It was an excellent AMIA (formerly SCAMC) meeting during the last week of October, in Washington DC. There were many presentations that were right on target for primary care. We were also finally able to get thirteen hours of credit after I went through the program hour by hour and wrote a justification for every presentation/panel/paper that was important to family practice and re-submitted the CME application through AMIA to the AAFP. I want to thank Dr. Bob Flaharty, from Bozeman, the AAFP person resposible for reviewing these CME applications, for re-considering our application for credit.
We had a good working group meeting on Monday night, the 28th, with a program that included a report from the Standards I meeting from last year in New Orleans. Dr. H.C. "Moon' Mullins, the Project Director, made the report and handed out the AHCPR published report from the New Orleans meeting. Dr. Mullins also outlined the Standards II meeting that would be occurring on October 29th, 30th and 31st, following the regular AMIA program. Copies of the report are available from AMIA and AHCPR.
Other highlights of the Working group meeting included awards made to Dr.'s Michael Fitzmaurice, Ed Hammond, Randy Miller for all the guidance and support they have provided our Working Group over the last three years.
Michael
Fitzmaurice
(Left)
Randy
Miller
(Right)
Our British friends and members, Dr's John Williams, Mike Bainbridge and Shiela Teasdale gave an excellent presentation on one of their medical informatics educational project. A highlight of the working group was members breaking into groups and discussing topics of common interest. Our Adminstrative Committee members, Drs. Bob Elsen, Moon Mullins, Rob Hausam, Richard Rathe, John Faughnan and Paul Kleeberg faciltated these groups. We also announced election results for the two Working Group Administrative Committee positions. Dr. Mullins, our Election Committee, Chair, will announce the results in a separate section of this newsletter and describe the interest and background of the new offIcers.
Following the regular AMIA program our Working Group kicked off the Standards II meeting. We started on Wednesday, November 29th and continued into the early evening on Thursday, the 30th. We had planned to continue into Friday for the "Free University" part of the program, but finished early on Thursay evenng with some excellent presentations by Sheila Teasdale, Mike Bainbridge, Larry Doritch and John Williams. Look in another section of this newsletter for a more complete description of the Standards II meeting by Dr. Mullins.
Our Working Group membership is now over 500. I am told by AMIA leadership that we are held up as model for how a new working should be organized and involvment with the overall AMIA program. One of my goals this year, as your elected, chair has been to get more members involved in the Working Group in a leadership capacity. We need more involvement in program planning and project activities such as the Standards meetings and offering demonstrations as well as reports on projects from your individual sites. In that regard, one the program ideas I am proposing for AMIA next Fall is an expanded "Free University" that will be an all day Working Group meeting that will allow us to share the ideas and issues of primary care medical informatics. Anyone with a idea for a demonstration, presentation or discussion within this all day Working Group meeting will have a opportunty to get into the "Free University". This strategy can bring us together in a forum to exchange our ideas, projects and dreams.
If any of you have other thoughts or want to take a more active role in this Working Group please contact me anytime.
Robert D. Price, PhD / rdprice@dfcm.uams.edu
Minutes from 10/28/96, 7-10 PM, Sheraton Washington Hotel, Washington, DC
Introductions The meeting was called to order by Chair Bob Price. Meeting attendees introduced themselves briefly to the rest of the group. Forty-eight attendees signed in: their names, organizational affiliation, and email addresses will be added to the WG web-based membership list (http://macorb.uthscsa.edu/famprac/members.htm)
Awards were presented to Randy Miller and Ed Hammond of AMIA and to J. Michael Fitzmaurice of AHCPR to acknowledge their support of WG initiatives, particularly the 'Moving Toward International Standards in Primary Care Informatics: Clinical Vocabulary' Conference held immediately following the 1995 Fall AMIA meeting in New Orleans. Each of the award recipients was present to receive their awards. Ed Hammond was especially laudatory of WG activities, commenting that he and other AMIA officials regarded the WG as a model to be emulated by others (that ought to make us real popular with the other WGs!). Randy Miller reminded folks that next year's AMIA was going to be in his home-base of Nashville, and encouraged everyone to come check it out (he stopped short of inviting the WG to his home...)
Given the presence of many new members at the meeting and that one of the main purposes of the WG is to foster networking amongst members with similar interests, a new format was tested. For about 30 minutes, the meeting was divided up into seven smaller breakout groups, each related to a broad primary care informatics topic. The topics (and session leaders in parenthesis) were: CPR (Moon Mullins / hmullins@jaguar1.usouthal.edu); Practice management systems (John Zapp / zappj@hal.hahnemann.edu); PDAs (John Faughnan / john@umnhcs.labmed.umn.edu); Patient ed and medical ed (Richard Rathe / rrathe@dean.med.ufl.edu); the Internet and intranets (Mike Green / mgreen@maroon.tc.umn.edu); Coding (Rob Hausam / robert.hausam@m.cc.utah.edu); and Decision Support (Bob Elson / relson@umnhcs.labmed.umn.edu). Each group had between 5-10 participants and discussions were lively. Drs. Miller and Fitzmaurice actively participated. Immediately following the breakouts, session leaders presented brief overviews of their sessions to the WG. The breakout process appeared to be well received but additional regarding whether to include such a process in future WG meetings would be appreciated (email Bob Price or Bob Elson).
Elections (Moon Mullins) Jim Legler, a pediatrician, was elected as a non-family physician member of the WG Administrative Committee, Ian Purves, of Great Britain, as a non-US resident member, and Mike Hagen, of the University of Kentucky, as a member-at-large. Phil Hagen, John Zapp, and Bob Bernst were acknowledged for throwing their hats in the ring.
Communication (John Faughnan) The mission of the WG Communication Subcommittee is to provide to members WG-related reference material, project support, a sense of community, and management support. Presently, the Subcommittee gives itself a grade of 'A' for community and news-related functions, 'B' for reference material, a 'D' for project support, and 'Incomplete' for management support. The WG actively maintains a web site (http://dragon.labmed.umn.edu/~john/fppcwg/index.html). John is the official 'webmaster', with oversight provided by Gary Barnas (barnas@post.its.mcw.edu) and Bob Elson. Another WG communication product is the newsletter, skillfully produced twice yearly by Richard Rathe. All content contributions to the newsletter are welcome and are generally due in to Richard ASAP following the Spring and Fall AMIA meetings. The newsletter can be accessed from the WG Home Page, as can the membership list and any future WG project-related information. While not formally related to the WG, Fam Med, a longstanding discussion list for primary care providers interested in computing issues, continues to be expertly moderated by Subcommittee member Paul Kleeberg (paul@gac.edu). Also see New Business below for additional information from AMIA regarding listserv and web page support.
Membership (Bob Price for Jim Legler / legler@uthscsa.edu) The WG now has over 500 members. Growth is believed to be due to a combination of early WG successes and the new AMIA policy permitting membership in two WGs (one related to professional affiliation and one related to an informatics topic or functional domain). A WWW-accessible list of members is maintained by Jim Legler (http://macorb.uthscsa.edu/famprac/members.htm). Any WG member not presently listed on this site should email contact information to Jim. A considerable number of internists and pediatricians were present at the WG meeting. Every effort must be made to ensure that the WG remain inclusive of all primary care providers. Suggestions are needed regarding how best to encourage participation by non-FPs in WG administrative and leadership functions.
All new members attending the WG meeting were eligible for a prize of free conference registration for AMIA '97 in Nashville. The winner was Dr. Cathy Schell of Earleton, Florida (cathy@36472afn.org).
Publication (Richard Rathe) The need for greater attention to getting members to commit and follow through with contributions to the newletter in a timely fashion was emphasized. The newsletter, as before, will be made available on the WWW.
Projects (Rob Hausam) Rob is the one to contact if anyone is interested in initiating a WG-sponsored project. Resources are available both from the WG and from AMIA for small project support, though few have taken advantage of these. AMIA looks highly upon collaborative projects between WGs. Many WG members are clamoring for some type of resource containing CPR product information, and pulling this information together certainly seems like an appropriate project (perhaps in conjunction with the CPR WG). Anyone interested in helping to nudge this along should contact Rob.
Conferences and Planning (Bob Elson, Bob Price) The Administrative Committee in general and the Program Planning Subcommittee in particular wish to plan programs and activities that serve the interests of a diverse and changing membership. Input and participation from any interested WG member is encouraged. Planning is necessary for WG meetings, WG-sponsored AMIA program submissions, and possible future AMIA post-conferences. The 1995 post-conference was widely held to be a success and the AHCPR printed a formal Conference Summary Report, copies of which were distributed. Anyone interested in obtaining a copy can call the AHCPR Publications Clearinghouse at 800-358-9295 and ask for AHCPR Publication No. 96-0069. The full text is also available on the WWW at:
http://www.ncl.ac.uk/~nphcare/PHCSG/conference/pcinfo95/outline.htm
A follow-up conference is also scheduled immediately following this year's AMIA meeting. Between 35-50 attendees are expected.
Sharon, from the AMIA office, informed the WG that AMIA will be setting up listservs for WGs. Initially, these will be set up for an entire WG, but ultimately topic oriented lists will be supported as well. The WG will need to identify a manager (not a moderator - it's a responsibility issue) for each list. AMIA will also be hosting WG home pages on its server. The WG will likely be able to maintain editorial control over content, but the final policy is not in place yet.
There being no further formal business, the business portion of the meeting was adjourned.
Sheila Teasdale and Mike Bainbridge presented information on the JIGSAW project in Great Britain, an effort to develop curriculum specifications and a training infrastructure for training trainers of clinical information system use.
Prepared by Bob Elson, MD / relson@medinfo.labmed.umn.edu
The group (re)elected the following at-large members to two year terms:
The Report from the First (1995) International Standards Conference is issued with the help of AHCPR. The Second Conference was held this year following the AMIA meeting in Washington, DC.
I would like to ask members to contribute to the Computerized Medical Records Resource that I am putting together. We are looking for any information that people would like to share regarding formal or informal evaluation of commercially available systems (and non-commercial ones that people are actually using successfully) and actual experiences with implementing and using computerized medical record systems. When ready, the site will be linked through the main WG site. Anyone who has materials should submit them to me (at the email address below). I will compile the submissions and integrate them into the Web site.
Robert R. Hausam, MD / robert.hausam@m.cc.utah.edu
The University of Southern California and the University of Colorado are planning a teleconferenced version of the 4 day OB ultrasound course that is usually done at the AAFP Scientific Sessions. We would like to make this educational experience available to other groups with an interest and with the necessary equipment. We are currently using one of two configurations: Picturetel on T1 lines, and Intel Proshare video conferencing on fast internet connections. We are putting in gateways to connect both types of equipment together in on network.
We have had several sessions to date, and find it to be an excellent experience for attendings, residents, and medical students. The teleconferencing aspect increases the utility of each session, and decreases the preparation required by each party by splitting it amongst the participating institutions.
If you are interested please contact me directly.
Sidney Ontai, MD / ontai@hsc.usc.edu
The Group is preparing for the Society of Teachers of Family Medicine (STFM) annual meeting in May. This year's meeting will feature a Computer Zoo to be coordinated by David Pepper and Nancy Clark. There will also be an "electronic poster session" with computer applications to medicine. We are hoping to have a plenary speaker on EMR/informatics--stay tuned.
Group members had an opportunity to review the AMIA's clinical vocabulary proposal. We are exploring ways for the Group and STFM to have a closer affiliation with AMIA.
STFM members interested in participating in the Group on Computing should contact me by email. Most Group activities center around the annual meeting. Creative ideas are welcomed.
Craig Gjerde, PhD / clgjerde@facstaff.wisc.edu
The Southern Group on Educational Affairs meeting will be held in Augusta, GA on March 20-22 this year. Anyone interested in helping plan the Computers in Medical Education Special Interest Group session should contact me by email.
Richard Rathe, MD / rrathe@dean.med.ufl.edu
I encourage members of the AMIA FP/PC workgroup to participate in the NLM/AHCPR Large Scale Vocabulary Trial. The trial is described in a fact sheet and a demo of the trial is available; go to:
http://www.nlm.nih.gov/publications/factsheets/lrgscl_vocab_test.html
Testers need to have Web access and some task related to health information vocabulary. Please note that the trial concludes on 12/31/96.
Charles Sneiderman, MD / charlie@nlm.nih.gov
In the forthcoming issue of Academic Medicine , Allegheny University of the Health Sciences (known until the middle of this year as Medical College of Pennsvylania and Hahnemann University) will publish its experience placing laptop computer-based learning tools in Family Medicine clerkship students' hands. In this article, authors Russ Maulitz, Bob Grealish, Martin Lipsky, Janet Ohles, and Rae Schnuth summarize their preliminary findings from the first year of "CyberDoc," a connectivity- and database-oriented toolkit for communty-based primary care students. The laptop project was rolled out at the same time as the new required FM rotation, back in July of 1995. After kicking its tires for a year Russ, Bob, et al. discovered in this suite of applications, and students' reactions to it, some surprising results. They promise to lay it out: the good, the bad, and the ugly, and hope members of the AMIA Working Group will read it and let us hear from you.
Russell C. Maulitz, MD, PhD / maulitz@allegheny.edu
Snomed, UMLS, Arden Syntax, ACHRP--sound like a Startrek convention? Perhaps a cotillion of sno-boarding grammarians??? No, no kiddies, this was the 1996 AMIA convention recently held in Washington, D.C. at the Sheraton Washington Hotel. It was quite an experience. I learned a lot about both how automation is transforming the practice of medicine, and, always unsettling, I learned some things about myself.
Medicine and computers. The phrase itself sounds so simple, yet what is occurring in our profession is anything but. I was expecting to find a group of clinical folks, mostly nerd-types who love these goofy machines like I do, lecturing on what they see as the up-and-coming new toys, some clinically oriented panel discussions (actually, I did get to one, but read on), and some neat computer vendors--NOT!
What went on during those five days in Washington was as professional and scientific an assembly as I have ever experienced. The level of my own inexperience and naivete' was forcefully brought home to me repeatedly. Medicine has a language I understand and speak pretty well. What I began hearing were words and abbreviations I couldn't even translate: MLM or medical logic module (I had no clue), enterprise master patient index (this at least sounds familiar), and NLP which is natural-language processing (I'm still not sure what this really is).
I attended the tutorials given on Saturday and Sunday. Saturday's sessions were on such diverse topics as the use of cognitive-thinking research techniques as they can apply to the evaluation of information systems, and an in-depth, exhaustive discussion of the problems involved with translating the medical record into a usable electronic record. Sunday I attended sessions on one of my personal areas of interest--hand-held interfaces like the Newton message pad and Fujitsu 1000. These tutorials were excellent in both content and format. Discussion was fascinating and the very knowledgeable people freely shared their experiences and recommendations, a real plus.
By Monday evening, after a day of the regular sessions of the AMIA convention, I was definitely suffering from brain overload. The professional level and content of the day's events was impressive. Many of the lectures I attended were highly investigational, and had little direct clinical applicability. Coming from a background of private practice with only a smattering of teaching experience, I found it all quite daunting. I truly had no idea of the depth and breadth of research being applied to this area of medicine.
Humbled by the day's experiences, I attended the Family Practice Work Group meeting on Monday evening. Attending this event was probably the best thing I did all week, and was like a breath of fresh air. I was able to put faces to the names I see every month on Fam-Med. These names which are familiar to you all like Paul Kleeberg, Bob Elson, Richard Rathe, and John Faughnan were just names to me. After this get together of fellow family docs, I was able to talk to them on a first name basis. At this meeting I actually had some input as to what was of interest to family docs! I felt a lot better about being at the convention after the meeting.
The real value of the Work Group to me was the ability to filter the vast amount of information being delivered through the knowledge and experience of not only these people, but others I met through the Group. I am grateful to them all for making my stay at the convention an enjoyable one. The most useful insight I was able to construct after having these people to discuss things with, was that the clinician is still an important part of the informatics team. I had begun to feel we in practice were quite unimportant and superfluous to informatics research and application. I came to understand my own level of interest was not in pure research as I had been thinking, but in how we in clinical medicine must learn to apply what all the brilliant folks at Stanford, Harvard, and U of P create for us, and how our experiences must direct their research.
The convention did a lot to clarify my thinking about my interest in automated systems, exposed me to the cutting-edge research in informatics, and allowed me to meet some really nice people I've come to know only through e-mail and newsletters. Overall, I'd recommend attending the convention. It was certainly an eye-opening experience for me. Think I'll go again next year. Now if I could only figure out why Arden put her Syntax on the UMLS object-oriented, knowledge-based, enterprise-wide, patient-centered, guideline-implemented...
Richard B. English, MD / rbenglis@epix.net
The AMIA Fall Symposium included several presentations about the Java Programming Language. The growing interest in Java has led me to propose two projects for the Working Group which will use Java to facilitate sharing of applications on the Internet and the development of standards for systems intended for use in educating medical students and residents in Family Medicine and other primary care disciplines.
Proposal to Develop a Java-based Computer-based Patient Record There is a growing need for a portable CBPR which students and residents could carry with them on a laptop, or use over the Internet, to record primary care records in a variety of teaching settings without the need to change the primary systems used in the teaching practices where they train. By developing the system in Java, it will be scaleable for future use as a primary record system, compatible with a variety of database systems, and useable on a variety of computer platforms including Windows, Mac, Unix, and the newly announced network computers such as the Sun Javastation. The record will be designed to comply with the ASTM E1384-96 Standard Guide for Content and Structure of the Computer-Based Patient Record.
Proposal to Develop a Java-based Case Teaching System One of the greatest challenges of primary care education is to provide a uniform core experience to students based at a wide variety of geographically distributed teaching sites. Use a standard core of clinical case material is one solution to this problem. We have developed a system for writing cases in SGML syntax extensions to HTML and presenting them to students using Java Applets or Java generated and serviced HTML forms. We are seeking to standardize the syntax for writing cases, expand the available courseware, and evaluate using this approach to teach students.
The Java Programming Language was introduced by Sun Microsystems in May 1995 and has been adopted by many vendors during 1996 as a standard for Internet programming. Java is three things: 1) A programming language derived from C++, 2) A variety of computer platforms based on the Java Virtual Machine which can run Java programs, and 3) A collection of Java Application Programmer Interfaces (APIs) which facilitate and simplify system development.
The language is strictly objected oriented and designed to prevent programmer errors, enforce security, and incorporate multithreading into the language. The platforms which run Java include Java enabled Web Browsers, Interpreters, Just-in-time compilers, the JavaOS, and Java Microprocessors. The APIs include the Advanced Windows Toolkit (AWT), Networking, and Java Database Connectivity (JDBC). Java Applications (standalone), Applets (embedded in web pages), and Servlets (server side of an Applet or HTML form) are true cross platform code where the same binary bytecode runs on all platforms without losing the personality of the native platform. Because Java code is compact and secure, it is ideal for use on the Internet.
If you are interested in participating in either of these projects, please consult the following World Wide Pages and send Email to Dr. Alan E. Zuckerman at the address shown below.
http://gucfm.georgetown.edu/jcbpr/ Computer-Based Patient Record
http://gucfm.georgetown.edu/jcase/ Clincal Case Authoring
Participation can take many forms including:
Authors will retain ownership rights to their software and courseware subject to data sharing agreements to be developed for these projects. We are seeking grant funding for these projects and would be interested in multi-site collaboration on government or privately sponsored funding proposals.
Alan E. Zuckerman, MD / zuckerma@gunet.georgetown.edu
I am a board-certified family practitioner in rural northwestern Ohio. I have been a member of AMIA for the past 4-5 years. I have been coming to the family practice/primary care working group meetings each year since its inception in St. Louis. Because I am in a solo practice in a rural community, it has become a pleasure for me to come to the SCAMC meetings. It is here that I can enjoy the company of other physicians who have an interest in computers in the use of patient care. I have absolutely no one with whom to discuss these matters back home. If it were not for SCAMC, and now the Internet, I would find it very difficult to learn of all the wondrous events and progress that is being made in handling medical and patient information. However, the one drawback that seems to impress me year after year is that I find a scarcity of physicians that share the same every day experiences as myself. This is the purpose of this message.
When I come to SCAMC I find that most of the physicians are members of large physician groups, work for academic institutions, work for software vendors, and many do not seem to treat patients on the day to day schedules that is my life. I realize that an organization like AMIA is basically here for the physicians who do just that. However, it is my hope that there could be more of a role in such an organization for physicians that share my experience. I am not sure what the percentages are regarding physicians that deal primarily with medical informatics in the academic world versus the physicians that deal with full time patient care. I would guess that the latter is a greater number. I also feel that the latter is the group that would benefit the most from the evolving products of medical informatics as would the patients whose care depends upon their management.
What I would like to see is more and more of a role of physicians in AMIA, and particularly in the FP/Primary Care group, in educating the average primary care physician on the usage of these tools. I would hope that this could be as standardized as possible and still allow for the individual personalities of each physician. This would help immensely in the day to day care and medical management of all of our patients. I feel that this would help diminish the ever increasing drudgery that has evolved in the documentation and endless office management duties that are present. I feel that this would allow most of us to recapture the enjoyment that we once felt in the direct patient care which first inspired us to enter medicine.
I am asking members of this group to respond to this article. I am challenging the members to help bridge the gap between the hard core informaticians and the active primary care physicians. How do we get the primary care physicians actively involved? The informaticians are already deelply involved. What will it take to bring the technology quickly, affordable, and easily to the small and large primary care facilities? Can this be a priority of the FP/PC working group? Please let me know of your ideas. I am prepared to actively help with this project. Anyone else?
Thomas C. Thornton, MD / tctmd@cerf.net
The "Pilot" is a hand-held personal information manager (PIM) from US Robotics of Los Altos, CA (1-800-881-7256). Weighing in at just 5 ounces and costing about $250, this device may have the best mix of features per ounce/dollar available today.
The general layout is very similar to the Apple Newton MessagePad with application buttons at the bottom of a vertical display area. Instead of using the entire screen however, handwriting is restricted to a small rectangle at the bottom. The buttons are "real," which allows you to browse most of the built-in applications without using the pen. The software is well designed and very efficient in most instances. A system of drop-down menus provides system-wide cut/copy/paste/undo similar to a desktop computer.
It is interesting that US Robotics did not even attempt true handwriting recognition for the Pilot (a round about complement for the Newton). Instead you are required to use block-printed Graffiti shorthand (an upside down 'V' for the letter "A" for example). These strokes closely resemble the letters they represent for all but five of the 26 alpha and 10 digit characters. Punctuation and special characters are a bit harder. This shorthand is not difficult to master and some users become quite fast (up to 30 words per minute). Accuracy depends on how closely you follow the "ideal" strokes. My handwriting is bad enough that, after several months, I still generate a significant number of typos. The latest Newton OS may have an edge here.
Summary of Features
A few criticisms are worth mentioning:
Overall the Pilot is a pleasure to use and a good choice for anyone needing a basic PIM with pen-only input. Some would argue that it is too limited to be a true Personal Digital Assistant (PDA). Its utility in clinical settings will certainly be limited. A simple patient tracking program would be possible but there is not enough memory to support full blown patient management or reference software. The lack of IR beaming makes it inappropriate for housestaff, medical students, and others who depend on sharing information "on the fly." For these applications the Newton is still the best bet.
More information is available from the US Robotics Web site:
http://www.usr.com/palm/5034.html
Richard Rathe, MD / rrathe@dean.med.ufl.edu
Report from the Communications Committee
This is the 3rd Connections column I've put out - somehow I find that a scary thought. Looking back over the past three columns there are some lessons to be learned. More on that after I review this year's communications committee report and the state of the FP/PCWG web site.
The Communications Comittee is made up of myself, Bob Elson, Richard Rathe , Gary Barnas, and Paul Kleeberg. All of our activities can be accessed via our web site:
http://dragon.labmed.umn.edu/~john/fppcwg/index.html
Our main activities are to produce this newsletter and manage our web site, including the working group membership list. In addition, although Fam-Med extends well beyond the FP/PCWG, we report on Fam-Med as well.
The newsletter is doing well. It's edited at least yearly by Richard Rathe, and summarizes the PCWG's activities. Richard publishes both a paper and web version of the newsletter.
Paul Kleeberg is the creator and sustainer of the Fam-Med Internet email List. It focuses on the intersection between primary care (ok, mostly FP) and information technology. Although Fam-Med extends well beyond our working group, it is really our main thread of community between meetings. Fam-Med remains a healthy and mature list. I recommend that all PCWG members subscribe. You can read about how to subscribe at:
http://apollo.gac.edu/
The web site has just been updated. That's not too hard, since it hasn't changed much in a year! Jim Legler has been ably updating our membership list. I've updated and greatly revised a page of links to primary care informatics web sites. This page focuses almost entirely on primary care medical informatics, with a few general medical informatics references and pointers to well maintained general references (FP Starter Bookmarks, Medical Matrix, Virtual Hospital).
Our projects page has changed little. Rob Hausam is still assembling an EMR implementation reference page, and the electronic publication projects are fairly static.
Overall, I'd say we're doing fine in the newsletter and Fam-Med domain. The web site has been a bit of a disappointment. We experimented with web based conferencing, but that experiment was a failure and has been terminated. The site is currently serving a basic introductory and integration function, but it is not an active part of the FP/PCWG's administration and ongoing projects. It has not helped tie together the diverse communities that are a part of the FP/PCWG. Most telling,ly it has played absolutely no role in the two conferences the FP/PCWG has held on primary care terminology.
Why is that? What lessons can we learn? I would say that my early expectations were unrealistic. Web technologies are still new to all of us. It is one thing to be comfortable operating a browser, another to make the web a part of one's ongoing work. The first requires a few concepts and a bit of practice, the second involves significant personal workflow reengineering. I think we know how long that will take! (Hint: think years and decades.)
Another, lesser, problem is the general immaturity of web tools. I am a bit stunned by how bad our web management and creation software remains. Web conferencing systems are only now beginning to implement the tools that might enable effective collaboration, particularly automated email notification of workgroup participants when new material is added to a workgroup area.
Where should we go now with the FP/PCWG web site? I'm very open to suggestions, providing they come along with volunteer support! :-). The pages can be sustained in their current form, with updates every six months or so. If a FP/PCWG member wishes to work on particular page (or take over the entire site!) they will be very welcome. I will be continuing to carefully monitor the evolving groupware scene for products that might be integrated into the FP/PCWG web site (such as AltaVista Forum 2.0, FrontPage 2.0+). Future additions will have to be considered on a project-by-project basis, with web work optionally built into any FP/PCWG project and managed by project members with web master coordination. If a project is funded, then it may be reasonable to budget money for creation and maintenance of an associated web site.
I think our communications framework is basically in place. Where it goes now depends entirely on the directions and activity of the FP/PCWG. I'll let you know what happens in 1997! Happy Thanksgiving, Solstice, and New Year.
John Faughnan, MD / john@umnhcs.labmed.umn.edu
An annotated update on informatics research relevant to primary care.
The focus of this issue's Literature Watch is on information needs in primary care. Please send me comments on this review or suggestions for topics or specific articles to be reviewed in the future.
Tang PC, Jaworski MA, Fellencer CA, Kreider N, LaRosa MP, Marquardt WC. Clinician information activities in diverse clinical practices. Proc Annu Symp Comput Appl Med Care. 1996:12-16 (Actually, JAMIA Supplement is probably the correct journal citation...)
Abstract: Ambulatory care is assuming an increasing role in health-care delivery. Yet most health-care information systems were developed for the acute-care setting. To address the needs of ambulatory care, developers need a comprehensive understanding of the information-related activiities of clinicians in heterogeneous outpatient practices. We studied the information activities of clinicians in seven diverse (primary-care, specialty-care, faculty, and independent private practices) ambulatory care sites. The results of our study allow us to characterize clinicians' information-related activities, their perceived information needs, and their satisfaction with computer resources. Developers of health-care information systems can use the results to design applications for clinicians in ambulatory care.
Comment: Paul Tang at Northwestern continues to make valuable contributions to our knowledge base regarding primary care information system performance characteristics and requirements. His piece from the 1994 Proceedings (Tang et al. Traditional medical records as a source of clinical data in the outpatient setting. Proc Annu Symp Comput Appl Med Care. 1994:575-9) was the first to define system failure rates for delivering needed patient data to decision-making physicians (at least one data item missing per encounter with a mean of 3.7 and range of 1-20). The current study is the first in over 20 years to comprehensively measure information-related activities of physicians in ambulatory care settings (for the last such study I could locate, see Mamlin. Combined time-motion and work sampling study in a general medicine clinic. Med Care. 1973;11:449-56.
Chambliss ML, Conley J. Answering clinical questions. J Fam Pract. 1996;43(2):140-4
Abstract: BACKGROUND. Physicians often have unanswered clinical questions. The purpose of this study was to determine how often the answers to these questions can be found in the medical literature. METHODS. We collected unanswered clinical questions from family physicians at the end of clinical half-days. The authors and medical librarians then used textbooks and MEDLINE to find answers to each question. We returned to the physicians one to five selected references for each question. Each physician rated these sources on how well they answered the questions and how they might influence the physician's practice. RESULTS. One hundred three questions were gathered. Physicians asked an average of 0.5 questions per half-day. We searched for answers to 86 questions, and the physicians returned ratings for 84. Forty-five (54%) of these questions were fully or nearly fully answered by the materials returned to the physicians. Of the questions for which answers were found, MEDLINE searches accounted for 71%; textbooks, 20%; and a combination, 9%. MEDLINE searches took an average of 27 minutes, whereas textbook searches averaged 6 minutes. CONCLUSIONS. The medical literature can provide answers to a majority of clinical questions; however, finding these answers is time-consuming and expensive. Physicians need more efficient ways to answer their clinical questions.
Comment: This is the latest study to attempt to define the information needs of primary care physicians. Thank God somebody finally actually measured how long it takes to retrieve information from printed material rather than only identifying questions and describing preferred knowledge resources to address those questions. Because of immutable time constraints on primary care physicians, the authors raise the interesting possibility of some type of service bureau to answer clinical questions, and even asked the study physicians how much money they would be willing to pay for such a service. If anybody can figure out a simple, cheap, and rapid mechanism for capturing, answering, and delivering responses to clinical questions as they arise in practice, they ought to run with it! As with all studies of this genre, the observational methods are unavoidably biased towards eliciting consciously recognized and verbalized information needs. Unrecognized needs related to routine situations (e.g., whether or not to order imaging studies for back pain or a urine culture for cystitis) may be more prevalent and more important from the standpoint of reducing practice variation. In other words, given what we know about the dramatic impact of computerized reminder and alert systems on physician decision-making, it's difficult to believe that there is really only one clinical information need that arises during each full day of practice.
Pestotnik SL, Classen DC, Evans RS, Burke JP. Implementing antibiotic practice guidelines through computer-assisted decision support: clinical and financial outcomes. Ann Intern Med. 1996;124(10):884-90
Abstract: OBJECTIVE: To determine the clinical and financial outcomes of antibiotic practice guidelines implemented through computer-assisted decision support. DESIGN: Descriptive epidemiologic study and financial analysis. SETTING: 520-bed community teaching hospital in Salt Lake City, Utah. PATIENTS: All 162 196 patients discharged from LDS Hospital between 1 January 1988 and 31 December 1994. INTERVENTION: An antibiotic management program that used local clinician-derived consensus guidelines embedded in computer-assisted decision support programs. Prescribing guidelines were developed for inpatient prophylactic, empiric, and therapeutic uses of antibiotics. MEASUREMENTS: Measures of antibiotic use included timing of preoperative antibiotic administration and duration of postoperative antibiotic use. Clinical outcomes included rates of adverse drug events, patterns of antimicrobial resistance, mortality, and length of hospital stay. Financial and use outcomes were expressed as yearly expenditures for antibiotics and defined daily doses per 100 occupied bed-days. RESULTS: During the 7-year study period, 63 759 hospitalized patients (39.3%) received antibiotics. The proportion of the hospitalized patients who received antibiotics increased each year, from 31.8% in 1988 to 53.1% in 1994. Use of broad-spectrum antibiotics increased from 24% of all antibiotic use in 1988 to 47% in 1994. The annual Medicare case-mix index increased from 1.7481 in 1988 to 2.0520 in 1993. Total acquisition costs of antibiotics (adjusted for inflation) decreased from 24.8% ($987,547) of the pharmacy drug expenditure budget in 1988 to 12.9% ($612,500) in 1994. Antibiotic costs per treated patient (adjusted for inflation) decreased from $122.66 per patient in 1988 to $51.90 per patient in 1994. Analysis using a standardized method (defined daily doses) to compare antibiotic use showed that antibiotic use decreased by 22.8% overall. Measures of antibiotic use and clinical outcomes improved during the study period. The percentage of patients having surgery who received appropriately timed preoperative antibiotics increased from 40% in 1988 to 99.1% in 1994. The average number of antibiotic doses administered for surgical prophylaxis was reduced from 19 doses in the base year to 5.3 doses in 1994. Antibiotic-associated adverse drug events decreased by 30%. During the study, antimicrobial resistance patterns were stable, and length of stay remained the same. Mortality rates decreased from 3.65% in 1988 to 2.65% in 1994 (P < 0.001). Conclusions: Computer-assisted decision support programs that use local clinician-derived practice guidelines can improve antibiotic use, reduce associated costs, and stabilize the emergence of antibiotic-resistant pathogens.
Comment: LDS Hospital in Utah does it again! Unlike the rest of the health care world, which relies on inspection and rework to ensure decision quality (a Deming deadly sin), they've figured out a way to get the decision right the first time. This study provides a marvelous example of what happens when you provide decision-making physicians with patient- and context-specific information at the time decisions are being made. For the rest of us that don't have the luxury of sophisticated real-time decision support, inspection occurs when the pharmacist detects a prescribing error (e.g., not on formulary, patient allergic, wrong dose) and phones you to re-order the Rx (that's the rework part). I know of at least one famous midwestern medical institution that has a full time infectious disease specialist sitting in a room reviewing hospital antibiotic orders. Using limited computer data to select patients who are not likely being treated in the best way possible, the ID specialist then wanders out to the wards to do unsolicited pseudo-consults and make suggestions for antibiotic changes. In spite of what they pay the specialist, the hospital saved $100K in the first year of the program. Quality management through inspection works in health care because, with LDS being a notable exception, we haven't got the information system infrastructure to support the real-time decision support necessary to get the decision-making right the first time. Disease state management programs run by pharmaceutical benefits management firms, which provide post-encounter recommendations to physicians and patients based on available prescription drug claims data, laboratory data, and other claims data, represent an emerging form of this better-late-than-never decision support.
Bob Elson, MD / relson@medinfo.labmed.umn.edu