Journal of Health and Biomedical Informatics

Introduction: The Importance of disease classification for facilitating medical research is clear. The Medical diagnosis classification is usually done through International Classification of Disease (ICD) system. Sometimes, diagnostic terms in medical records require to be replaced by equivalent term according to international classification of disease system. In order to optimize the patient’ medical records, using information technology, especially designing and developing application in classification of local medical diagnosis are recommended. This research aimed to identify local cardiovascular diagnoses and develop an application for classification and coding them.

Method: This research is an applied study, conducted on 500 medical records in Mashhad Imam Reza and Ghaem hospitals. After that, the concept mapping developed between diagnostic terms and the ICD terms. Data were collected through observation, interview, and checklist, and then the application was developed for coding diagnoses. Furthermore, the coding agreement coefficient related to first and second final diagnoses recorded in medical records was calculated among three raters via interclass correlation coefficient (ICC).

Results: In this research, 1081 codes were investigated and 676 diagnoses of them were recorded in the record summary form. The number of the local diagnoses and abbreviations with their codes were 147 cases. The coding agreement rate among raters was 70% and 88% in the first and second final diagnosis, respectively.

Conclusion: Due to the excellent agreement between raters about the local cardiovascular terms performed through the coding application, it can be concluded that the designed application has high reliability in coding and can be used for classification of diagnoses in different hospital departments.

Introduction: The use of cancer suffering patients' information is possible when this information was organized and categorized properly through encoding the diagnoses and therapeutic procedures. Therefore the aim of this study was to determine the accuracy rate of the neoplasm coding in Seyed Al-Shohada Hospital of Isfahan city in 2011.

Method: This study was a descriptive and cross-sectional study. The population of this study were medical records created during the second half of 2011,308 ones of which were selected as sample. A self-designed checklist was the research tool, which was used after validation. Data analysis was performed using SPSS v16. Software through descriptive statistics.

Results: Investigating the surveyed records, the researchers found that the accuracy rate of the records in this hospital was 68%. Also the highest accuracy rate of the coding has been associated with neoplasms of the connective tissue (94%).

Conclusion: Regarding the obtained results, it is recommended that coding of morphology & related Z codes of neoplasms be set in coders' work order. It is also recommended that continuous educational coding courses be held in order to increase the accuracy rate of the neoplasm coding.

Introduction: The increasing influence of ICT on health and changing information systems to electrical form makes using the information, data transmission, and also preparation printouts of information so easy that the importance of internal and external disclosure policy, data security, and confidentiality standards in these systems have been doubled.

Method: At the beginning of research, all the combinations of key words were searched, then the history and importance of the health data security standards were studied. So the most prevalent and reliable standards were selected to perform the full text. For the next step the researchers extracted the properties which were used to be compared with the selected standards and finally the comparison was discussed.

Results: PCI-DSS, HIPAA, and ISO-27799:2008 properties were classified in 8 groups and 25 subgroups.  ISO-27799:2008 was attended to all properties in Encryption group, but HIPAA was just attended to Encryption in storage, and asymmetric key, and PCI-DSS was considered on Encryption in storage, using Hash algorithm and use of asymmetric key. Operation system security was considered only in HIPAA. Only PCI-DSS standard considered RFID and DNS security and cell phone security, and PCI-DSS as well as ISO-27799:2008 considered wireless networks security.

Conclusion: One can use the standard that is stronger in context. So, it is recommended to use PCI-DSS for cell phone or PDA systems, and ISO-27799:2008 or PCI-DSS for wireless networks. It is better for security in operation systems to use HIPAA. Combined standard with all these three standards aspects can be used as the safest approach.