firefoxC-Gate is an advanced multilingual tool and expert system for the comfortable generation of electronic medical records. It supports encoding of diagnoses and procedures and makes available the official classification systems ICD-10, ICD-9-CM Vol. 3 (procedures) and additional special classification systems like TNM for solid tumours, AO for bone fractures and others. Even the former ICD-9 is still supported, so existing elderly data sets can be compared.

The software system is based on client – server technology and uses object orientated methods. With a perfect interface (OLE/COM technology) C-Gate provides a fast and comfortable interaction and data exchange with the hospital information system (HIS) and other subsystems.

Advantage of computer assisted medical encoding (CAME)

The application of classification systems in clinical practice reveals frequently the same problems worldwide:

To look up a medical text in the systematic tabular list is time consuming and sometimes unsuccessful. Numerous additional conditions have to be recognized, the most important are the inclusion and exclusion notes and the dual classification scheme for aetiology and manifestation, the so-called dagger and asterisk system.

Direct encoding of a medical text in clear is often difficult, because the tabular lists provide mainly descriptions of diagnoses and procedures in an abstract classification language. Only few specific examples were given in the tabular list, even the alphabetic index by WHO (English language) covers only a very small part of the tremendous number of medical diagnosis and procedure names.

Therefore manual encoding needs a well-trained staff in order to ensure an unequivocal and comprehensible result. Computer assisted medical encoding (CAME) enables the medical staff (doctors, nurses) to make a detailed and complete clinical documentation and encoding without faults and implausibilities, which is appropriate for electronic data processing, statistics and retrieval.

Analysis of medical expressions for diagnoses and procedures

To look up the classification code for a given medical text in clear (search string) the characters may be entered in english, chinese or german language. Other languages are available on request. C-Gate will show all diagnosis or procedure expressions from the thesaurus containing the search string. The C-Gate diagnosis thesaurus contains about 12.500 original ICD-10 classification texts and about 10.000 additional diagnosis terms. Procedure thesaurus consists on about 1.600 ICD-9-CM procedure classification texts and more than 25.500 additional procedure terms. Further diagnoses and procedures will be added continuously by Med-I-Class Company and will be delivered at least once a year.

After entering a diagnosis or procedure text string it will result in a list of medical diagnoses resp. procedures containing the search string. The responsible doctor has to choose the expression that fits the clinical situation best. After selection and double click the encoded diagnoses and procedures are collected on a documentation overview screen. Multiple diagnoses and procedures may be edited on this screen before final data transfer to HIS and storage in the patient database.

Comfortable encoding using individual "Concept Boxes" for departments

C-Gate provides clearly arranged hit lists in order to present the most frequently used diagnoses and procedures for each clinical department. These Concept Boxes may individually be changed, completed or shortened, according to the demand of the specialists. It is very easy to switch between diagnoses and procedures. Groups of diagnoses may be linked with corresponding procedures.

Graphical Encoding

Some groups of diagnoses are difficult to describe, because a precise description of the location is needed. This is of special importance for example in the treatment of tumours or injuries. C-Gate will provide a graphical module which allows to define diagnoses by pointing to the specified location. The correct ICD-10-codes are created automatically. The basis graphical module is the human skeleton. Further modules will follow and will be delivered according to maintenance.

Documentation of tumour stage

If a specified diagnosis refers to a malignant tumour, C-Gate checks whether there exist detailed TNM-categories for tumour stage. According to the definitions given by the International Union Against Cancer (UICC, 1997/2002) C-Gate provides selected menus for the estimation of primary tumour (T), lymph node metastases (N) and distant metastases (M). The definitions of all levels and sublevels of the TNM-system may be selected, always fitting to the tumour site.