C2i: A tool to gather medical indexed information

Choosing the appropriate diagnosis codes in a nomenclature is a non-intuitive task for the practitioner. Mistakes are frequent with severe consequences on healthcare evaluation and funding. As in many countries where the coding is accomplished in a decentralized way, most of the French physicians have to assign a code for everything they do and they are not spared with these kinds of errors and the coding-experts at the Medical Information Department supervise the making of the unit discharge abstracts, and their transmission to the HAS (High Authority in Health Care). The proposed system named C2i aims at supporting the medical coding task for the two involved actor types in order to ensure its completeness and to avoid errors without losing time The proposed approach consists in collecting useful and pertinent medical information in accordance with the physician activities and the patient medical context and, thus, in exploiting this data by a generic approach. The C2i platform is at the same time an inference system, a notification system and a tracking system. The C2i inference system gathers and applies the rules dedicated at each information source while the C2i notification system proposes the coding advices of each source independently or in a combined manner. The C2i tracking system conserves all the facts and applied rules as coding warrant for the retained codes by the physician and as an information source for patient further coding. A prototype of the C2i based on relational database is under development and already illustrates the potential of such a system but also the limits of the relational model to manage complex, highly interrelated information.