Winter 1995 / Volume 2 / Number 1
Family Practice/Primary Care Working Group
American Medical Informatics Association
Edited by Richard Rathe, MD / rrathe@ufl.edu
Available on-line at http://medinfo.ufl.edu/other/pcnews/
Please send submissions to Dr. Rathe via email or fax at 904-392-6482
The ABFP computer based recertification project continues to progress. Data structures and algorithms for generating patients with interesting histories and health care concerns are largely completed, as are algorithms for evolving patients as they are treated. The next major step in the project will be knowledge acquisition. The algorithms are extremely data intensive, and require reasonable estimates the following kinds of information:
Although these data are not easily available, and do not fully describe reality (some age - duration of illness interactions are not fully described) a little reflection may convince you that they can be combined in a huge number of combinations to describe plausible patient presentations. Consequently, the long term cost of "authoring" cases could eventually be very low, as authoring will be fully automated. The ABFP expects to try to get much of this information from medical record systems in use at family practice clinics. The ABFP has developed some relationships with medical record developers, but will probably always welcome input from anyone who has access to data of this sort.
Walt Sumner, MD / wsumner@uklans.uky.edu
The following is a summary of essential items from the draft guidelines. Questions or Comments should be directed to Joe Ferguson at 800-336-6236 or respond electronically to fam-med@gac.edu.
Attitudes, Knowledge, Skills
Source: FAM-MED Digest v95 n2 (1/10/95)
The University of Florida is developing an interactive program for Geriatric Education. The materials being developed will include tutorials, cases, images, and references covering a core geriatrics curriculum:
The program is targeted at medical students and primary care residents. Anyone who would like to contribute or receive more information should contact Cathy Schell, MD (VA Geriatrics Fellow) at 904-376-1611 x6894 or email care of rrathe@ufl.edu.
A demonstration is available on the World Wide Web at:
The Baseline Project was started in the fall of 1994 to create a virtual handbook of primary care on the Internet. The goals of the project include the following:
Send submissions, comments, or questions to:
Your participation is welcome!
The Primary Care Baseline Project can be found at:
Metcalfe, ES; Frisse, ME; Hassan, SW; Schnase, JL. Academic Networks: Mosaic and World Wide Web. ACAD MED. 1994; 69(4):270-273
This is an excellent short article on Mosaic, World Wide Web, and the future of multimedia.
At the last SCAMC I was elected to be a "member-at-large" of the primary care working group. My personal statement outlined my understanding of the position: learn and represent the interests of working group members - people who have an interest in primary care informatics. I prefer to define the scope of the primary care working group functionally rather than by specialty or profession. Primary care is the work of clinicians who care for people in a continuous fashion usually) in the ambulatory setting; the primary care clinician is trained to deal with undifferentiated complaints and to manage the medical system.
In addition to learning the interests of members I want to use this regular column, called "Connections", to let folks know what's happening in primary care informatics. In particular I'd like to establish liaisons to various organizations, and encourage collaboration. As a family physician I have a fair sense of what's happening within family practice, and I've gotten some leads into general internal medicine. Thus far I've no leads to general pediatrics, nurse practitioner, or physician assistant primary care informatics.
I'll list a few of the activities and persons in this issue's column. This list is no measure of importance, it's a quick summary of my quirky knowledge base. Email addresses follow BELOW. Please send me additional information I can use! Next time I'd like to also mention a few folks doing interesting primary care informatics work. If anyone wishes to incorporate this info in a WWW server please go ahead! I can then post the server URL in a future column.
The largest and most powerful primary care organization is expressing more interest in informatics. In the past this has not been a priority. At the AAFP's annual meeting in September two important resolutions were passed (excerpted): to establish a technical panel on office practice technology ... [including] evaluation of emerging technology ... patient care, communication, data storage, retrieval, sharing, and electronic claims. The AAFP recommends that a White Paper on Office Computer Technology be developed for information and consideration by the 1995 Congress of Delegates. If you want to lobby the AAFP to be more active try sending email to: 74144.1573@compuserve.com.
A quite small but energetic organization of teachers and academics, including many non-physicians, STFM is taking a strong interest in informatics. Paul Kleeberg and I are on the STFM communications committee, which is chaired by Beth Burns. Pending projects include using list servers to coordinate small projects, and eventually initiating a WWW server (along with the rest of the known galaxy). Resources are modest but interest is strong. A computer working group within STFM manages informatics education at the annual meeting, particularly a very well received "petting zoo". Bob Elson (relson@medinfo.labmed.umn.edu, my office-mate) chairs that group.
The ABFP has been involved in an ambitious computerized testing project with sophisticated case generation. I don't know of any WWW servers, or of any plans to make the knowledge base they've created available. This could be an excellent knowledge resource for primary care. I don't have an official ABFP contact person - any volunteers?
Gary Barnas (barnas@post.its.mcw.edu) reports that the microcomputer users group is the center for informatics activity, coordinated by Dr. Bob Wigton at the Univ. of Nebraska (I don't have his email address). They meet once at the annual meeting and demo computer medical education applications. Some SGIM members interested in informatics also participate in the Society for Medical Decision Making (SMDM).
Fam-Med and Family-L are two very well run lists concerned with primary care. Fam-Med focuses specifically on family practice informatics, but it should be of interest to all primary care clinicians. It's run by the famed Paul Kleeberg (Paul@gac.edu), a Minnesota family physician. Family-L focuses primarily on academic family practice, but informatics topics can also be relevant (in selected cases). Run by Max Crocker (FPRMAXC@UKCC.uky.edu) and also highly recommended. Contact Max or Paul if you'd like more information.
There seem to be several new WWW servers with medical themes every day. Although I've not found any focusing on primary care informatics, the following three are good places to explore. By the time you read this I suspect you'll find pointers in one of these locales to primary care informatics. Lee Hancock's long maintained an Internet list that provides a blizzard of pointers to medical references. The Home Page was last updated 4 months ago (an eternity on the net), but I expect Lee will keep it pretty complete. It's called Medical Matrix:
UCSF Division of General Internal Medicine Server
U of Chicago Topics in Primary Care Server
John Faughnan, MD / jfaughnan@medinfo.labmed.umn.edu
An annotated update of informatics research relevant to primary care.
The focus of this issue's Literature Watch is on computerized reminder systems. Please send me comments on this review or suggestions for topics or specific articles to be reviewed in the future.
Johnston ME, Langton KB, Haynes RB, Mathieu A. Effects of computer-based clinical decision support systems on clinician performance and patient outcome. A critical appraisal of research. Ann Intern Med. 1994;120(2):135-42.
Abstract: OBJECTIVE: To review the evidence from controlled trials of the effects of computer-based clinical decision support systems (CDSSs) on clinician performance and patient outcomes. DATA SOURCES: The literature in the MEDLARS, EMBASE, SCISEARCH, and INSPEC databases was searched from 1974 to the present. Conference proceedings and reference lists of relevant articles were reviewed. Evaluators of CDSSs were asked to identify additional studies. STUDY SELECTION: 793 citations were examined, and 28 controlled trials that met predefined criteria were reviewed in detail. DATA EXTRACTION: Study quality was assessed, and data on setting, clinicians and patients, method of allocation, computer system, and outcomes were abstracted and verified using a structured form. Separate summaries were prepared for physician and patient outcomes. Within each of these categories, studies were classified further according to the primary purpose of the CDSS: drug dose determination, diagnosis, or quality assurance. RESULTS: Three of 4 studies of computer-assisted dosing, 1 of 5 studies of computer-aided diagnosis, 4 of 6 studies of preventive care reminder systems, and 7 of 9 studies of computer-aided quality assurance for active medical care that assessed clinician performance showed improvements in clinician performance using a CDSS. Three of 10 studies that assessed patient outcomes reported significant improvements. CONCLUSIONS: Strong evidence suggests that some CDSSs can improve physician performance. Additional well-designed studies are needed to assess their effects and cost-effectiveness, especially on patient outcomes.
Comments: This evaluation of controlled trials of the effects of computer-based decision support systems stops short of being a true meta-analysis, in that there was no data pooling and reanalysis. This was not necessary because the magnitude of the effect of the intervention in most of the trials was large enough to achieve statistical significance even when sample sizes were small. (Not since the days of antibiotic trials have effects this large been seen!) The consistency of the demonstrated effect of preventive care reminder and quality assurance systems is remarkable. The outcome measure in most of these trials is physician performance, with much less data available on actual patient outcomes (it's a lot easier to measure the impact of the intervention on the rate that stool hemoccult cards are dispensed or tetanus vaccine is administered than it is to measure the impact on colon cancer detection or on the actual occurrence of tetanus). A meta-analysis of preventive reminder system trials (presented at SCAMC this fall) found that results from trials for some preventive care services, such as tetanus immunizations, were so positive that additional randomized controlled trials of reminder systems for those services would be unethical. (Austin SM, et al. Effect of physician reminders on preventive care: Meta-analysis of randomized clinical trials. Proc Annu Symp Comput Appl Med Care. 1994;121-5). Unlike reminder systems, which help to overcome the involuntary time and mental processing constraints typical of primary care practice, diagnostic decision support systems, which operate at the level of inference, have yet to be shown to improve physician performance (see also Berner ES, et al. Performance of four computer-based diagnostic systems. N Engl J Med. 1994;330:1792-6 and accompanying editorial in the same issue on pages 1824-5: Kassirer JP. A report card on computer-assisted diagnosis--the grade: C).
Frame PS, Zimmer JG, Werth PL, Hall WJ, Eberly SW. Computer-based vs manual health maintenance tracking. A controlled trial. Arch Fam Med. 1994;3(7):581-8.
Abstract: OBJECTIVE: To compare computer-based with manual health maintenance tracking systems to determine whether (1) a computer-based system will result in better provider compliance with the practice health maintenance protocol, (2) the incremental cost of operating a computer-based vs a manual health maintenance tracking system differs, and (3) inactive patients will respond to health maintenance reminders. DESIGN: Two-year prospective, randomized, controlled trial. SETTING: Rural, multiple-office, nonprofit, fee-for-service family practice. PATIENTS: Adult members of families in which at least one member had been seen by the practice within the past 2 years. INTERVENTION: A computer-based health maintenance tracking system that generated annual provider and patient reminders for all patients regardless of appointment status compared with a manual flowchart-based tracking system in which patient reminders were triggered by provider request. OUTCOME MEASURES: Provider compliance with the health maintenance protocol determined by preintervention and postintervention chart audits, costs of computer-based tracking, and response of inactive patients to health maintenance reminders. RESULTS: Overall provider compliance with the health maintenance protocol increased 15 percentage points in the computer-based tracking group and four percentage points in the manual group. The computer-based tracking group had significantly higher provider compliance than the manual group for eight of 11 procedures. The computer-based tracking system cost 78 cents per patient per year to operate. It was not associated with increased office visits or patient billings. CONCLUSIONS: Computer-based health maintenance tracking improved provider health maintenance compliance compared with a manual system. The finding that health maintenance compliance improved without a significant increase in patient visits or billings requires confirmation in other settings but suggests that considerable health maintenance can be incorporated into ongoing patient care.
Comments: This is an important addition to the reminder system literature. It is the largest and most rigorously conducted preventive care reminder system trial ever to have been conducted in a community-based primary care setting. It also demonstrates the feasibility of partially integrated computerized reminder systems (i.e. Frame's system runs on a PC which downloads data from the clinics' administrative minicomputer). This is in contrast to trials that have been conducted in university-based family practice settings using reminder systems embedded within a fully integrated computerized medical record (see Ornstein SM, et al. Computer-generated physician and patient reminders. Tools to improve population adherence to selected preventive services. J Fam Pract. 1991;32:82-90). Finally, it reduces the commonly cited administrative concern (especially in prepaid, managed care environments) that reminder systems will increase costs due to increased visit frequency as a result of reminder system prompts. Frame's practice is predominantly fee-for-service, however, so the results related to visit frequency may not be generalizable to managed care settings. (See also the accompanying editorial by: McPhee SJ. Computer-assisted preventive care: time to 'byte' the bullet? Arch Fam Med. 1994;3:576-8).
Rind DM, Safran C, Phillips RS, Wang Q, Calkins DR, Delbanco TL, Bleich HL, Slack WV. Effect of computer-based alerts on the treatment and outcomes of hospitalized patients. Arch Intern Med. 1994;154:1511-7.
Abstract: BACKGROUND: Hospital computing systems play an important part in the communication of clinical information to physicians. We sought to determine whether computer-based alerts for hospitalized patients can affect physicians' behavior and improve patients' outcomes. METHODS: We performed a prospective time-series study to determine whether computerized alerts to physicians about rising creatinine levels in hospitalized patients receiving nephrotoxic or renally excreted medications led to more rapid adjustment or discontinuation of those medications, and to determine whether such alerts protected renal function. RESULTS: Laboratory data were observed for 20,228 hospitalizations, with documentation of 1573 events (instances of rising creatinine levels during treatment with a nephrotoxic or renally excreted drug). During the intervention period, doses were adjusted or medications discontinued an average of 21.6 hours sooner after such an event (P < .0001). For patients receiving nephrotoxic medications during the intervention period, the relative risk of serious renal impairment was 0.45 (95% confidence interval, 0.22 to 0.94) as compared with the control period, and the mean serum creatinine level was 14.1 mmol/L (0.16 mg/dL) lower on day 3 (P < .01) and 25.6 mmol/L (0.29 mg/dL) lower on day 7 (P < .05) after an event. Forty-four percent of physicians who responded to a questionnaire said that the alerts had been helpful in the care of their patients, whereas 28% found them annoying. Sixty-five percent wished to continue receiving alerts. CONCLUSIONS: Computer-based alerts regarding patients with rising creatinine levels affect physician behavior, prevent serious renal impairment, preserve renal function, and are accepted by clinicians.
Comments: This is perhaps the most dramatic study published to date of the impact of a computerized reminder system on a measurable patient outcome. As such, it is the sort of data that the Johnston review paper pointed out as being lacking. For anyone involved in primary care informatics research, the implications of this study are profound. It's somewhat disappointing that it has received so little attention....
Bob Elson, MD / relson@medinfo.labmed.umn.edu
For Your Bookshelf: Computers in Clinical Practice
Published by the American College of Physicians and edited by Jerome A. Osheroff, MD, FACP, "Computers in Clinical Practice" covers the waterfront of technology. Due out this spring, "this comprehensive guide cuts through the jargon and intricate terminology and provides thoughtful advice on how to choose the hardware and software more appropriate for you." Chapters include Practice Management, Medical Record Systems for Office Practice, Medical Literature Management, Diagnostic and Therapeutic Decision Support, Patient Education, Personal Continuing Medical Education, CD-ROM and Full-Text Information Retrieval, and Portable Computing Devices. Also featured is a chapter on telecommunications by our own FAM-MED moderator, Dr. Paul Kleeberg. Price: $29 members, $38 non-members. Call 800-523-1546, extension 2600 to order.
Carol Albright, MS / syzygy@maroon.tc.umn.edu
IMIA Working Group 5 - General / Family Practice Proposed Meeting 1st - 3rd November 1995 (11/3/95)
I have been collaborating with Professor 'Moon' Mullins from the University of South Alabama and Dr. Glyn Hayes, current Chair of working group 5, to organize the first working group 5 conference on Medical Informatics in Genera l Practice / Family Practice. We propose to hold a three day meeting immediately after SCAMC 1995, which this year is in New Orleans, at the Marriott Grand Hotel, Point Clear, on the Eastern Shore of Mobile Bay near the Gulf Coast of Alabama.
We hope that this location will provide easy and rapid access from New Orleans enabling international participants to have a bumper week in the USA at two exciting venues!
I am sending this preliminary communication to friends internationally who I hope will be able to help in the organization of this event, and would welcome rapid feedback.
Local Coordinating Committee (LCC)
I hope that Moon will be able to commandeer local assistance for direct negotiation of detail at the venue ( I have visited the Grand Hotel in November and it is excellent!), and the opening / closing plenaries, and a social program.
Organizing Committee (OC)
There is an urgent need now to set up an active Organizing Committee:
Last but not least, a Program committee (PC):
Suggested names for the three committees are as follows:
Not all of you may have heard about this! I propose to act fast in the next few days on Email. We need 80-200 delegates, and less than 80 will probably mean non-viability. So in the first instance collect email addresses, send me feedback, ideas and volunteer/devolunteer yourselves or other people!
Happy New Year, look at the list of people I have sent this to, and forward it to people who will be interested in the organization stage. I look forward to hearing from you all.
Nick Booth, MD / N.S.Booth@newcastle.ac.uk