The Quality of Medical Data in a Large Patient Data Base — Experiences with the Goettingen H. I. S. —

As part of our Hospital-Information-System (HIS) we have developed a semiautomatic encoding system for diagnoses and therapies (1) (2) (3) (9) . We have been using this encoding system for 6 years, and now the following 5 clinical departments Neurology, Urology, Orthopedics, Neurosurgery and Pediatrics take advantage of its facilities. In our patient data base 105,000 diagnoses and therapy-entries (especially surgical operations) are stored for 32,000 in-patients, which are 36% of all inpatients of the total hospital. With the exception of 2 departments which have general objections in respect of data protection, all other departments want to introduce our encoding system. We hesitate, however, with their connection because we want to incorporate our experience in an improved system.