Summer 1995 / Volume 2 / Number 2
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
Computer petting zoos are becoming a popular event at physician meetings. Designed to give the uninitiated opportunities to play with technology, these labs let you "kick the tires" but without a vendor breathing down your neck. Watch for at least three zoos this year.
As another neophyte zoo coordinator, I am discovering they require infinite patience in tracking infinite details, from whether or not to have tablecloths to what's our liability if someone dumps coffee into a borrowed computer. I believe there will be a Zoo at AAFP this year, but was unable to connect with my contact before last call for articles. If you're organizing a zoo, please share your tale in a future issue.
For more information, please contact:
Carol Albright, MS / syzygy@maroon.tc.umn.edu
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.
The Geriatrics Education Project is available on the World Wide Web at:
Primary care informatics will be the theme for the January 1996 issue of the award winning journal Florida Family Physician. Authors are being sought on wide variety of topics such as:
Anyone interested should contact guest editor:
Richard Rathe, MD ^University of Florida ^PO Box 100215 ^Gainesville, FL 32610 ^rrathe@ufl.edu
Since my last summary of primary care medical informatics (PCMI, yet another acronym) activities the World Wide Web has grown only a tiny bit. Actually it's rather bigger -- I'm just tiring of the usual superlatives. It looks like the web will indeed live up to its many promises, including promoting connections and collaboration in primary care informatics. Of course there are still a few kinks in the system. Many web sites are "called", but few are chosen! Maintenance can be burdensome. Check out the URLs I list here, and let me know of ones you find particularly useful.
In keeping with the theme of this column I've emphasized web sites of special interest to primary care informatics folks. I've omitted the myriad (hundreds?) of clinical web sites. I strongly recommend the NetScape browser for Windows/Mac users. (I'm told OS/2's web browser is quite good, but I'm only now shifting from OS/2 2.11 to 3.0.) I hope new browsers do a better job of maintaining hundreds and thousands of bookmarks! Web sites are usually much more responsive between 4 am and 8 am local time.
Please send me any information you have on primary care informatics activities in your region or institution. I'll add it to future columns. I'll continue to update and refine this outline so that it can serve as an evolving resource. NOTE: I've put email addresses of persons I refer to at the end of this column.
University of Minnesota: Bob Elson and I are family physicians and informatics fellows. Jeff Hertzberg has a general internal medicine background. Others: Let me know what's happenin' in PCMI at your institution!
I've not heard much from the AAFP. I can't say if they're making any progress on last September's primary care informatics resolutions (see last column).
I'm still looking for any informatics on informatics in pediatrics. Pediatrics has to be the most under-represented specialty in medical informatics. Any contacts would be most welcome!
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. Walt Sumner is my contact on this project.
The RACGP maintains an Information Management Committee. It's chaired by Dr. Michael Kidd. The RACGP is much more active than any comparable US primary care organization. They have a number of ongoing publications, publish medical records standards, do research on GP informatics, and stage a biennial national GP computing conference (June 1-3, 1995 -- Sydney). Dr. Kidd has summarized his group's activities elsewhere in this newsletter.
Gary Barnas reports that the microcomputer users group is the center for informatics . 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).
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. Paul is making swift progress on setting up a WWW HomePage for STFM.A computer working group within STFM manages informatics education at the annual meeting, particularly a very well received "petting zoo". Bob Elson (my office-mate) chairs that group.
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, 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 and also highly recommended. Contact Max or Paul for more information.
The AMIA Internet Working group has a very active list, with many pointers to new Internet medical informatics resources. Check out:
or email Gary Malet to find out how to join.
R. Brown at the U of Wisconsin, Madison is publishing a biweekly digest of health and medical informatics web sites. Much of this digest is of interest to us:
Richard Rathe (our editor and a family doc/informatician) publishes this primary care newsletter on the web at:
The European Federation for Medical Informatics (EFMI) Working Group on Primary Care Informatics (WG7) has now set up a new area to promote primary care informatics / telematics. The site is supported by Charing Cross & Westminster Medical School:
General medical informatics (not particularly primary care) sites include Stanford's CAMIS:
and Duke's elegant server:
The Duke server includes pointers to many general medical informatics sites, and includes a medical informatics annual calendar. The U of Minnesota has a server with some information on our program:
Lastly, here are some addresses that will connect one with the vast galaxy of Internet resources:
Medical Matrix:
Virtual Hospital:
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 coding. Please send me comments on this review or suggestions for topics or specific articles to be reviewed in the future.
Yarnall KS, Michener JL, Broadhead WE, Hammond WE, Tse CK. Computer-prompted diagnostic codes. J Fam Pract. 1995;40(3):257-62.
Abstract: BACKGROUND. The purpose of this study was to develop and evaluate a computer system that would translate patient diagnoses noted by a physician into appropriate International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes and maintain a patient-specific up-to-date problem list. METHODS. The intervention consisted of a computerized list (dictionary) of diagnoses, including practice-specific synonyms and abbreviations, linked to their corresponding ICD-9-CM codes. To record the diagnoses for the office visit before the intervention, physicians used International Classification of Health Problems in Primary Care (ICHPPC-2) codes. After the intervention, physicians used their own words or checked previously identified diagnoses on the computer-generated problem list. The computer then identified the correct ICD-9-CM code. Accuracy of coding was compared before and after the new computerized system was implemented. RESULTS. Visits in which all diagnoses matched increased from 58% to 76% (P < .001) with use of the computer system. Visits in which no computer diagnoses matched the chart decreased from 22% to 8% (P < .001). Errors of omission declined from 38% to 18% (P < .001). Errors of commission decreased from 19% to 11% (P = .006). Overall accuracy increased from 62% to 82% (P < .001). CONCLUSIONS. Outpatient medical diagnosis coding can be simplified and accuracy improved by using a computerized dictionary of practice-specific diagnoses and synonyms linked to appropriate ICD-9-CM codes. Such a system provides a computer-generated problem list that accurately reflects the chart and assists with prompted coding on subsequent visits.
Comments: This study was done using paper-based encounter forms (TMR at Duke), rather than on-line, real time coding by physicians. Even so, the availability of a printed listing of ICD-9-CM diagnoses from previous encounters at the time diagnoses for the current encounter had to be assigned had a significant positive effect on the accuracy and completeness of the coding process. Apparently, practice diagnoses were recorded using IHCPPC-2 and then converted to TMR codes which were then mapped to ICD-9-CM codes. Because of this, it is unlikely that this methodology will be directly transferable to other sites unless they are using TMR. Overall, I found the methodology/analysis somewhat confusing and difficult to follow. Nonetheless, the conclusion that prompted coding produces a more reliable coding list is probably correct and is important. Unfortunately, this still doesn't help with the problem that the coding languages themselves (i.e. ICD-9-CM) are inherently incapable of accurately and comprehensively representing clinical concepts in primary care. Merely capturing a more complete listing of ICD-9 diagnoses that were dealt with during an encounter may bring music to the ears of administrators responsible for maximizing reimbursement, but is unlikely to improve how well those codes represent what actually occurred during the encounter. As a related aside, it looks like SNOMED is in and the Read Codes are out........(Humphreys B. Vocabularies for computer-based patient records: Identifying candidates for large scale testing. Minutes of a meeting sponsored by National Library of Medicine and Agency for Health Care Policy and Research, Bethesda, MD., December 5-6, 1994)
Bob Elson, MD / relson@medinfo.labmed.umn.edu
The Information Management Committee of The Royal Australian College of General Practitioners promotes better information management in Australian general practice. Obviously this involves the use of information technology solutions where appropriate.
The committee has volunteer representatives from each state of Australia; each state runs its own program of educational meetings and events for general practitioners.
The committee supervises the work of an Information Management Fellow who carries out research projects and provides an advisory service for general practitioners.
The committee has produced a number of publications including a national directory of medical hardware and software suppliers, a guide to computerized practice accounting and a set of standards for computerized medical record systems.
Committee members are involved in a variety of research projects. Current major projects at the moment include the development of Australian standards for the electronic transmission of pathology details, evaluation of the Read codes in Australian general practice, telecommunications for isolated rural general practitioners and the development of computerized medical and patient education programs.
The major activity of the committee is the staging of a biennial national General Practice Computing Conference. The next conference will be held in Sydney on June 1-3, 1995. The program will feature national and international experts on the use of information technology in general practice, as well as research forums, instruction courses, software hands-on training sessions and an extensive trade display.
The committee also has national and international links. It serves as the official general practice Special Interest Group of The Health Informatics Society of Australia and members are actively involved in presentations at the forthcoming WONCA and IMIA world conferences.
Further information about any of these activities can be obtained from the committee chair, Dr Michael Kidd.
Michael Kidd, MD / michael.kidd@med.monash.edu.au
This form is a convenient way for you to respond to the working group leadership.