A Deployed Application for Automated Medical Coding

Currently, virtually all medical coding is done manually using either reference books or computerized code lookup systems. The system is at best a computer-aided human. For storage, paper documents have been the mainstay of medical records, but there is increasing pressure to move to the electronic medical record (EMR), also referred to as the computerized patient record. Although the EMR has been a major goal in health information management (HIM) for more than two decades, the success of such systems has been seriously limited because of the relative inaccessibility of the information in free-text clinical documentation. Attempts to change the documentation habits of physicians have not had significant success largely because of the increased time and inconvenience associated with using computer interfaces that require formatted input.