Registration and classification in the future

Towards an optimal support of the GP (and the first line) in daily practice,

now and in the future

Kees van Boven

The constraints of primary care

• Between 7 and 20 minutes for typical encounter

• Between 1 and 6 problems addressed per encounter

• Average 2-4 minutes per problem

• …plus prevention (screening), documentation, administrative services

• …plus negotiation and education

• We use shortcuts. We don’t care so much about precision.

We don’t care so much about diagnosis.

Core questions to answer: primary care classification

• What domains must be included to accurately capture the work of primary care?

• How can data capture work within the constraints of primary care practice?

• Who collects it? Who uses it? For what?

• How does it link to other sources of information?

• How do we accommodate the perspective of the patient – and does it matter?

Future

Registration of care and not of diagnosis

Starting from the basics in primary care and focused on the

future.

• Person-oriented, taking into account

• Family / residential context

• Focused on problem identification and solution

• Changes / progress, continuity

• Open for "patient involvement" and cooperation with P (+)

• Comprehensive, multi-morbidity (+)

• Coordination (+), much staff (+), part-time (+)

• Prevention and risk indicators, individual (+)

• Collaboration (Public Health +, other people in the first line(+)

• Prevention of medicalization

+ = more than it is now

Embrace the diversity, person and family focussed

Collaboration

Frank Zappa goes insane on the montana’s improvisation

Continuityhttp://www.youtube.com/music/watch?v=rAPVxHNPN6s

What information should be recorded to provide proper care and to analyze this care?

• SOAP and Context data: reasons for encounter, complaints, history, examination findings, procedures, diagnoses / problems, policies, data from letters, interactions, allergies, social stratum, history

• But also preferences / opinions of patients about treatment / medication, outcomes in terms of impact of a problem / illness on the patient, etc. (+)

• Information of other first line providers who are not using the written letters are entered electronically (+)

• Data from patients that they collect themselves and enter the EMR electronically (+)

All these data lead

To a "contextual evidence". Evidence that we often use for our policy!

This in addition to the evidence-based guidelines linked to the illness / problem.

Example Context!

Some months ago during an out of hour service in Dordrecht a man of 68, chronic lung sufferer, was very puffy. Upon entering the house I went up against a wall of smoke. The interior was brown. At the table, with a full ashtray and Telegraph, sat an emaciated, tanned man who clearly was out of breath.

But I could not easily meet him. The wife had a strategically position, took her cigarette from the mouth and said: "This is certainly the flu, right doctor?" They were both vaccinated, so I could tell her that this was unlikely. Her face had a satisfied expression, and after a sharp pull she concluded: "You see, right from the Moerdijk Fire disaster, I knew it!"

Why registration and classification?

• To support our thinking. More insight into what factors determine our policy (both disease-related factors and the contextual factors). (+)

• More output options: data for comparison at the level of diagnosis / episode but also at outcome level. (+)

• Better reminder of the facts (+)

• Better communication with others (+)

• For accountability to patients and others (+)

• Scientific research

Please note: Garbage in, garbage out

What problems are now in our registration and classification?

• The stories are until now mostly in our heads and not in our EHR. Important data are missing.

• The ICPC classifies reasons for encounter, processes and assessment. In the Netherlands the ICPC (besides TransHis) is only used for the classification of the problem/diagnosis.

• The episode concept is problem-focused and ignores data (context) that focus on the patient.

• Data are if possible linked to one episode, a concept that brought together inter-related information, complaints, descriptions of the problem (diagnosis), research findings and policy (medication, advice, therapeutic conversation, research, etc.)

• Contextual information in addition to the episode data is often relevant to the analysis of the consultation, the policy and the ultimate outcome of our actions are recorded

How can the EHR support us? (1)

And this is a lot, especially for a simple classification such as the ICPC! Comfort slides

How can the EHR support us? (2)

All that must be systematically recorded and classified!

Paul Valery

Ce qui est simple est toujours faux, ce qui est compliqué est inutilisable”.

Comforting (1)

• We often think, naively, that missing data are the primary impediments to intellectual progress

just find the right facts and all problems will dissipate. But barriers are often deeper and more abstract in thought. We must have access to the right metaphor, not only to the requisite information.

Stephen Jay Gould

Comforting (2)

How can the EHR support us? (3)

What is already available?

ICPC-2 with a link to the ICD-10 with the advantage that all conditions / diseases can be classified

Exchanging information at episode level with specialist is possible

For all categories inclusion, exclusion criteria are present and consider information

And of course TransHIS an EHRwhich allows coding/classifying of reasons for encounter, interventions, problems and policies and that can produce many forms of output.

What needs to be developed?

• An input / connection for different first-dieters with limited viewing  and registration options in the EHR (short term)

• A grading / classification of contextual data (medium term)

• A grading / classification of risk indicators (medium term)

• A core EHR (CCR) with patient data relevant to specialty cross (medium term)

• A grading / classification of severity (short / medium term)

• A link to the classification of functioning (ICF) (long term)

Yeah and then there is something like ... .. TransHIS

No, but maybe yes for free from the TransHIS groep

Benefits of TransHIS

• Clear logical structure of the consultation

• Importance of the RFE

• Results Table

• Repeat Medication Screen

• It is built as an episode record (not all on one lot)

Benefits TransHIS

• Independence of HIS vendor

• Huge standard output

• Pop-up screens

• Link with clinical rules

• Indicator sets itself easily to enter

• Flexible and self-adaptable

• To be used by nurses assistants