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Role: Medical Coder
Provided data fields have been configured for medical coding via MedDRA and WHO Drug dictionaries, data collected against those fields becomes eligible for coding in the Medical Coding > Data module. Here, ClinSpark provides an opportunity to auto-code terms by looking for a best match in the respective dictionary or the opportunity to manually code each term by browsing the dictionary tree. If collected data is updated after initial coding has occurred, the user is prompted to re-code the updated term.
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For this dictionary we only search against LLT, but we perform search in three different ways relaxing search contains more and more and thus lowering confidence level.
Confidence | Search Target | Search Match | Example |
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50% | LLT | Partial Match on first part of the term | Influenza B → Influenza |
75% | LLT | Partial Match on entire term | Influen → Influenza |
100% | LLT | Full Match on entire term | Influenza → Influenza |
LLT* = Lowest Level Term
Example with full match:
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For this dictionary we do not calculate confidence level, and instead we allow an employee to select best option from the drop down list of matching items. We use the following sequence of searches to build a list of matching items:
Priority | Search Target | Search Match | Example |
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1 | Any Drug Name (Generics and Non Generics) | Full Match | Remicade → Remicade |
2 | Any Drug Name (Generics and Non Generics) | Partial Match | Remi → Remicade, Infliximab |
Example with full match in Generic and Trade names:
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Example of multiple matches of the same drug bound to a different placers with in ATC ontology:
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Currently, when adding a Medication or a Medical Term, the auto-coding feature allows for subsequent edition of the hierarchical tree. This may be undesirable, as it can lead to false classification. In a later release of ClinSpark, the feature will likely restrict the edition of the hierarchical tree to avoid this challenge. When adding a Medication, it is possible to change the hierarchical tree, from top to bottom. Changes do not affect downstream fields. The original term is non-editable. All changes (including original coding) remain in the audit trail. When adding a new Medical Term, the top to bottom changes for the hierarchical tree are allowed, with the request to update the fields downstream. The original term is non-editable. All changes (including original coding) remain in the audit trail. |