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Prateeksha, Pawar* Dr. B. V. Yadav. "A Review on Medical Coding in Healthcare." International Journal of Pharmaceutical Sciences 3, no. 4 (2025): 1863–78. https://doi.org/10.5281/zenodo.15222504.
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Medical coding serves as a vital bridge connecting healthcare providers, insurance companies, and regulatory organizations, ensuring smooth communication and efficient operations within the healthcare ecosystem. This overview highlights the core objectives of medical coding, explores its transformative relationship with artificial intelligence (AI), and delves into key aspects such as the coding process, certification programs, the critical importance of accuracy, and opportunities for careers or entrepreneurship in this dynamic field. The advent of AI has dramatically reshaped the landscape of medical coding. By employing technologies like machine learning algorithms, AI has made the coding process more efficient and precise. Automated systems can now analyze vast amounts of healthcare data, translating complex narrative details into accurate medical codes with remarkable speed. This innovation not only accelerates the workflow but also significantly reduces the risk of errors, ultimately enhancing the overall quality of medical coding practices.
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Reid, Beth. "Analysing DRG Data from a Coding Perspective." Australian Medical Record Journal 18, no. 2 (1988): 59–62. http://dx.doi.org/10.1177/183335838801800206.
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In this paper the author discusses the benefits of analysing diagnosis related groups (DRGs) from a coding perspective. Relevant literature is reviewed on issues associated with local coding practices, selection of principal diagnosis, “DRG creep”, the accuracy of coded data and methods for detecting coding errors. The author argues for employing a coding expert such as a medical record administrator in order to gain important insight into the analysis of DRG data and to provide feedback to coders for continuing quality assurance of coded data.
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Schapira, Marilyn M., Keri L. Rodriguez, Sumedha Chhatre, et al. "When Is a Harm a Harm? Discordance between Patient and Medical Experts’ Evaluation of Lung Cancer Screening Attributes." Medical Decision Making 41, no. 3 (2021): 317–28. http://dx.doi.org/10.1177/0272989x20987221.
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Background A shared decision-making (SDM) process for lung cancer screening (LCS) includes a discussion between clinicians and patients about benefits and potential harms. Expert-driven taxonomies consider mortality reduction a benefit and consider false-positives, incidental findings, overdiagnosis, overtreatment, radiation exposure, and direct and indirect costs of LCS as potential harms. Objective To explore whether patients conceptualize the attributes of LCS differently from expert-driven taxonomies. Design Cross-sectional study with semistructured interviews and a card-sort activity. Participants Twenty-three Veterans receiving primary care at a Veterans Affairs Medical Center, 55 to 73 y of age with 30 or more pack-years of smoking. Sixty-one percent were non-Hispanic African American or Black, 35% were non-Hispanic White, 4% were Hispanic, and 9% were female. Approach Semistructured interviews with thematic coding. Main Measures The proportion of participants categorizing each attribute as a benefit or harm and emergent themes that informed this categorization. Key Results In addition to categorizing reduced lung cancer deaths as a benefit (22/23), most also categorized the following as benefits: routine annual screening (8/9), significant incidental findings (20/23), follow-up in a nodule clinic (20/23), and invasive procedures (16/23). Four attributes were classified by most participants as a harm: false-positive (13/22), overdiagnosis (13/23), overtreatment (6/9), and radiation exposure (20/22). Themes regarding the evaluation of LCS outcomes were 1) the value of knowledge about body and health, 2) anticipated positive and negative emotions, 3) lack of clarity in terminology, 4) underlying beliefs about cancer, and 5) risk assessment and tolerance for uncertainty. Conclusions Anticipating discordance between patient- and expert-driven taxonomies of the benefits and harms of LCS can inform the development and interpretation of value elicitation and SDM discussions.
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Narroschke, Matthias. "Benefits and costs of scalable video coding for internet streaming." Journal of Visual Communication and Image Representation 16, no. 4-5 (2005): 397–411. http://dx.doi.org/10.1016/j.jvcir.2004.11.010.
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Cole, Rebekah, Audra G. Garrigan, Sidney A. Peters, et al. "Medical Students’ Integration of Formative Feedback During Simulation: A Grounded Theory Study." Military Medicine 188, Supplement_3 (2023): 48–55. http://dx.doi.org/10.1093/milmed/usac378.
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ABSTRACT Introduction Formative feedback is critical for trainees’ growth and development. However, there is a gap in the professional literature regarding the ways in which formative feedback affects student performance during simulation. This grounded theory study addresses this gap by exploring the ways in which medical students received and integrated ongoing formative feedback throughout a multiday, high-fidelity military medical simulation, Operation Bushmaster. Materials and Methods Our research team interviewed 18 fourth-year medical students in order to investigate how they processed formative feedback during the simulation. Guided by the grounded theory tradition of qualitative research, our research team used open coding and axial coding to categorize the data. We then used selective coding to determine the casual relationships between each of the categories that emerged from the data. These relationships determined our grounded theory framework. Results Four phases emerged from the data and provided a framework to delineate the process in which students received and integrated formative feedback throughout the simulation: (1) ability to self-assess, (2) self-efficacy, (3) leadership and teamwork, and (4) appreciation of feedback for personal and professional growth. The participants first focused on feedback related to their individual performance but then shifted to a teamwork and leadership mindset. Once they adapted this new mindset, they began to intentionally provide feedback to their peers, increasing their team’s performance. At the end of the simulation, the participants recognized the benefits of formative feedback and peer feedback for ongoing professional development throughout their careers, signifying a growth mindset. Conclusions This grounded theory study provided a framework for determining how medical students integrated formative feedback during a high-fidelity, multiday medical simulation. Medical educators can use this framework to intentionally guide their formative feedback in order to maximize student learning during simulation.
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Walker, Sue, Maryann Wood, Jeffrey Wilks, and Jennifer Nicol. "Comparing ICD-9-CM and ICD-10 Classification Systems in a Primary Health Care Setting: Some Initial Observations." Health Information Management 25, no. 3 (1995): 83–86. http://dx.doi.org/10.1177/183335839502500305.
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The ICD-10 is due to be introduced into Australia during the late 1990s, superseding the current and widely used ICD-9-CM. Improvements in areas such as number of codes, an expanded external cause framework, and more context to injuries are expected to make the ICD-10 a more streamlined system for practitioners. The present study examined both classification formats using data from 1183 presentations to primary health clinics at island tourist resorts. Some initial observations are made about differences in the two systems, highlighting the greater coding detail provided by the ICD-10, particularly in the area of injuries. It is recommended that further empirical testing be undertaken using the ICD-10 in a variety of settings so as to identify benefits in the coding of both medical conditions and injuries.
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Ullah, Fasee, Izhar Ullah, Atif Khan, M. Irfan Uddin, Hashem Alyami, and Wael Alosaimi. "Enabling Clustering for Privacy-Aware Data Dissemination Based on Medical Healthcare-IoTs (MH-IoTs) for Wireless Body Area Network." Journal of Healthcare Engineering 2020 (November 28, 2020): 1–10. http://dx.doi.org/10.1155/2020/8824907.
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There is a need to develop an effective data preservation scheme with minimal information loss when the patient’s data are shared in public interest for different research activities. Prior studies have devised different approaches for data preservation in healthcare domains; however, there is still room for improvement in the design of an elegant data preservation approach. With that motivation behind, this study has proposed a medical healthcare-IoTs-based infrastructure with restricted access. The infrastructure comprises two algorithms. The first algorithm protects the sensitivity information of a patient with quantifying minimum information loss during the anonymization process. The algorithm has also designed the access polices comprising the public access, doctor access, and the nurse access, to access the sensitivity information of a patient based on the clustering concept. The second suggested algorithm is K-anonymity privacy preservation based on local coding, which is based on cell suppression. This algorithm utilizes a mapping method to classify the data into different regions in such a manner that the data of the same group are placed in the same region. The benefit of using local coding is to restrict third-party users, such as doctors and nurses, when trying to insert incorrect values in order to access real patient data. Efficiency of the proposed algorithm is evaluated against the state-of-the-art algorithm by performing extensive simulations. Simulation results demonstrate benefits of the proposed algorithms in terms of efficient cluster formation in minimum time, minimum information loss, and execution time for data dissemination.
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Trombert-Paviot, Beatrice, Alan Rector, Robert Baud, et al. "The Development of CCAM: The New French Coding System of Clinical Procedures." Health Information Management 31, no. 1 (2003): 2–11. http://dx.doi.org/10.1177/183335830303100103.
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A new French coding system of clinical procedures, the Classification Commune Des Actes Medicaux (CCAM), has been developed at the turn of the millennium (between 1996 and 2001). Two methodologies were used: a traditional domain-experts consensus method, and an artificial-intelligence-based semantic representation. An economic evaluation of clinical procedures was also undertaken for the rating for fee-for-service payment. We present the methodologies used and stress how the European Union research project, ‘European Consortium, Generalised Architecture for Languages, Encyclopaedias and Nomenclatures in Medicine’ (GALEN), facilitated the sharing and maintaining of consistent medical knowledge. This country case study highlights the significant cost to individual countries in developing their own classifications in isolation. It also demonstrates the benefits of contributing to international efforts such as GALEN that enable harmonisation, yet still allow for diversity.
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Nurfena, Deta Nurfena, Laela Indawati, Deasy Rosmala Dewi, and Puteri Fannya. "Analisis Ketepatan Kode Diagnosis Typhoid Fever Pada Rekam Medis Rawat Inap di Rumah Sakit Islam Karawang Tahun 2020." Cerdika: Jurnal Ilmiah Indonesia 2, no. 4 (2022): 491–96. http://dx.doi.org/10.36418/cerdika.v2i4.363.
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Medical record is a file containing records and documents regarding patient identity, examination, treatment, actions and other services that have been provided to patients. where one of the services provided is the management of patient medical record documents that contain coding of diagnoses and actions given to patients. The implementation of coding disease diagnoses in hospitals is a very important activity, namely by classifying disease diagnoses into several groups for the benefit of reports that the hospital does every month, both for internal reports and external reports and plays an important role in the financing system at the hospital itself. The purpose of this study was to determine the accuracy of the diagnosis code for typhoid fever in inpatients at the Karawang Islamic Hospital. The research methodology was carried out using quantitative descriptive methods, the population was 200 medical records of typhoid fever patients in 2020, with a total sample of 67 samples. The sampling technique used is simple random sampling. How to collect data is done by direct observation. The accuracy of the code obtained is 31 (46%) correct codes and 36 (54%) incorrect codes, the inaccuracy of the code is caused by the medical record professional staff in charge of the coding section who are still not focused and not careful with laboratory results to determine the results of the coding. It is correct and only codes for the H titer, while in determining the diagnosis of typhoid fever, it is seen from the O titer. Suggestions for coding the diagnosis carried out at the Karawang Islamic Hospital are expected that the coding is carried out correctly according to the diagnosis, history, and laboratory results.
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Moens, Maarten, Leen Van Doorslaer, Maxime Billot, et al. "Examining the Type, Quality, and Content of Web-Based Information for People With Chronic Pain Interested in Spinal Cord Stimulation: Social Listening Study." Journal of Medical Internet Research 26 (January 30, 2024): e48599. http://dx.doi.org/10.2196/48599.
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Background The increased availability of web-based medical information has encouraged patients with chronic pain to seek health care information from multiple sources, such as consultation with health care providers combined with web-based information. The type and quality of information that is available on the web is very heterogeneous, in terms of content, reliability, and trustworthiness. To date, no studies have evaluated what information is available about neuromodulation on the web for patients with chronic pain. Objective This study aims to explore the type, quality, and content of web-based information regarding spinal cord stimulation (SCS) for chronic pain that is freely available and targeted at health care consumers. Methods The social listening tool Awario was used to search Facebook (Meta Platforms, Inc), Twitter (Twitter, Inc), YouTube (Google LLC), Instagram (Meta Platforms, Inc), blogs, and the web for suitable hits with “pain” and “neuromodulation” as keywords. Quality appraisal of the extracted information was performed using the DISCERN instrument. A thematic analysis through inductive coding was conducted. Results The initial search identified 2174 entries, of which 630 (28.98%) entries were eventually withheld, which could be categorized as web pages, including news and blogs (114/630, 18.1%); Reddit (Reddit, Inc) posts (32/630, 5.1%); Vimeo (Vimeo, Inc) hits (38/630, 6%); or YouTube (Google LLC) hits (446/630, 70.8%). Most posts originated in the United States (519/630, 82.4%). Regarding the content of information, 66.2% (383/579) of the entries discussed (fully discussed or partially discussed) how SCS works. In total, 55.6% (322/579) of the entries did not elaborate on the fact that there may be >1 potential treatment choice and 47.7% (276/579) did not discuss the influence of SCS on the overall quality of life. The inductive coding revealed 4 main themes. The first theme of pain and the burden of pain (1274/8886, 14.34% coding references) explained about pain, pain management, individual impact of pain, and patient experiences. The second theme included neuromodulation as a treatment approach (3258/8886, 36.66% coding references), incorporating the background on neuromodulation, patient-centered care, SCS therapy, and risks. Third, several device-related aspects (1722/8886, 19.38% coding references) were presented. As a final theme, patient benefits and testimonials of treatment with SCS (2632/8886, 29.62% coding references) were revealed with subthemes regarding patient benefits, eligibility, and testimonials and expectations. Conclusions Health care consumers have access to web-based information about SCS, where details about the surgical procedures, the type of material, working mechanisms, risks, patient expectations, testimonials, and the potential benefits of this therapy are discussed. The reliability, trustworthiness, and correctness of web-based sources should be carefully considered before automatically relying on the content.
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Shenoda, Botros B., and Seena K. Ajit. "Modulation of Immune Responses by Exosomes Derived from Antigen-Presenting Cells." Clinical Medicine Insights: Pathology 9s1 (January 2016): CPath.S39925. http://dx.doi.org/10.4137/cpath.s39925.
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Exosome-mediated signaling is important in mediating the inflammatory response. To exert their biological or pathophysiological functions in the recipient cells, exosomes deliver a diverse array of biomacromolecules including long and short coding and non-coding RNAs, proteins, and lipids. Exosomes secreted by antigen-presenting cells can confer therapeutic benefits by attenuating or stimulating the immune response. Exosomes play a crucial role in carrying and presenting functional major histocompatibility peptide complexes to modulate antigen-specific T cell responses. Exosomes from Dendritic Cells (DCs) can activate T and B cells and have been explored for their immunostimulatory properties in cancer therapy. The immunosuppressive properties of exosomes derived from macrophages and DCs can reduce inflammation in animal models for several inflammatory disorders. This review focuses on the protective role of exosomes in attenuating inflammation or augmenting immune response, emphasizing studies on exosomes derived from DCs and macrophages.
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Rajabi, Sadegh, Huda Fatima Rajani, Niloufar Mohammadkhani, et al. "Long Non-Coding RNAs as Novel Targets for Phytochemicals to Cease Cancer Metastasis." Molecules 28, no. 3 (2023): 987. http://dx.doi.org/10.3390/molecules28030987.
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Metastasis is a multi-step phenomenon during cancer development leading to the propagation of cancer cells to distant organ(s). According to estimations, metastasis results in over 90% of cancer-associated death around the globe. Long non-coding RNAs (LncRNAs) are a group of regulatory RNA molecules more than 200 base pairs in length. The main regulatory activity of these molecules is the modulation of gene expression. They have been reported to affect different stages of cancer development including proliferation, apoptosis, migration, invasion, and metastasis. An increasing number of medical data reports indicate the probable function of LncRNAs in the metastatic spread of different cancers. Phytochemical compounds, as the bioactive agents of plants, show several health benefits with a variety of biological activities. Several phytochemicals have been demonstrated to target LncRNAs to defeat cancer. This review article briefly describes the metastasis steps, summarizes data on some well-established LncRNAs with a role in metastasis, and identifies the phytochemicals with an ability to suppress cancer metastasis by targeting LncRNAs.
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Welke, Karl F., Tara Karamlou, and Brian S. Diggs. "Databases for assessing the outcomes of the treatment of patients with congenital and paediatric cardiac disease – a comparison of administrative and clinical data." Cardiology in the Young 18, S2 (2008): 137–44. http://dx.doi.org/10.1017/s1047951108002837.
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AbstractThe introduction of the reporting of medical and surgical outcomes to the public and the potential implementation of initiatives involving pay-for-performance have invigorated debates about the relative benefits of administrative and clinical databases for comparing rates of mortality at the level of the hospital and surgeon. While general agreement exists that public performance report cards must use the highest quality data available, debate continues regarding whether administrative or clinical data should be utilized for this purpose. Clinical databases may contain information more relevant to risk-adjustment, but the currently available clinical databases are voluntary and suffer from validity concerns. Administrative data, however, suffer from inaccuracies of coding and a lack of potentially informative covariates. Particularly problematic to congenital heart surgery is the non-uniform application of coding algorithms to define complex reconstructive procedures for which there is no unique code assignment. The purposes of this manuscript are; therefore, to discuss the relative advantages and limitations of both clinical and administrative data, and to provide a brief introduction to currently available databases germane to the study of congenital cardiac disease.
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Szymczak, Julia E., Brandi M. Muller, Nikitha Shankar Shakamuri, et al. "Prescriber perceptions of fluoroquinolones, extended-spectrum cephalosporins, and Clostridioides difficile infection." Infection Control & Hospital Epidemiology 41, no. 8 (2020): 914–20. http://dx.doi.org/10.1017/ice.2020.183.
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AbstractBackground:Fluoroquinolones (FQs) and extended-spectrum cephalosporins (ESCs) are associated with higher risk of Clostridioides difficile infection (CDI). Decreasing the unnecessary use of FQs and ESCs is a goal of antimicrobial stewardship. Understanding how prescribers perceive the risks and benefits of FQs and ESCs is needed.Methods:We conducted interviews with clinicians from 4 hospitals. Interviews elicited respondent perceptions about the risk of ESCs, FQs, and CDI. Interviews were audio recorded, transcribed, and analyzed using a flexible coding approach.Results:Interviews were conducted with 64 respondents (38 physicians, 7 nurses, 6 advance practice providers, and 13 pharmacists). ESCs and FQs were perceived to have many benefits, including infrequent dosing, breadth of coverage, and greater patient adherence after hospital discharge. Prescribers stated that it was easy to make decisions about these drugs, so they were especially appealing to use in the context of time pressures. They described having difficulty discontinuing these drugs when prescribed by others due to inertia and fear. Prescribers were skeptical about targeting specific drugs as a stewardship approach and felt that the risk of a negative outcome from under treatment of a suspected bacterial infection was a higher priority than the prevention of CDI.Conclusions:Prescribers in this study perceived many advantages to using ESCs and FQs, especially under conditions of time pressure and uncertainty. In making decisions about these drugs, prescribers balance risk and benefit, and they believed that the risk of CDI was acceptable in compared with the risk of undertreatment.
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Falis, Matúš, Aryo Pradipta Gema, Hang Dong, et al. "Can GPT-3.5 generate and code discharge summaries?" Journal of the American Medical Informatics Association 31, no. 10 (2024): 2284–93. http://dx.doi.org/10.1093/jamia/ocae132.
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Abstract Objectives The aim of this study was to investigate GPT-3.5 in generating and coding medical documents with International Classification of Diseases (ICD)-10 codes for data augmentation on low-resource labels. Materials and Methods Employing GPT-3.5 we generated and coded 9606 discharge summaries based on lists of ICD-10 code descriptions of patients with infrequent (or generation) codes within the MIMIC-IV dataset. Combined with the baseline training set, this formed an augmented training set. Neural coding models were trained on baseline and augmented data and evaluated on an MIMIC-IV test set. We report micro- and macro-F1 scores on the full codeset, generation codes, and their families. Weak Hierarchical Confusion Matrices determined within-family and outside-of-family coding errors in the latter codesets. The coding performance of GPT-3.5 was evaluated on prompt-guided self-generated data and real MIMIC-IV data. Clinicians evaluated the clinical acceptability of the generated documents. Results Data augmentation results in slightly lower overall model performance but improves performance for the generation candidate codes and their families, including 1 absent from the baseline training data. Augmented models display lower out-of-family error rates. GPT-3.5 identifies ICD-10 codes by their prompted descriptions but underperforms on real data. Evaluators highlight the correctness of generated concepts while suffering in variety, supporting information, and narrative. Discussion and Conclusion While GPT-3.5 alone given our prompt setting is unsuitable for ICD-10 coding, it supports data augmentation for training neural models. Augmentation positively affects generation code families but mainly benefits codes with existing examples. Augmentation reduces out-of-family errors. Documents generated by GPT-3.5 state prompted concepts correctly but lack variety, and authenticity in narratives.
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Burks, Kristie, Jessie Shields, Joseph Evans, Jodi Plumley, Jarrett Gerlach, and Susan Flesher. "A systematic review of outpatient billing practices." SAGE Open Medicine 10 (January 2022): 205031212210990. http://dx.doi.org/10.1177/20503121221099021.
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Objectives: Healthcare coding and billing are an important aspect of practice management that directly impacts the financial stability of a health care practice. To financially sustain or grow a medical practice, it is imperative that resident and faculty physicians have knowledge and skills for accurate billing in every patient encounter. Methods: A systematic review was conducted to identify recently published studies that report on improvements in medical coding and billing accuracy, clinical documentation, and reimbursement rate. A search of three databases yielded a total of 5754 records. After screening, 41 records were sought for retrieval and a total of 18 records were obtained for review. Results: Following a thorough review of literature, the most common reasons for inaccurate or inappropriate billing were a lack of formal education within residency curriculum, inadequate clinical documentation supporting level of billing, and lack of a feedback system aimed to correct billing errors. Conclusion: A formal education curriculum implemented in training could enhance knowledge and application of accurate billing and coding and further benefit practice longevity. The purpose of this systematic review is to apply knowledge gained to the development and implementation of a quality improvement study intended to improve accuracy of coding and billing within an academic pediatric outpatient center.
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Toney, Ashley, María Piñeros-Leaño, Nancy Pérez-Flores, Diana Gomez, and Liliana Aguayo. "Health Beliefs About Diabetes Among Latina Mothers Living in Mexico and the United States: A Qualitative Study." Current Developments in Nutrition 6, Supplement_1 (2022): 868. http://dx.doi.org/10.1093/cdn/nzac065.052.
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Abstract Objectives Type 2 Diabetes Mellitus (T2DM) is the leading cause of death in Mexico and a serious health concern among Hispanic/Latinos in the United States (US). Using the Health Belief Model (HBM), this study aims to understand the beliefs about T2DM that inform the prevention and treatment behaviors of Mexican and Hispanic/Latina mothers living in Mexico and the US. Methods The Holistic Obesity Prevention Study (HOPS) used purposive sampling methods to recruit low-income Mexican or Hispanic/Latino mothers in San Luis Potosí, Mexico and Illinois, US. Semi-structured interviews were conducted in English (n = 1) and Spanish (n = 24) and transcribed verbatim. The HBM framework guided the examination of mothers’ perceptions about T2DM. Authors did 5 cycles of coding including initial memos, coding the quotes into the HBM framework, assigning an in vivo code followed by a process code, and lastly assigning themes and subthemes using axial coding in NVivo 12. Results Most mothers (n = 22, 88%) knew someone with T2DM. The HBM revealed the following themes: Perceived susceptibility: Mothers believed it can happen to them/anyone, and risks increased with strong emotions/a big scare, and with genetic predisposition. Perceived severity: Mothers mentioned constantly being careful (facing consequences), and difficulties of living with T2DM. Perceived benefits: Mothers recognized benefits of avoiding T2DM or controlling it, benefits from having a healthy diet, exercising, and staying in good spirits. Perceived barriers: Barriers included costs, continuing/starting exercise and dieting, not having time, and challenges modifying habits/willpower. Perceived cues to action: Cues to action were perceived from results from medical exams, and from feeling fear (from commercials, knowing people with T2DM, and having parents with T2DM). 6) Self-efficacy: Mothers shared their belief that the majority of those living with T2DM can live a healthy life by controlling their weight and exercising, watching what you eat, keeping up with their treatments/medications, and continuing to carry on. Conclusions Latinas believe they can live a healthy life, but face barriers in preventing T2DM. Findings can inform future T2DM prevention interventions that aim to promote behavioral changes among Mexican and Hispanic/Latina mothers. Funding Sources HOPS was supported by the USDA.
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Thoma, Brent, Eric Warm, Stanley J. Hamstra, et al. "Next Steps in the Implementation of Learning Analytics in Medical Education: Consensus From an International Cohort of Medical Educators." Journal of Graduate Medical Education 12, no. 3 (2020): 303–11. http://dx.doi.org/10.4300/jgme-d-19-00493.1.
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ABSTRACT Background With the implementation of competency-based assessment systems, education programs are collecting increasing amounts of data about medical learners. However, learning analytics are rarely employed to use this data to improve medical education. Objective We identified outstanding issues that are limiting the effective adoption of learning analytics in medical education. Methods Participants at an international summit on learning analytics in medical education generated key questions that need to be addressed to move the field forward. Small groups formulated questions related to data stewardship, learner perspectives, and program perspectives. Three investigators conducted an inductive qualitative content analysis on the participant questions, coding the data by consensus and organizing it into themes. One investigator used the themes to formulate representative questions that were refined by the other investigators. Results Sixty-seven participants from 6 countries submitted 195 questions. From them, we identified 3 major themes: implementation challenges (related to changing current practices to collect data and utilize learning analytics); data (related to data collection, security, governance, access, and analysis); and outcomes (related to the use of learning analytics for assessing learners and faculty as well as evaluating programs and systems). We present the representative questions and their implications. Conclusions Our analysis highlights themes regarding implementation, data management, and outcomes related to the use of learning analytics in medical education. These results can be used as a framework to guide stakeholder education, research, and policy development that delineates the benefits and challenges of using learning analytics in medical education.
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Gishen, Faye, and Rima Chakrabarti. "Medical student perceptions of reflective practice in the undergraduate curriculum." MedEdPublish 12 (July 25, 2022): 53. http://dx.doi.org/10.12688/mep.19211.1.
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Introduction: Reflective practice (RP) forms a core component of medical professionalism but, despite its benefits, it remains largely undervalued among medical students. The aim of this study was to explore medical students’ attitudes and barriers to engagement with RP in the undergraduate programme at a UK based medical school. Methods: This was a qualitative study based on the methodology of phenomenology. All penultimate year medical students at University College London Medical School (n=361) were approached for this study and altogether thirteen participants were recruited, with data collected through two focus group discussions. Thematic analysis was used to generate the coding framework. Results: Five key themes emerged around student attitudes to RP, which were grouped into three domains: ‘value of RP’, ‘barriers to engagement’, and ‘strategies for enabling RP’. ‘Value of RP’ centred on the themes of humanising medicine and developing empathy, developing professionalism and RP as a tool for sense-making. ‘Barriers to engagement’ centred on the purpose and tokenism of RP and in the third domain, ‘strategies for enabling RP’, the theme of student agency in RP emerged strongly. Conclusion: Overall, the value of RP was not fully appreciated until students began their clinical placements. Potential strategies identified by participants for optimising engagement included student co-design and positioning RP within a broader pastoral role early in the undergraduate curriculum.
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Gishen, Faye, and Rima Chakrabarti. "Medical student perceptions of reflective practice in the undergraduate curriculum." MedEdPublish 12 (December 8, 2022): 53. http://dx.doi.org/10.12688/mep.19211.3.
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Introduction: Reflective practice (RP) forms a core component of medical professionalism but, despite its benefits, it remains largely undervalued among medical students. The aim of this study was to explore medical students’ attitudes and barriers to engagement with RP in the undergraduate programme at a UK based medical school. Methods: This was a qualitative study based on the methodology of phenomenology. All penultimate year medical students at University College London Medical School (n=361) were approached for this study and altogether thirteen participants were recruited, with data collected through two focus group discussions. Thematic analysis was used to generate the coding framework. Results: Five key themes emerged around student attitudes to RP, which were grouped into three domains: ‘value of RP’, ‘barriers to engagement’, and ‘strategies for enabling RP’. ‘Value of RP’ centred on the themes of humanising medicine and developing empathy, developing professionalism and RP as a tool for sense-making. ‘Barriers to engagement’ centred on the purpose and tokenism of RP and in the third domain, ‘strategies for enabling RP’, the theme of student agency in RP emerged strongly. Conclusion: Overall, the value of RP was not fully appreciated until students began their clinical placements. Potential strategies identified by participants for optimising engagement included student co-design and positioning RP within a broader pastoral role early in the undergraduate curriculum.
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Gishen, Faye, and Rima Chakrabarti. "Medical student perceptions of reflective practice in the undergraduate curriculum." MedEdPublish 12 (October 27, 2022): 53. http://dx.doi.org/10.12688/mep.19211.2.
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Introduction: Reflective practice (RP) forms a core component of medical professionalism but, despite its benefits, it remains largely undervalued among medical students. The aim of this study was to explore medical students’ attitudes and barriers to engagement with RP in the undergraduate programme at a UK based medical school. Methods: This was a qualitative study based on the methodology of phenomenology. All penultimate year medical students at University College London Medical School (n=361) were approached for this study and altogether thirteen participants were recruited, with data collected through two focus group discussions. Thematic analysis was used to generate the coding framework. Results: Five key themes emerged around student attitudes to RP, which were grouped into three domains: ‘value of RP’, ‘barriers to engagement’, and ‘strategies for enabling RP’. ‘Value of RP’ centred on the themes of humanising medicine and developing empathy, developing professionalism and RP as a tool for sense-making. ‘Barriers to engagement’ centred on the purpose and tokenism of RP and in the third domain, ‘strategies for enabling RP’, the theme of student agency in RP emerged strongly. Conclusion: Overall, the value of RP was not fully appreciated until students began their clinical placements. Potential strategies identified by participants for optimising engagement included student co-design and positioning RP within a broader pastoral role early in the undergraduate curriculum.
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Epstein, Andrew S., Elyse Shuk, Danielle R. Romano, et al. "Stakeholders' perceptions and information needs regarding research medical donation (RMD)." Journal of Clinical Oncology 36, no. 34_suppl (2018): 27. http://dx.doi.org/10.1200/jco.2018.36.34_suppl.27.
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27 Background: Issues pertinent to serious illness are more prevalent in the current medical landscape of increasing technologic sophistication. RMD, the process of human tissue extraction within hours after death benefits cancer research but data are limited regarding barriers institutions face in accruing to RMD programs. Such data are needed due to the complex RMD process, such as communicating with patients (pts) and their proxies, and procuring tissue in a timely manner that also respects end-of-life care sensitivities. Methods: We explored perceived core needs and challenges of RMD by engaging stakeholders (cancer clinicians, pts, and their caregivers) in 8 teleconference focus groups from 2017-2018. Clinicians caring for pts with breast, pancreas, and lung cancers comprised 2 groups. Each cancer separately had 2 groups for pts and their caregivers. Each group lasted 90 minutes, was audio-recorded and transcribed. Research team members (2-3) recorded their observations about key themes from each transcript in an analysis template, with illustrative quotes supporting each theme. Following independent analysis, the coding team met to reach consensus on primary themes for that transcript. A consensus template describing the team’s views about themes from the transcript was generated. The team then met to establish agreement on the consensus templates and identify primary common and divergent themes across transcripts. Results: 45 people (13 clinicians, 24 pts, and 8 caregivers) participated in the groups. The themes identified were: 1) clinicians and pts generally had limited to no previous knowledge about RMD; 2) RMD was seen to mainly benefit research, not pts or families; 3) logistical and privacy questions and concerns arose; 4) introducing RMD was deemed sensitive and the timing patient-specific; 5) cancer type did not generally seem to impact RMD acceptability or participation. Conclusions: Patients, families, and cancer clinicians have generally low knowledge of RMD but upon learning about it, see it as a valuable program for scientific advancement, necessary to be carried out with individualized sensitivity to end-of-life issues, and through training programs with involved clinical staff.
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Hoare, Johanna, Sarah Garnett, Louise Baur, Natalie Lister, and Hiba Jebeile. "A Novel Method to Determine a Custom Sample Size for Image-Based Instagram Content Analysis." Current Developments in Nutrition 6, Supplement_1 (2022): 768. http://dx.doi.org/10.1093/cdn/nzac063.010.
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Abstract Objectives Most Instagram users are young people, and social media is often used to search nutrition information. Health interventions aimed at young people should consider such information sources. Content analyses of Instagram images offer insights into types of content that may influence nutrition-related decision making and health behaviors. However, the number of analyzed images in existing studies has varied, and methods to determine data-specific sample sizes to reach saturation have not been explored. We aimed to develop a method to determine sample sizes for image-based content analyses on Instagram. We piloted the method and determined the reliability by identifying the saturation point for content categorized under two separate nutrition-related hashtags. Methods Instagram ‘top posts’ for a 21-year-old user were searched using hashtags ‘mindfuleating’ and ‘intuitiveeating’. 1200 images from each were extracted. Hashtag-specific coding frameworks were constructed inductively by two authors, initially coding the image- and text-based elements of the first 90 images collaboratively. Next, increments of 45 images were coded independently, then compared, solving disagreements by discussion. The process was repeated until saturation occurred when no new codes emerged. This was repeated seven weeks later to determine reliability. Results The coding frameworks constructed for #mindfuleating at first and second capture comprised 63 and 74 distinct codes, with saturation occurring at 360 and 405 images, respectively. The #intuitiveeating frameworks comprised 83 and 86 codes, with saturation at 450 and 495 images, respectively. The codes captured detailed pictorial content (e.g., ‘female’, ‘White’, ‘young adult’) and text (e.g., ‘nutrition information’, ‘relationship with food’). For both hashtags, the number of image-based codes decreased while text-based codes increased between coding. Conclusions Variations in coding frameworks and sample sizes over a short timeframe reflect the dynamic nature of Instagram content. Assessment of diet trends on social media requires accurate sampling to ensure nuances of a specific topic are captured, while research efficiency benefits from reduced data redundancy. Funding Sources NHMRC Peter Doherty Early Career Fellowship; Sydney Medical School Foundation, The University of Sydney.
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Hsieh, Ping Ang, and Ja-Ling Wu. "A Review of the Asymmetric Numeral System and Its Applications to Digital Images." Entropy 24, no. 3 (2022): 375. http://dx.doi.org/10.3390/e24030375.
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The Asymmetric Numeral System (ANS) is a new entropy compression method that the industry has highly valued in recent years. ANS is valued by the industry precisely because it captures the benefits of both Huffman Coding and Arithmetic Coding. Surprisingly, compared with Huffman and Arithmetic coding, systematic descriptions of ANS are relatively rare. In 2017, JPEG proposed a new image compression standard—JPEG XL, which uses ANS as its entropy compression method. This fact implies that the ANS technique is mature and will play a kernel role in compressing digital images. However, because the realization of ANS involves combination optimization and the process is not unique, only a few members in the compression academia community and the domestic industry have noticed the progress of this powerful entropy compression approach. Therefore, we think a thorough overview of ANS is beneficial, and this idea brings our contributions to the first part of this work. In addition to providing compact representations, ANS has the following prominent feature: just like its Arithmetic Coding counterpart, ANS has Chaos characteristics. The chaotic behavior of ANS is reflected in two aspects. The first one is that the corresponding compressed output will change a lot if there is a tiny change in the original input; moreover, the reverse is also applied. The second is that ANS compressing an image will produce two intertwined outcomes: a positive integer (aka. state) and a bitstream segment. Correct ANS decompression is possible only when both can be precisely obtained. Combining these two characteristics helps process digital images, e.g., art collection images and medical images, to achieve compression and encryption simultaneously. In the second part of this work, we explore the characteristics of ANS in depth and develop its applications specific to joint compression and encryption of digital images.
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Deer, Rachel, Janna Lehe, Colleen James, and Erin Hommel. "Translating Research Findings Into an Evidenced-Based Approach to Improve Hospital Practices for Malnutrition." Innovation in Aging 4, Supplement_1 (2020): 141. http://dx.doi.org/10.1093/geroni/igaa057.461.
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Abstract Malnutrition is a common problem that often goes unrecognized. In a recent UTMB-OAIC funded pilot, we found 49% of older adults were at risk of malnutrition at hospital admission. Malnutrition is associated with increased length of stay, poorer patient outcomes, and higher risk of mortality. Also, malnutrition severity alters hospital reimbursement rates. In 2018, the UTMB health system recognized the need for institutional guidelines to help identify, diagnose, document, and code mild/moderate/severe malnutrition. At baseline, compared to similar academic medical centers, UTMB ranked in the bottom quartile for malnutrition diagnosis. A multidisciplinary committee formed with physicians, nurses, researchers, dieticians, coding, and information technology. Preliminary data from the pilot study found the Nutritional Risk Screen (NRS) had the best sensitivity, specificity, positive and negative predictive values. The NRS was made more user friendly with scripting/prompts in the electronic medical record (EMR) to improve consistency/compliance among nurses. The Subjective Global Assessment was used in EMR by dieticians to document malnutrition diagnosis. A Best Practice Advisory was created to give physicians the option to easily add malnutrition diagnosis to the problem list. Since “go-live” in February 2019, NRS completion improved from 10.6% to 70.0%. Coding of malnutrition increased from 3.7% to 5.8%. In a 6 month follow-up, 113 patients were found to have direct benefits from the new process, resulting in an estimated financial impact of $945,605. Going forward, we have identified multiple areas of continued education needs to further improve the implementation and uptake of the new screening tool and diagnostic processes.
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Coronado, Rogelio, Kristin R. Archer, Tyler Toledo, et al. "137 Patient perceptions of nonpharmacological pain treatment in the emergency department setting." Journal of Clinical and Translational Science 7, s1 (2023): 41–42. http://dx.doi.org/10.1017/cts.2023.219.
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OBJECTIVES/GOALS: This study examined patient perceptions on the benefits, barriers, and facilitators of conventional and complementary/behavioral pain strategies that can be offered in the ED setting including physical therapy, mindfulness, acupuncture, and yoga. METHODS/STUDY POPULATION: We conducted and recorded semi-structured interviews with 30 patients who presented to the ED with musculoskeletal pain. Interviews focused on patients’ perceptions of NP pain treatments, barriers/facilitators to utilization, and recommendations that would promote engagement. A hierarchical coding system was developed and refined using the interview guide, the Theory of Planned Behavior, and preliminary review of the transcripts. The iterative process of developing the coding system allowed us to identify preliminary themes. RESULTS/ANTICIPATED RESULTS: Patients believe education on pain and the mind-body connection would give a sense of pain control. Likely barriers to engaging at the ED include lights, noise, interruptions, and uncertainty of their medical status. Post-discharge NP treatment barriers are financial and logistical. Engagement can be facilitated by a desire to avoid opioids, familiarity with meditation practices, and consistent positive communication with the health care team. Patients desire evidence on effectiveness, including testimonials, and suggested NP techniques should be introduced early, with written materials used for post-discharge referral. Patients prefer in-person treatment but would appreciate a virtual option. The initial session should occur in-person to build trust and facilitate virtual session engagement. DISCUSSION/SIGNIFICANCE: Patients are willing to engage in nonpharmacological pain treatment, however the unpredictable ED environment, uncertainty of their medical status, and financial and time constraints are significant barriers.
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Cooper, Richard, Claire Anderson, Tony Avery, et al. "Stakeholders’ views of UK nurse and pharmacist supplementary prescribing." Journal of Health Services Research & Policy 13, no. 4 (2008): 215–21. http://dx.doi.org/10.1258/jhsrp.2008.008004.
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Objectives: Supplementary prescribing (SP) by pharmacists and nurses in the UK represents a unique approach to improving patients’ access to medicines and better utilizing health care professionals’ skills. Study aims were to explore the views of stakeholders involved in SP policy, training and practice, focusing upon issues such as SP benefits, facilitators, challenges, safety and costs, thereby informing future practice and policy. Method: Qualitative, semi-structured interviews were conducted with 43 purposively sampled UK stakeholders, including pharmacist and nurse supplementary prescribers, doctors, patient groups representatives, academics and policy developers. Analysis of transcribed interviews was undertaken using a process of constant comparison and framework analysis, with coding of emergent themes. Results: Stakeholders generally viewed SP positively and perceived benefits in terms of improved access to medicines and fewer delays, along with a range of facilitators and barriers to the implementation of this form of non-medical prescribing. Stakeholders’ views on the economic impact of SP varied, but safety concerns were not considered significant. Future challenges and implications for policy included SP being potentially superseded by independent nurse and pharmacist prescribing, and the need to improve awareness of SP. Several potential tensions emerged including nurses’ versus pharmacists’ existing skills and training needs, supplementary versus independent prescribing, SP theory versus practice and prescribers versus non-prescribing peers. Conclusion: SP appeared to be broadly welcomed by stakeholders and was perceived to offer patient benefits. Several years after its introduction in the UK, stakeholders still perceived several implementation barriers and challenges and these, together with various tensions identified, might affect the success of supplementary and other forms of non-medical prescribing.
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Jutel, Annemarie, and Deborah Lupton. "Digitizing diagnosis: a review of mobile applications in the diagnostic process." Diagnosis 2, no. 2 (2015): 89–96. http://dx.doi.org/10.1515/dx-2014-0068.
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AbstractAn increasing number of smartphone and software applications (“apps”) have been developed and marketed to assist in the process of diagnosis, yet little attention has been paid to their content, claims, potential risks, limitations or benefits of their use. This study sought to describe and catalogue available diagnosis apps and explore their impact on the diagnostic process. We undertook a content analysis of the app descriptions and developers’ websites using the descriptions provided for 131 medical diagnosis smartphone apps that were available in the Google Play and Apple App stores. Each app was reviewed for its content and approach, and its claims to medical authority. Four major categories of apps were identified: 1. apps for diagnosing; 2. diagnosis coding apps; 3. books, journals, or other publications in app format; 4. apps for medical education. Our analysis found that while these apps provide access to medical information previously widely not available to lay users and offered a convenient diagnostic tool for practitioners, many failed to describe the evidence base underpinning, or any other credential supporting, their design and use. These apps potentially shift how diagnosis operates, reconfiguring disease concepts and lay-professional relations. However they also raise the risk of conflict of interest and presenting inaccurate information. Further research is required into how these apps are used, the implications for medical practice and the impact on doctor-patient relationship.
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Wang, Jian, Xian-Hua Han, Yingying Xu, et al. "Sparse Codebook Model of Local Structures for Retrieval of Focal Liver Lesions Using Multiphase Medical Images." International Journal of Biomedical Imaging 2017 (2017): 1–13. http://dx.doi.org/10.1155/2017/1413297.
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Characterization and individual trait analysis of the focal liver lesions (FLL) is a challenging task in medical image processing and clinical site. The character analysis of a unconfirmed FLL case would be expected to benefit greatly from the accumulated FLL cases with experts’ analysis, which can be achieved by content-based medical image retrieval (CBMIR). CBMIR mainly includes discriminated feature extraction and similarity calculation procedures. Bag-of-Visual-Words (BoVW) (codebook-based model) has been proven to be effective for different classification and retrieval tasks. This study investigates an improved codebook model for the fined-grained medical image representation with the following three advantages: (1) instead of SIFT, we exploit the local patch (structure) as the local descriptor, which can retain all detailed information and is more suitable for the fine-grained medical image applications; (2) in order to more accurately approximate any local descriptor in coding procedure, the sparse coding method, instead of K-means algorithm, is employed for codebook learning and coded vector calculation; (3) we evaluate retrieval performance of focal liver lesions (FLL) using multiphase computed tomography (CT) scans, in which the proposed codebook model is separately learned for each phase. The effectiveness of the proposed method is confirmed by our experiments on FLL retrieval.
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Hardwick, Laura. "A Comparative View on Molecular Alterations and Potential Therapeutic Strategies for Canine Oral Melanoma." Veterinary Sciences 8, no. 11 (2021): 286. http://dx.doi.org/10.3390/vetsci8110286.
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Canine oral melanoma (COM) is a highly aggressive tumour associated with poor prognosis due to metastasis and resistance to conventional anti-cancer therapies. As with human mucosal melanoma, the mutational landscape is predominated by copy number aberrations and chromosomal structural variants, but differences in study cohorts and/or tumour heterogeneity can lead to discordant results regarding the nature of specific genes affected. This review discusses somatic molecular alterations in COM that result from single nucleotide variations, copy number changes, chromosomal rearrangements, and/or dysregulation of small non-coding RNAs. A cross-species comparison highlights notable recurrent aberrations, and functionally grouping dysregulated proteins reveals unifying biological pathways that may be critical for oncogenesis and metastasis. Finally, potential therapeutic strategies are considered to target these pathways in canine patients, and the benefits of collaboration between science, medical, and veterinary communities are emphasised.
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Ly, Daniel, and Rima Chakrabarti. "‘I’m looking as white and as straight as possible at all times’: a qualitative study exploring the intersectional experiences of BAME LGBTQ+ medical students in the UK." BMJ Open 14, no. 8 (2024): e086346. http://dx.doi.org/10.1136/bmjopen-2024-086346.
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ObjectivesThe positive formation of professional identity is considered crucial in how medical students begin to feel and act as clinicians. Although, awareness of how Professional Identity Formation (PIF) may be affected among minoritised groups is increasing, understanding from an intersectional lens remains limited. The aim of this study was to explore the experiences of Black, Asian, Minoritised Ethnic (BAME) and Lesbian, Gay, Bisexual, Transgender, Queer (LGBTQ+) medical students in the undergraduate Bachelor of Medicine, Bachelor of Science programme.DesignBased on the methodology of phenomenography, all medical students identifying as BAME and LGBTQ+ were eligible for participation. Semistructured interviews were conducted with data collection continuing until theoretical saturation was reached. The coding framework was developed independently by the principal researcher and supervisor before being compared to create a shared analytical framework.SettingUniversity College London Medical School (UCLMS) between October 2022 and February 2023.ParticipantsSix UCLMS students were recruited, one of whom was in the ‘early’ years (years 1–3) with the remainder in the ‘later’ years (years 4–6)ResultsSix main themes emerged from the data, which were categorised into three main areas: challenges to intersectionality, benefits to intersectionality and protective factors. Challenges to intersectionality included three themes, ‘The BAME identity interacting with the LGBTQ+identity’, ‘BAME background influencing LGBTQ+identity exploration’ and ‘no true safe spaces for BAME and LGBTQ+ students to be themselves’. Benefits to intersectionality included ‘greater insight into the self’ and protective factors included two themes of ‘peer support networks’ and ‘visibility within the university and clinical environments.’ConclusionBy exploring PIF among medical students from an intersectional lens, this study highlights the increased emotional burden faced by those who identify as BAME and LGBTQ+, as they attempt to reconcile both these identities with becoming a future doctor, affecting their sense of belonging socially and within the profession. Despite being based at a single medical school, it highlights the importance of creating a truly inclusive environment through positive role modelling and increased visibility among the BAME, LGBTQ+ community in the undergraduate programme.
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Sonenshine, Daniel E., and Philip E. Stewart. "Microbiomes of Blood-Feeding Arthropods: Genes Coding for Essential Nutrients and Relation to Vector Fitness and Pathogenic Infections. A Review." Microorganisms 9, no. 12 (2021): 2433. http://dx.doi.org/10.3390/microorganisms9122433.
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Background: Blood-feeding arthropods support a diverse array of symbiotic microbes, some of which facilitate host growth and development whereas others are detrimental to vector-borne pathogens. We found a common core constituency among the microbiota of 16 different arthropod blood-sucking disease vectors, including Bacillaceae, Rickettsiaceae, Anaplasmataceae, Sphingomonadaceae, Enterobacteriaceae, Pseudomonadaceae, Moraxellaceae and Staphylococcaceae. By comparing 21 genomes of common bacterial symbionts in blood-feeding vectors versus non-blooding insects, we found that certain enteric bacteria benefit their hosts by upregulating numerous genes coding for essential nutrients. Bacteria of blood-sucking vectors expressed significantly more genes (p < 0.001) coding for these essential nutrients than those of non-blooding insects. Moreover, compared to endosymbionts, the genomes of enteric bacteria also contained significantly more genes (p < 0.001) that code for the synthesis of essential amino acids and proteins that detoxify reactive oxygen species. In contrast, microbes in non-blood-feeding insects expressed few gene families coding for these nutrient categories. We also discuss specific midgut bacteria essential for the normal development of pathogens (e.g., Leishmania) versus others that were detrimental (e.g., bacterial toxins in mosquitoes lethal to Plasmodium spp.).
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Armitage, Richard, and Ana Teresa Afonso. "WHO Emergency Medical Teams Minimal Data Set in Conflict-Stricken Ukraine: Comparative Analysis of a New Primary Health Care Coding Tool." Prehospital and Disaster Medicine 37, S2 (2022): s57. http://dx.doi.org/10.1017/s1049023x2200156x.
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Background/Introduction:The WHO EMT Minimum Data Set (EMT-MDS) was designed for data collection in sudden-onset disasters. Using EMT-MDS in the context of primary health care (PHC) generated large quantities of low granularity data that threatened the successful delivery of UK-Med’s clinical programs in Ukraine. Accordingly, UK-Med developed, piloted, and implemented a new coding tool (PHC-CT) tailored to PHC presentations prevalent in humanitarian settings.Objectives:To assess the performance of EMT-MDS and PHC-CT in the generation of programmatically-useful diagnostic codes from data collected in mobile PHC clinics in Ukraine during active conflict.To compare the performance of EMT-MDS and PHC-CT in this setting and to suggest recommendations for data collection tool improvements.Method/Description:After multiple iterations, the final version of PHC-CT was used to collect clinical data from all UK-Med clinical encounters in Ukraine from March 28, 2022-May 13, 2022. Clinical data using EMT-MDS were collected simultaneously. The prevalence of each diagnostic code was calculated using both EMT-MDS and PHC-CT, expressed as a proportion of the total diagnoses, and compared between the two coding tools.Results/Outcomes:1,390 clinical encounters took place during the study. Data coded using EMT-MDS generated 1,756 diagnoses (86.8% of total diagnoses) categorized as “Other Diagnosis” while the same data coded using PHC-CT generated 37 diagnoses (1.8% of total diagnoses) categorized as “Other Diagnosis.” Only seven of the available 25 diagnostic codes in EMT-MDS were used, while 48 of the 67 available diagnostic codes in PHC-CT were used.Conclusion:PHC-CT offers substantial benefits beyond those provided by EMT-MDS when utilized in mobile PHC clinics in humanitarian settings.Tables and Figures (optional)Table 1.Number of Clinical Encounters, Unique Diagnoses, and Frequency of Selected Diagnostic Codes for EMT-MDS and PHC-CT. (Note: % refers to proportion of diagnoses made)
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Mahdani, Resty, Tinika Yaumi, Yuda Syahidin, and Yuyun Yunengsih. "TATA KELOLA REKAM MEDIS BERBASIS ELEKTRONIK DALAM PEMBUATAN LAPORAN POLIKLINIK PASIEN RAWAT JALAN MENGGUNAKAN METODE AGILE." Jurnal Indonesia : Manajemen Informatika dan Komunikasi 4, no. 3 (2023): 1050–60. http://dx.doi.org/10.35870/jimik.v4i3.315.
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This study aims to determine the governance of electronic-based medical records in making outpatient polyclinic reports using the agile method. The research method used is qualitative research with a descriptive approach. After analyzing the needs of the polyclinic reporting system, this study presents the steps of implementing the agile method of extreme programming. By using this method, a system that is adaptable, responsive, and focused on user needs can be developed. The results show that the use of the agile extreme programming method in the development of an electronic-based medical record system provides significant benefits. The process of planning, designing, coding, testing, and releasing is done iteratively and collaboratively. With this approach, the system can be continuously improved and adjusted to meet changing user needs and priorities. By describing the system design flowmap, context diagram, DFD and ERD to visualize the relationship between the components in the system that provides a systematic description of the stages of the report generation process. In conclusion, electronic-based medical record governance in making outpatient polyclinic reports using the agile extreme programming method is an effective and efficient approach. By combining the advantages of agile and extreme programming methods, an adaptive and responsive system can be developed.
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Bell, Amanda, Aaron Johnston, Edward Makwarimba, and Rebecca Malhi. "Rewards and recognition for Canadian distributed medical education preceptors: a qualitative analysis." MedEdPublish 12 (June 17, 2022): 36. http://dx.doi.org/10.12688/mep.19152.2.
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Background: Recognition of Distributed Medical Education (DME) preceptors by medical schools ensures that important community-based training opportunities remain available to learners. Yet the literature seldom explores what rewards are meaningful to this population of teachers. The goal of our national project was to provide guidance to medical schools about the financial remuneration and non-financial rewards that are most valued by DME preceptors. Methods: In this qualitative study, we invited DME faculty members from all Canadian medical schools to participate in semi-structured interviews. Participants with a range of medical specialties, stages of career, and geographic locations were interviewed via Zoom videoconferencing. The sessions in English and French were audio-recorded and transcribed. We used line-by-line inductive coding and thematic analysis to examine participant talk about meaningful preceptor recognition. Results: Fourteen participants from multiple provinces were interviewed. Results indicated that the DME faculty are a diverse group of people with diverse needs. Most of the interviewees appreciated the rewards and recognition provided by their medical schools but felt that there are areas for improvement. Recognition is not necessarily monetary and should be tailored to the needs and the values of the recipient. Other themes included: benefits and challenges of being a preceptor, current institutional structures and supports, and the impact of the pandemic on preceptors. Conclusions: The interviews highlighted the importance placed by preceptors on personal rewards and a wide variety of forms of recognition. Based on the findings, we suggest specific steps that medical schools can take to support, engage, and recognize DME faculty.
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Ozeran, L., C. Hamann, W. Bria, and J. Shoolin. "Association of Medical Directors of Information Systems Consensus on Inpatient Electronic Health Record Documentation." Applied Clinical Informatics 04, no. 02 (2013): 293–303. http://dx.doi.org/10.4338/aci-2013-02-r-0012.
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SummaryIn 2013, electronic documentation of clinical care stands at a crossroads. The benefits of creating digital notes are at risk of being overwhelmed by the inclusion of easily importable detail. Providers are the primary authors of encounters with patients. We must document clearly our understanding of patients and our communication with them and our colleagues. We want to document efficiently to meet without exceeding documentation guidelines. We copy and paste documentation, because it not only simplifies the documentation process generally, but also supports meeting coding and regulatory requirements specifically. Since the primary goal of our profession is to spend as much time as possible listening to, understanding and helping patients, clinicians need information technology to make electronic documentation easier, not harder. At the same time, there should be reasonable restrictions on the use of copy and paste to limit the growing challenge of ‘note bloat’. We must find the right balance between ease of use and thoughtless documentation. The guiding principles in this document may be used to launch an interdisciplinary dialogue that promotes useful and necessary documentation that best facilitates efficient information capture and effective display. Citation: Shoolin J, Ozeran L, Hamann C, Bria W. II. Association of Medical Directors of Information Systems Consensus on Inpatient Electronic Health Record Documentation. Appl Clin Inf 2013; 4: 293–303http://dx.doi.org/10.4338/ACI-2013-02-R-0012
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Bell, Amanda, Aaron Johnston, Edward Makwarimba, and Rebecca Malhi. "Rewards and recognition for Canadian distributed medical education preceptors: a qualitative analysis." MedEdPublish 12 (May 16, 2022): 36. http://dx.doi.org/10.12688/mep.19152.1.
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Background: Recognition of Distributed Medical Education (DME) preceptors by medical institutions ensures that important community-based training opportunities remain available to learners. Yet the literature seldom explores what rewards are meaningful to this population of teachers. The goal of our national project was to provide guidance to medical schools about the financial remuneration and non-financial rewards that are most valued by DME preceptors. Methods: In this qualitative study, we invited DME faculty members from all Canadian medical schools to participate in semi-structured interviews. Participants with a range of medical specialties, stages of career, and geographic locations were interviewed via Zoom videoconferencing. The sessions in English and French were audio-recorded and transcribed. We used line-by-line inductive coding and thematic analysis to examine participant talk about meaningful preceptor recognition. Results: Fourteen participants from multiple provinces were interviewed. Results indicated that the DME faculty are a diverse group of people with diverse needs. Most of the interviewees appreciated the rewards and recognition provided by their institutions but felt that there are areas for improvement. Recognition is not necessarily monetary and should be tailored to the needs and the values of the recipient. Other themes included: benefits and challenges of being a preceptor, current institutional structures and supports, and the impact of the pandemic on preceptors. Conclusions: The interviews highlighted the importance placed by preceptors on personal rewards and a wide variety of forms of recognition. Based on the findings, we suggest specific steps that medical institutions can take to support, engage, and recognize DME faculty.
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Lalos, Aris S., Luis Alonso, Elli Kartsakli, et al. "RLNC-Aided Cooperative Compressed Sensing for Energy Efficient Vital Signal Telemonitoring." IEEE Transactions on Wireless Communications 14, no. 7 (2015): 3685–99. https://doi.org/10.5281/zenodo.56447.
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Wireless body area networks (WBANs) are composed of sensors that either monitor and transmit vital signals or act as relays that forward the received data to a body node coordinator (BNC). In this paper, we introduce an energy efficient vital signal telemonitoring scheme, which exploits compressed sensing (CS) for low-complexity signal compression/reconstruction and distributed cooperation for reliable data transmission to the BNC. More specifically, we introduce a cooperative compressed sensing (CCS) approach, which increases the energy efficiency of WBANs by exploiting the benefits of random linear network coding (RLNC). We study the energy efficiency of RLNC and compare it with the store-and-forward (FW) protocol. Our mathematical analysis shows that the gain introduced by RLNC increases as the link failure rate increases, especially in practical scenarios with a limited number of relays. Furthermore, we propose a reconstruction algorithm that further enhances the benefits of RLNC by exploiting key characteristics of vital signals. With the aid of electrocardiographic (ECG) and electroencephalographic (EEG) data available in medical databases, extensive simulation results are illustrated, which validate our theoretical findings and show that the proposed recovery algorithm increases the energy efficiency of the body sensor nodes by 40% compared to conventional CS-based reconstruction methods.
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Sun, Benjamin B., Mitja I. Kurki, Christopher N. Foley, et al. "Genetic associations of protein-coding variants in human disease." Nature 603, no. 7899 (2022): 95–102. http://dx.doi.org/10.1038/s41586-022-04394-w.
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AbstractGenome-wide association studies (GWAS) have identified thousands of genetic variants linked to the risk of human disease. However, GWAS have so far remained largely underpowered in relation to identifying associations in the rare and low-frequency allelic spectrum and have lacked the resolution to trace causal mechanisms to underlying genes1. Here we combined whole-exome sequencing in 392,814 UK Biobank participants with imputed genotypes from 260,405 FinnGen participants (653,219 total individuals) to conduct association meta-analyses for 744 disease endpoints across the protein-coding allelic frequency spectrum, bridging the gap between common and rare variant studies. We identified 975 associations, with more than one-third being previously unreported. We demonstrate population-level relevance for mutations previously ascribed to causing single-gene disorders, map GWAS associations to likely causal genes, explain disease mechanisms, and systematically relate disease associations to levels of 117 biomarkers and clinical-stage drug targets. Combining sequencing and genotyping in two population biobanks enabled us to benefit from increased power to detect and explain disease associations, validate findings through replication and propose medical actionability for rare genetic variants. Our study provides a compendium of protein-coding variant associations for future insights into disease biology and drug discovery.
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Hajar, Muhammad Hafizd Ibnu, Galang Persada Nurani Hakim, Ahmad Firdausi, and Eko Ramadhan. "Comparison in Quality of service Performance For Wireless Sensor Network Routing between Fuzzy Topsis and SAW Algorithm." Jurnal Informatika: Jurnal Pengembangan IT 6, no. 2 (2021): 114–18. http://dx.doi.org/10.30591/jpit.v6i2.2530.
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one of the advantages of Wireless Sensor Network would be its ability to reduce cost of communication system using node to node communication. Because of many things data transfer is Wireless Sensor Network operation sometimes has disturbance. A routing algorithm is a network coding that intends to enhance network performance for better operation with or without any disturbance. Fuzzy TOPSIS and SAW as MCDM algorithm is proposed for routing algorithm in Wireless Sensor Network operation. From our simulation both SAW and Fuzzy Topsis algorithm can be used in network coding (routing) to provide better QOS for Wireless Sensor Network compare with shortest path routing. For delay it perform better at about 2/3 (shortest path routing 50 millisecond, both SAW and Fuzzy Topsis algorithm 33 millisecond), and for packet loss at about 3/4 (shortest path routing 21 bit loss, both SAW and Fuzzy Topsis algorithm 16 bit loss). From our simulation both SAW and Fuzzy Topsis algorithm algorithm has benefit which is lower delay and packet loss but at higher cost which is more hopping for communication channel (shortest path routing 3 hopping, both SAW and Fuzzy Topsis algorithm 5 hopping)
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Heilbrun, M. Peter, and John R. Adler. "The 2009 devaluation of radiosurgery and its impact on the neurosurgery–radiation oncology partnership." Journal of Neurosurgery 113, no. 1 (2010): 10–15. http://dx.doi.org/10.3171/2010.1.jns09842.
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Neurosurgeons, radiation oncologists, and, increasingly, other surgical specialists recognize that radiosurgery is an important tool for managing selected disorders throughout the body. The partnership between neurosurgeons and radiation oncologists has resulted in collaborative studies that have established the clinical benefits of radiosurgery. Today, however, a range of political and financial issues is straining this relationship and thereby undermining the practice of radiosurgery. Neurosurgeons and radiation oncologists recently restricted the definition of radiosurgery to include only cranial- and spine-focused radiation treatments. Meanwhile, organized radiation oncology decided unilaterally that radiosurgery administered to other parts of the body would be termed stereotactic body radiation therapy. Finally, neurosurgical and radiation oncology coding experts developed new Current Procedural Terminology codes for cranial vault and spine radiosurgery, which were approved for use by the Relative Value Scale Update Committee as of 2009. The authors suggest that the neurosurgery strategy—which included 1) reasserting that all of the tasks of a radiosurgery procedure remain bundled, and 2) agreeing to limit the definition of radiosurgery to cranial vault and spine—has failed neurosurgeons who perform radiosurgery, and it may jeopardize patient access to this procedure in the future. The authors propose that all of the involved medical specialties recognize that the application of image-guided, focused radiation therapy throughout the body requires a partnership between radiation and surgical disciplines. They also urge surgeons to reexamine their coding methods, and they maintain that Current Procedural Terminology codes should be consistent across all of the different specialties involved in these procedures. Finally, surgeons should consider appropriate training in medical physics and radiobiology to perform the tasks involved in these specific procedures; ultimately all parties should receive equivalent reimbursement for similar assigned tasks, whether performed individually or jointly.
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Park, Hee Jun, Sung Uk Ma, and Hye-Yoon Lee. "A Qualitative Study on the Students' Perceptions of Elective Courses in Korean Medical Education." Journal of Korean Medicine 46, no. 1 (2025): 139–53. https://doi.org/10.13048/jkm.25010.
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Objectives: This study aimed to investigate the perceptions and assess the satisfaction of Korean medical students regarding elective courses in Korean medical educationMethods: Two rounds of online surveys and a focus group interview were conducted with second- and third-year student groups, with a total of twelve students participating—six students in each group. The first survey (March 19– 22, 2024) assessed students’ selection criteria and satisfaction levels using a 5-point Likert scale. Based on these results, a second survey (March 24–27, 2024) refined key topics for discussion. FGIs were held on March 25 and 26, 2024, with semi-structured questions. Interviews were recorded, transcribed verbatim, and analyzed using content analysis, applying In vivo and lean coding for categorization.Results: Survey results showed that faculty reputation, course content, and assessment difficulty were key factors in course selection. While syllabi were often referenced, their reliability was questioned due to content discrepancies. Initially, online lectures were favored for flexibility, but concerns arose over limited availability and inconsistent evaluations. FGI analysis confirmed that teaching styles and assessment methods significantly influenced decisions. As students recognized the benefits of in-person classes, their preference for face-to-face learning grew. Overall satisfaction with electives was moderate, with students highlighting the need for more practical courses and better faculty-student communication.Conclusions: Ensuring syllabus accuracy, standardizing evaluation criteria, incorporating student needs into course design, and enhancing faculty-student interaction may improve elective course selection.
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O'Keeffe, Mary, Alexandra Barratt, Christopher Maher, et al. "Media Coverage of the Benefits and Harms of Testing the Healthy: a protocol for a descriptive study." BMJ Open 9, no. 8 (2019): e029532. http://dx.doi.org/10.1136/bmjopen-2019-029532.
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IntroductionMuch testing in medicine is aimed at healthy people to facilitate the early detection of health conditions. However, there is growing evidence that early detection is a double-edged sword that may cause harm in the form of overdiagnosis. The media can be seen as a major generator of consumer demand for health services. Previous research shows that media coverage tends to overstate the benefits and downplay the harms of medical interventions for the sick, and often fails to cover relevant conflicts of interest of those promoting those interventions. However, little is known about how the benefits and harms of testing the healthy are covered by media. This study will examine the media coverage of the benefits and harms of testing the healthy, and coverage of potential conflicts of interest of those promoting the testing.Methods and analysisWe will examine five tests: 3D mammography for the early detection of breast cancer; blood liquid biopsy for the early detection of cancer; blood biomarker tests for the early detection of dementia; artificial intelligence technology for the early detection of dementia; and the Apple Watch Series 4 electrocardiogram sensor for the early detection of atrial fibrillation. We will identify media coverage using Google News and the LexisNexis and ProQuest electronic databases. Sets of two independent reviewers will conduct story screening and coding. We will include English language media stories referring to any of the five tests from January 2016 to May 2019. We will include media stories if they refer to any benefits or harms of the test for our conditions of interest. Data will be analysed using categorical data analysis and multinomial logistic regression.Ethics and disseminationNo ethical approval is required for this study. Results will be presented at relevant scientific conferences and in peer-reviewed literature.
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Makahleh, Hisham Y., Emma Jayne Sakamoto Ferranti, and Dilum Dissanayake. "Assessing the Role of Autonomous Vehicles in Urban Areas: A Systematic Review of Literature." Future Transportation 4, no. 2 (2024): 321–48. http://dx.doi.org/10.3390/futuretransp4020017.
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Autonomous vehicles (AVs) aim to improve safety and comfort of road users while contributing to the reduction of traffic congestion, air pollution, fuel consumption, and enabling mobility and accessibility of disabled and older people. As AV technology is rapidly advancing, there is an urgent need to explore how those new mobility services will impact urban transport systems, including the users, the infrastructure, and the design of future urban areas. This paper applies a systematic review to assess the role of AVs in urban areas. It reviews 41 articles published between 2003 and 2023, and uses inductive and deductive coding approaches to identify seven themes and thirty sub-themes within the literature. The seven include: benefits, attitudes, and behaviours and user perception, climate adaptation, climate mitigation, legislation and regulations, sustainability, and infrastructure. Studies related to benefits accounted for 25% of the sample, followed by behaviours and user perception (24%) and sustainability (22%). The least amount of research has been undertaken on the role of AVs to support climate adaptation. Geographically, almost half (#22) of the papers originate within Europe, followed by America (#10) and Asia (#7). There is only limited research originating from the Global South. This systematic review sets the scene for considering how AVs in public transport can be implemented in urban areas by establishing the current state of knowledge on user attitudes, perceptions, and behaviour, the benefits of AVs, the infrastructure and legislation and regulations required for AVs, and the role AVs have in climate mitigation, adaptation, and sustainability.
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Toussi, Nima, Caroline Zhang, Jocelyn Kang, and Edward J. Licitra. "Impact of AI medical scribes on physician productivity and satisfaction in medical oncology." Journal of Clinical Oncology 43, no. 16_suppl (2025): 11167. https://doi.org/10.1200/jco.2025.43.16_suppl.11167.
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11167 Background: AI Scribes are a leading example of AI implementation in clinical settings, with Oncology practices demonstrating exponential uptake since their introduction. Despite their ever-increasing usage, there are limited studies which directly interrogate the impact of AI Scribes on physician productivity metrics, and few which assess qualitative interpretations of the technology. Methods: This single-center, multi-site study enrolled 27 Medical Oncologists and 3 Primary Care Physicians randomly assigned in a 1:2 ratio to exposure to the Knowtex AI scribe in the initial phase (Phase 1) or control phase (Phase 2). Billing data was collected for 6 months prior to Phase 1 onboarding with Knowtex and for 16 weeks afterward—all within the 2024 fiscal year. During the same period, Phase 2 physicians billing data served as a non-exposed comparison group. Physicians completed opt-in surveys at Week 0 and Week 8 post-exposure assessing confidence and motivation to use the AI Scribe, documentation burden, documentation quality, and experience with the electronic medical record (EMR). Results: All providers adopted the Knowtex AI scribe during their study phase. 4 Phase 2 physicians were excluded from data analysis due to incomplete 2024 fiscal year data. Phase 1 physicians exhibited an increase in mean units (t(10) = 4.44, p < 0.01, d = 1.34, CI [0.90, 2.72]) and mean total billings per working day (t(10) = 4.30, p < 0.01, d = 1.28, CI [$377.55, $1206.75]), a pattern not observed in Phase 2 during the same period. There was no change in the number of diagnostic codes per unit amongst Phase 1 physicians. No learned effect emerged over time in Phase 1 billing metrics or diagnostic coding. Survey findings revealed a strong positive association between Week 0 self-assessed Knowtex understanding and increased units (r(13) = .579, p = 0.024). Physicians reported increased satisfaction with documentation workflow, a reduction in-clinic hours spent on documentation, and increased time spent with patients. Physicians' net impression of EMR challenges markedly decreased following the implementation of the AI scribe (U = 274.5, z=4.054, p < 0.0001). Conclusions: Adoption of an AI Scribe in oncology may enhance certain billing metrics and positively shift physician perceptions of EMR interactions, without affecting the quality of documentation. These findings highlight potential benefits of AI Scribes in improving physician productivity and satisfaction. As AI Scribes trend towards delivering multimodal clinical support tools, future research may focus on the adjunctive effects of AI scribes on procedural efficiencies, such as consistency in billing codes.
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Wang, Yan, Shutong He, and Yanmin Chen. "Why do you choose this program?—A decision-making model of medical students based on grounded theory." PLOS ONE 18, no. 9 (2023): e0291634. http://dx.doi.org/10.1371/journal.pone.0291634.
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Background This study aims to investigate the reasons behind the decline in the number of applicants and dropouts from N University’s reformed program, which includes increased research experience, an optimized curriculum, and other benefits. The ultimate goal is to identify areas for improvement and make the program more appealing to potential students. Methods This study utilized the Grounded Theory approach, conducting semi-structured in-depth interviews and applying data collection, coding, and the constant comparative method. As a result, a decision-making model for college students was constructed. Results Following the initial stages of individual expectation formation, which include inducement and self-efficacy, and the subsequent stage of value assessment, individuals reach a decision. Throughout this process, the individual’s circumstances and surroundings continue to influence their decision-making. Additionally, the decision-making procedure follows a Hierarchy Pyramid of Educational Needs. Our findings show that job prospects and continuing education are the primary factors influencing interviewees’ decisions. However, it is important to note that individuals may place varying levels of importance on these factors. Additionally, the preferences and priorities of teachers, such as their commitment to research guidance, curriculum development, and maintaining fairness in examinations, can also play a role in shaping these decisions. Conclusion To attract more talented individuals to research-oriented programs, universities should provide more job and higher education opportunities, reform the curriculum thoroughly, and enhance teachers’ teaching devotion.
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Khoirunnisa, Diana, Fitri Mardiani Rahayu, Yuda Syahidin, Irda Sari, and Neneng Yuniarty. "Design of JKN Claim Information System for Outpatient BPJS Patients with SDLC Method." Nuansa Akademik: Jurnal Pembangunan Masyarakat 8, no. 2 (2023): 299–310. http://dx.doi.org/10.47200/jnajpm.v8i2.1699.
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BPJS claim is the submission of all BPJS patient care costs by the Hospital to the BPJS Health, carried out collectively and billed to the BPJS Health every month through the verification process. BPJS Health is a legal entity established to administer the Health Insurance program. Health Insurance is a guarantee in the form of health protection so that participants obtain health maintenance benefits and protection in meeting basic health needs provided to everyone who has paid contributions or whose contributions are paid by the government. This study aims to design a medical record management system to support JKN claims for outpatients at Muhammadiyah Bandung Hospital. The research method used in this research is qualitative with a descriptive approach. The data collection techniques used were interview, observation and literature study. The results showed that there were problems that occurred, namely unclear resumes, illegible SEPs, missing referral letters, and there was still 1 outpatient period that was mixed up so that coding officers found it difficult to read it and became an obstacle to claiming. Based on this research, it can be concluded that there is a need for a quality audit of specific medical resume writing and incomplete BPJS patient requirement files.
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Hayes, Victoria, Robert Bing-You, Dan Pitts, and Lauren Manning. "The Benefits of Honoring Patients as Teachers:." PRiMER 2 (February 12, 2018). http://dx.doi.org/10.22454/primer.2018.242345.
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Introduction: Medical training could not occur without the contributions of patients. Few programs are available that recognize patients for their essential role in medical education, and even fewer explore their impact. The Patients as Teachers (PaT) program was developed to provide an opportunity for medical students to formally honor patients for their contributions and to evaluate their effect on students’ medical education. Methods: This qualitative study involved the evaluation of transcripts of audiotaped interviews conducted with students and their honorees following participation in the PaT program in 2015 and 2016. Two different sets of authors independently examined transcripts from each year utilizing a descriptive coding strategy. Consensus was reached on theme selection and relationships between themes explored for theory development. A third author ensured grounding of the concepts in the data analyzed. Results: Four themes emerged: (1) appreciating humanism in medicine, (2) expressing gratitude, (3) connecting patients and students, and (4) experiencing a unique event. Conclusion: The Patients as Teachers program provides meaningful benefits to both students and patients and has the potential to infuse elements of humanism into medical training.
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Yuan, Zhe, Bin Kang, Xin Wei, and Liang Zhou. "Exploring the Benefits of Cross-Modal Coding." IEEE Transactions on Circuits and Systems for Video Technology, 2022, 1. http://dx.doi.org/10.1109/tcsvt.2022.3196586.
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Xu, Yicong, Huanbing Zhu, Zhijun Xu, et al. "Physician–clinical coder collaboration effectively improves coding accuracy: A single-centre prospective study in China." Health Information Management Journal, December 16, 2024. https://doi.org/10.1177/18333583241302402.
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Background: Clinical coding is important for reimbursement, resource planning, administration and medical research. Objective: This study aimed to evaluate clinical coding accuracy and its influencing factors, especially the benefits of physician–clinical coder collaboration. Method: Twenty-four physicians and one senior clinical coder participated in the quality audit. The audit checklist, assessment criteria, training program and physician–clinical coder collaboration mechanism were clearly defined. The homepage filling standards, homepage filling guidelines and the guidelines of the International Classification of Diseases were used as the assessment criteria for evaluating accuracy. Results: A total of 323,320 medical records were reviewed. The average accuracy of homepage completion was 60.4% and poor-quality homepages accounted for 89.9% of coding errors. The average coding accuracy and correction percentage were 83.4% and 62.3%, respectively. After physician–clinical coder collaboration, the coding accuracy increased from 78.9% to 87.1% (χ² = 799.904, p < 0.001) and correction percentage increased from 52.0% to 73.0% (χ² = 1628.015, p < 0.001). Multivariate logistic regression revealed that complexity of medical records (odds ratio (OR) = 0.625), quality of homepages (OR = 20.445), month of physician–clinical coder collaboration (OR = 1.133–2.297), coder’s major (OR = 1.616), coding experience (OR = 1.953), work engagement (OR = 1.290) and day of the week (OR = 1.054) were factors influencing coding accuracy. Conclusion: Physician–clinical coder collaboration effectively improved clinical coding accuracy and clinical coders benefited greatly. However, homepage quality was not improved. Furthermore, homepage quality and psychological factors influenced coding accuracy. Implications: Managers should implement regular standardised training for homepage completion, alongside ongoing improvements in coding practices and training.