Assigning Clinical Codes with Semi-Automated Medical Language Processing.

Medical diagnosis coding is essential for hospital operations, yet the current process-reviewing patient files, searching for diagnoses, and assigning codes-can be time-consuming and error-prone. We propose a semi-automated system, the Smart Data Extractor, designed to streamline this task by extracting ICD-10 codes from electronic health records. In our evaluation, a medical expert using the Smart Data Extractor assigned 537 ICD-10 codes for 125 hospital stays in just 92 minutes, compared to 275 codes in 240 minutes when coding manually for the same patients. Moreover, manual coding resulted in more errors. Our solution is user-friendly, transparent, and efficient, requiring no prior training while significantly improving coding speed and accuracy. The Smart Data Extractor offers a practical, time-saving alternative to traditional coding methods, enhancing both productivity and reliability in hospital settings.KEYWORDSICD-10 coding, automated medical entity recognition