department of insurance investigation. In the future, if hospitals wish to construct a classification of clinical diagnosis and a standard proposal of clinical diagnosis is presented by a medical society, the standardization of diagnosis seems to be possible.

Key words Clinical diagnosis;Disease classification;