Evaluation of Documentation and Coding Requirements of Medical Records in the Implementation of a Payment System Based on Diagnosis-Related Groups (DRG) in Medical Education Centers of Urmia University of Medical Sciences

Background and Aim: In the health system, reimbursement methods are an important criterion for the allocation of resources and the performance of service providers. The use of diagnosis-related groups (DRG) system reduces the length of stay and additional costs of the patient, prevents unnecessary treatment, increases resource efficiency and transparency of health care services. The development of the DRG system focuses on the accurate documentation of medical records and the correct coding of diagnoses and procedures. The purpose of this research is to evaluate the documentation and coding requirements of medical records in the implementation of a payment system based on diagnosis-related groups in Iran. Materials and Methods: This research was descriptive-cross-sectional and was conducted in 2022. The data collection tool was a researcher-made checklist, the validity of which was confirmed based on the opinion of experts (health information management health economics) and its reliability was obtained by calculating Cronbach’s alpha (0.83). The research population consisted of 418 medical records in five medical training centers affiliated to Urmia University of Medical Sciences, which were selected through stratified-proportional sampling. Data were analyzed using SPSS software. Results: The results of the evaluation of the documentation and coding requirements of medical records for the implementation of the DRG system showed that the demographic/administrative variables including age, sex, type of admission, length of stay, health insurance, and doctor’s expertise were completely recorded. Evaluation of clinical variables also showed that the main diagnosis, main procedure, secondary diagnosis and other procedures were documented in medical records in 98%, 97%, 88% and 75% respectively. Regarding the coding of the main diagnosis and the main procedure, 100%, secondary diagnosis 68% and other procedures 80% have been done. Conclusion: Considering that some essential clinical variables for the implementation of DRG, especially co-morbidities, complications and other procedures are not recorded separately and completely, therefore it is necessary to define separate information elements in medical records and HIS for accurate recording of these variables and proper interaction between coders and doctors is established to increase the possibility of correct coding. It is also suggested that the DRG system be implemented in our country in a phased and gradual approach so that necessary changes are made in the documentation process and hospital information systems

Substance Abuse Poisoning Registry development Based on Lessons Learned from a Pilot Implementation

Introduction: Substance abuse has been recognized as a national problem in which poisoning with pharmaceutical drugs, opioids and alcohols is a common problem in Iran. Due to the lack of a comprehensive information system related to Substance abuse, despite the systematic information in health services, and to achieve this goal, the purpose of this research was to develop a registry system for substance abuse poisoning in - Urmia University of Medical Sciences. Material and Methods: This research is a practical development study that was done in 4 phases. In the first phase, minimum data set (MDS) of the system were determined. In the second phase, the registration system was designed. The third phase includes the implementation of the system, and finally, the system was evaluated by QUIS questionnaire. Results: A total of 58 data elements in 6 classes were recognized as essential for this system from the point of view of experts. The system was implemented on the ASP.NET platform using C# language and SQL Server database in the poisoning department of Taleghani Hospital in Urmia. The evaluation of usability of the system showed score obtained in the 6 main categories were in set of terms of the system 8.52, screen 8.36, ability to learn 8.8, overall functionality 8.04, user interface 7.98, and the overall interaction is 7.73 respectively. Conclusion: Considering the capabilities of the system for registering poisonings caused by drug abuse, it seems necessary to implement this system in the form of a national network, in order to make the necessary interventions to control drug abuse while using resources efficiently

Performance Evaluation of Hormozgan University of Medical Sciences (HUMS) hospitals based on Pabon Lasso Model

Background: Hospitals need a system for evaluating and monitoring performance for promotion the efficiency and effectiveness of their services and outcomes. Pabon Lasso model is a graphical chart that can be used to identify the current status and performance level of hospitals by combining hospital indicators, simultaneously.  Therefore, this study aimed to evaluate the performance of Hormozgan University of Medical Sciences (HUMS) hospitals during a six-year period using this model. Methods: This descriptive study includes all teaching and non-teaching hospitals affiliated with the HUMS. After gathering the required information related to three indices: Bed Occupancy Rate, Bed Turnover Rate and Average Length of Stay for the years 2009 to 2014 from the statistical systems and yearbooks, the situation of hospitals in terms of indices by drawing Pabon Lasso graphical charts using SPSS version 16, were analyzed. Results: The results showed that during a six-year period, on average, 26 percent of hospitals were placed in zone I, that is the inefficient area, 28 percent in zone II, 30 percent in zone III which is an efficient area of the model and 16% in zone IV of the Pabon Lasso model. Conclusion: The findings indicated that the utilization of hospitals beds is relatively desirable.  Periodic monitoring of province centers and determining their status in the model, and also, performance assessment from another dimension is suggested in order to achieve more comprehensive and more accurate results

Additional file 1 of End-users’ perspectives on factors affecting implementation and utilization of the Iranian electronic health record system: a qualitative study in a developing country

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