Working Group Meeting at SCAMC '95
Moon Mullins leads the Working Group meeting during the 19th SCAMC at the Hilton Riverside Hotel in New Orleans. Moon was honored as the founding chair of the Working Group.
Family Practice/Primary Care Working Group
American Medical Informatics Association
Edited by Richard Rathe, MD / rrathe@dean.med.ufl.edu
Available on-line at http://www.med.ufl.edu/medinfo/pcnews/
Please send submissions to Dr. Rathe via email or fax at 904-392-6482.
We had a very successful post-conference "Standards" meeting in New Orleans. Over seventy people attended the meeting and all were involved in the process of examining the issues and problems of arriving at a consensus on the concepts and principles of a clinical vocabulary. After a half-day of reviewing current models, a lengthy discussion was continued into a second half-day directed at achieving consensus from the group on issues and possible approaches to standardized clinical Vocabulary. This process was planned and facilitated by Drs. Nancy Lorenzi. Bob Riley and Mullins. A small working group led by Dr. Mullins is developing a set of proceedings from the meeting. Proceedings will be printed and distributed. All conference attendees will get progress reports and drafts as they are generated. Many individuals contributed to the success of this meeting and a complete list of participants is available with e-mail addresses. Thanks to all of those that helped make this very important meeting a productive and very stimulating Working Group endeavor. Thanks also to Dr. Mullins for giving birth to the idea as well as staying with a very tough and difficult delivery.
One of my goals for the next year is to increase involvement from the membership. I have asked each Administrative Committee member to solicit two members for the committees that they chair so we can get "new blood" involved in leadership roles. Jim Legler is chairing our membership committee. Jim has sent out a survey to the membership requesting your interest areas in medical informatics. If you have not responded to him by the time you read this, please do so quickly. You can also contact me directly if you want to become more involved.
We are beginning to plan for next year's fall conference. The Program Committee needs good ideas and help. Get involved. Send me your thoughts on the organization. Send Richard Rathe Information, articles, updates, project descriptions, etc. for the Newsletter.
Bob Price, PhD / rdprice@dfcm.uams.edu
Working Group Meeting at SCAMC '95
Moon Mullins leads the Working Group meeting during the 19th SCAMC at the Hilton Riverside Hotel in New Orleans. Moon was honored as the founding chair of the Working Group.
Ian Purves reports on the Primary Health Care Specialist Group Annual Conference held in Cambridge, England. Ian chairs the FP/PC WG International Committee.
John Faughnan tells the group about the new FP/PC Working Group Home Page on the World Wide Web. John co-chairs the FP/PC WG Communications Committee with Richard Rathe.
Work Group Election Results
The group (re)elected the following at-large members to two year terms:
| Previous Committees | Current Committees | New Chairs |
|---|---|---|
| Nominations / Elections | Nominations / Elections | Moon Mullins |
| Program and Education | Program | Bob Elson |
| Electronic Communications / Publications | Communications | Richard Rathe John Faughnan |
| Planning (eliminated) | ||
| Automated Medical Record | Projects | Rob Hausam |
| International | International | Ian Purves |
| By-laws (eliminated, work done for now) | ||
| Membership (new) | Jim Legler | |
| Awards (new) | Rob Hausam |
Bob Price suggested that each WG Committee be Chaired by a member of the WG Administrative Committee but that each Committee also be comprised of 2 people from the general WG membership (i.e. not on the Administrative Committee), and there was uniform agreement. This was viewed as a valuable strategy to increase involvement in WG affairs by the general WG membership and to promote the development of future WG leaders. Bob Price requested that each WG Committee Chair complete the following tasks:
Bob Elson was re-appointed as Secretary/Treasurer
November 1-2, 1995, New Orleans (post-SCAMC)
This meeting cosponsored by our working group and Working Group V of IMIA, was attended by 80 participants from 9 countries. It was very successful, far exceeding our expectations. The resulting consensus of the conference includes several statements, elements considered essential for vocabularies for primary care, strengths and weaknesses of the Vocabularies examined, and recommendations for the future.
A report of the deliberations of the conference will be published soon and will be "widely" distributed by the AHCPR. A presentation will be made at the FP/PC Working Group Meeting at the Spring AMIA meeting Friday, June 7th, 1996 in Kansas City. The tentative proceedings are posted on the WWW at the following URL:
A follow up meeting is tentatively planned to be held on Weds and Thurs October 30-31, 1996 ,at the Washington Sheraton Hotel, in Washington D.C. immediately after SCAMC. "Carpe Diem" - seize the day, was the theme of the New Orleans meeting. Primary Care providers should "seize the day" and actively shape the future for primary care. You are urged to attend and participate in this follow up meeting and be a part of shaping the future of Primary Care Informatics.
Moon Mullins / Conference Chair / hmullins@jaguar1.usouthal.edu
STFM Group on Computing
Craig Gjerde <clgjerde@facstaff.wisc.edu> of the University of Wisconsin at Madison has agreed to chair the Society of Teachers of Family Medicine Group on Computing. Thanks to Bob Elson who has chaired the group for the past two years. Nancy Clark and John Faughnan did a great job running the "Computer Petting Zoo" at this year's annual meeting.
Southern Group on Educational Affairs
The Second Southeastern Medical Informatics Conference (SMIC) was held on March 30, 1996 in conjunction with the AAMC Southern Group on Educational Affairs (SGEA) hosted by the University of Florida College of Medicine. The proceedings from the conference are available at http://www.med.ufl.edu/medinfo/smic96/.
Conference Program
The Apple Newton Message Pads have captured the greatest interest with a unique graphical user interface exploiting handwriting recognition and tap navigation. Tapping eliminates the clumsy cursor behavior and allows users to actually point and tap their way through a program. Currently the Newton MP120 is able to luxuriously manage a host of reference books including the "Little Black Book of Primary Care Pearls", the "Current Clinical Strategies Series", "The 5 Minute Clinical Consultant", and "Complete Pharm Reference." The biggest problem with these books is that to accommodate them all you could easily spend more for a lavishly large memory card than you did for the Newton that houses it. Still, the hinted-at promise of books yet to come has Newton users drooling at the future.
Patient tracking programs are finally catching up to bedside speed as well. The somewhat lethargic, but nevertheless elegant, "Pocket Doc" is leading the way in patient data management. Information can be entered into a patient database by writing it onto the screen. Alternatively, one can follow prompts to literally tap in an exhaustively complete H and P. The information can be faxed, printed, or (infrared) beamed at a later time.
An exciting new program "Newt's Cape" is currently in its final beta version. This program allows users to create true Newton Books from HTML files. As anyone can learn to hack together a workable HTML file in about 10 minutes, this program dramatically increases capacity of the Newton to be individualized by owner. Everyday users will now be able to create functional, truly personalized Newton texts.
For more information, surf over to http://www.med.ufl.edu/medinfo/pda/newton/. This report is respectfully submitted from handwritten, interpreted text on a Newton MP120.
Christopher Cogle, MS3 / c@grove.ufl.edu
Eric Mansell, MS3 / mans@grove.ufl.edu
A professor at a major US university received numerous death threats after his e-mail account was broken into and used to distribute a racist message to more than 20,000 computer users. He described it as "the digital equivalent of a drive-by shooting." (Atlanta Journal Constitution 10/94 by way of EDUPAGE)The bottom line is that SECURITY IS ALWAYS IMPORTANT. Don't share your password with anyone. Change your password if you think someone else might know it. Always log out when you are finished using the system. Your password is the only thing protecting you from pranks or more serious harm. These are good rules to follow when using any computer system, not just email.
Hyper-G. Java. Roaster. Blackbird. We don't need spy novels any more - we've got the Internet. A seething cauldron of rumor, suspense, conflict, and high drama. Anyone can play investigative journalist; hopping about the net and watching the latest new world being assembled. It's a birthing Mary Shelley would have recognized.
I know there's fire out there. Heck, I think there's a bleedin' volcano beneath all those clouds. But a lot of the promises are still worth the electrons they're written on. We still need solutions.
No, this isn't yet another whine that the Internet is all style and no substance. It's pretty routine for me to find answers to all kinds of questions on the net, frequently within minutes. From the artwork of William Blake to preferred cold weather cycling gear, I can find it all quickly and easily on the net. There's already tremendous power out there. On the other hand, we're still lacking the kinds of tools that our working group could use. Tools that would enable small groups to collaborate across time and space.
I've reviewed a dozen contenders for the small group collaboration solution. Lotus Notes and Microsoft's vapor-Exchange are big-boys tools, strictly a corporate product. Collabra Share and Novell's GroupWise are single platform. First Class and TeleFinder cover Mac and Windows platforms and do a decent job, but they still falls short in many ways.
All of these tools need a server. That just won't fly for the small groups I work with, including AMIA, STFM (Society of Teachers of Family Medicine), fellow graduate students (mostly with less gray hair than I), and others. Most of these organizations can't maintain a server. The public/private server market has to evolve. I'm surprised that First Class and other vendors aren't encouraging entrepreneurs to set up servers in their basements.
Of course, it's only a matter of time, probably 18 months or so. In the meanwhile, we cobble together cross-platform tools using email and the world-wide web. We use lists for ongoing dialogs, and web sites to provide summaries and reference materials. We're developing tools to manage web sites, and to create web-based representations of list dialogs. It's all pretty kludgy, but it's a start.
Our web pages are growing apace. The main page is in Minnesota at:
From that page you can jump to our membership list (maintained in Texas by James Legler, with email and URL links), our Newsletters (Florida, by Richard Rathe), Meeting Minutes (Minnesota, by Robert Elson). The Projects page lists current projects, which should someday each have their own web page maintained by project leaders. Nowadays only the communication committee's (Bob Elson, Richard Rathe, Gary Barnas, Paul Kleeberg, and myself) electronic publication page is up. Visit it for a list of what we've done, and what we'd like to do. Note that we're keenly looking for volunteers to take up parts of these projects. If you'd like to put up a small web page related to the FP/PCWG, let me (or one of the other committee members) know. We can provide server space if you need it.
I'm continuing to explore solutions and technologies. I'm looking for more advanced web publishing tools, from Clay Basket to HotMetal (love those names!). If you've got any advice or thoughts about web publishing in general, and small group collaboration in particular, send me an enote!
John Faughnan, MD / jfaughnan@medinfo.labmed.umn.edu
The focus of this issue's Literature Watch is on errors in medicine. Please send me comments on this review or suggestions for topics or specific articles to be reviewed in the future.
Bates DW, Cullen DJ, Laird N, Petersen LA, Small SD, Servi D, Laffel G, Sweitzer BJ, Shea BF, Hallisey R, et al. Incidence of adverse drug events and potential adverse drug events: implications for prevention. JAMA. 1995;274(1):29-34.
Abstract: OBJECTIVES--To assess incidence and preventability of adverse drug events (ADEs) and potential ADEs. To analyze preventable events to develop prevention strategies. DESIGN--Prospective cohort study. PARTICIPANTS--All 4031 adult admissions to a stratified random sample of 11 medical and surgical units in two tertiary care hospitals over a 6-month period. Units included two medical and three surgical intensive care units and four medical and two surgical general care units. MAIN OUTCOME MEASURES--Adverse drug events and potential ADEs. METHODS--Incidents were detected by stimulated self-report by nurses and pharmacists and by daily review of all charts by nurse investigators. Incidents were subsequently classified by two independent reviewers as to whether they represented ADEs or potential ADEs and as to severity and preventability. RESULTS--Over 6 months, 247 ADEs and 194 potential ADEs were identified. Extrapolated event rates were 6.5 ADEs and 5.5 potential ADEs per 100 non obstetrical admissions, for mean numbers per hospital per year of approximately 1900 ADEs and 1600 potential ADEs. Of all ADEs, 1% were fatal (none preventable), 12% life-threatening, 30% serious, and 57% significant. Twenty-eight percent were judged preventable. Of the life-threatening and serious ADEs, 42% were preventable, compared with 18% of significant ADEs. Errors resulting in preventable ADEs occurred most often at the stages of ordering (56%) and administration (34%); transcription (6%) and dispensing errors(4%) were less common. Errors were much more likely to be intercepted if the error occurred earlier in the process: 48% at the ordering stage vs 0% at the administration stage. CONCLUSION--Adverse drug events were common and often preventable; serious ADEs were more likely to be preventable. Most resulted from errors at the ordering stage, but many also occurred at the administration stage. Prevention strategies should target both stages of the drug delivery process.
Leape LL, Bates DW, Cullen DJ, Cooper J, Demonaco HJ, Gallivan T, Hallisey R, Ives J, Laird N, Laffel G, et al. Systems analysis of adverse drug events. ADE Prevention Study Group. JAMA. 1995;274(1):35-43.
Abstract: OBJECTIVE--To identify and evaluate the systems failures that underlie errors causing adverse drug events (ADEs) and potential ADEs. DESIGN--Systems analysis of events from a prospective cohort study. PARTICIPANTS--All admissions to 11 medical and surgical units in two tertiary care hospitals over a 6 month period. MAIN OUTCOME MEASURES--Errors, proximal causes, and systems failures. METHODS--Errors were detected by interviews of those involved. Errors were classified according to proximal cause and underlying systems failure by multidisciplinary teams of physicians, nurses, pharmacists, and systems analysts. RESULTS--During this period, 334 errors were detected as the causes of 264 preventable ADEs and potential ADEs. Sixteen major systems failures were identified as the underlying causes of the errors. The most common systems failure was in the dissemination of drug knowledge, particularly to physicians, accounting for 29% of the 334 errors. Inadequate availability of patient information, such as the results of laboratory tests, was associated with 18% of errors. Seven systems failures accounted for 78% of the errors; all could be improved by better information systems. CONCLUSIONS--Hospital personnel willingly participated in the detection and investigation of drug use errors and were able to identify underlying systems failures. The most common defects were in systems to disseminate knowledge about drugs and to make drug and patient information readily accessible at the time it is needed. Systems changes to improve dissemination and display of drug and patient data should make errors in the use of drugs less likely.
Comment: These 2 studies by Lucian Leape's group at the Harvard School of Public Health, along with the accompanying editorial (Kahn KL. Above all 'do no harm'. How shall we avoid errors in medicine? JAMA. 1995;274:75-6 2.) provide powerful ammunition for proponents of a systems approach to error reduction in health care delivery. In the first study, 42% of the life-threatening and serious adverse drug reactions (ADEs) were classified as preventable, and 56% of these occurred at the ordering stage. This validates the widely held belief among informaticians that computerized physician order entry (POE) is the major key to systematically reducing such errors. The second study provides a more in depth systems analysis of these errors. Inadequate information dissemination to physicians and inadequate availability of patient information at the time of decision making were found to be the most important system failures. Rule violations and slips/memory lapses were also important. The publication of these studies in the wake of the highly publicized Dana Farber drug dosing disasters was quite timely. In fact, Dr. Leape appeared on 20/20 and it warmed my heart to hear him paraphrase Clem McDonald on national TV (something about the inevitability of human error or oversight, i.e. McDonald's "non-perfectability of man"). Better information systems, the authors conclude, will cure many of the ills uncovered by this work. For a more general overview of how computerized patient records can help to reduce physician error, see: Elson RB, Connelly DP. Computerized patient records in primary care. Their role in mediating guideline-driven physician behavior change. Arch Fam Med. 1995;4:698-705. Abstract available on-line at:
http://www.ama-assn.org/journals/archive/fami/vol_4/no_8/abstract.htmBob Elson, MD / relson@medinfo.labmed.umn.edu
One of the most popular topics for Papers presented at the conference were the various uses for Multi-Media technology. These ranged from it's use as an Educational tool for Medical Students (Bradley et al), to it's efficacy in presenting Information to Patients (Wood et al) to it's possible role in General Practice Patient consultations (Bainbridge & Hayes). Although it was generally proven that there is a future for Multi-Media in all these areas, the possible added value that the technology offers is perhaps not yet viable for reasons such as cost, efficiency and reliability.
A vibrant conference where the buzz word was 'Security', especially in terms of the planned NHS Network. This was a very recent development and although the Proceedings of the Conference did not reflect this important subject it was very much in the forefront of the delegates minds. A wide spectrum of views was represented with Fleur Fisher from the BMA, Tony King, Head of Networking from the NHS Information Management Group, Ross Anderson author of the recent Report on NWN Security and the PHCSG Chairman Dr John Williams all putting their various perspectives across.
The McLuhan Initiative
The Conference also saw the launch of the McLuhan Initiative which is an attempt by one of the PHCSG's Special Interest Groups, Intersig (formerly Eurosig), to create a register and library resource for Research and Evaluation projects in Primary Care Informatics. Marshall McLuhan was the originator of the global-village concept, and it is hoped that creating a "global-village" of primary care informaticians will lead to greater collaboration, cross-fertilization of ideas and cooperation in terms of Coding Standards for example.
More Information
For further details on see:
Rob Wilson / rob.wilson@newcastle.ac.uk