I am a general practitioner and academic GP with a research interest in informatics. My research focuses on how routinely collected data can be used for quality improvement and how IT is best used at the point of care. My quality improvement work has been in: cardiovascular disease, chronic kidney disease, diabetes, mental health and osteoporosis. I have led the development of on-line information sources for primary care but latterly focussed more on the evaluation of how these and electronic patient record (EPR) systems might best be incorporated into clinical practice. I am trained as an educator and have developed new courses including the UK’s first full time undergraduate informatics degree; I also have a long experience of supervising undergraduate and post graduate students. I am Head of General Practice and Primary Care, a role which involves supervision of an academic team and a network of nearly 300 practices. I have been a partner in my practice for over twenty years and have been active in the local health community, including a period as PEC (Professional Executive Committee) chair.
Abstract: BACKGROUND: There is a lack of tools to evaluate and compare Electronic patient record (EPR) systems to inform a rational choice or development agenda. OBJECTIVE: To develop a tool kit to measure the impact of different EPR system features on the consultation. METHODS: We first developed a specification to overcome the limitations of existing methods. We divided this into work packages: (1) developing a method to display multichannel video of the consultation; (2) code and measure activities, including computer use and verbal interactions; (3) automate the capture of nonverbal interactions; (4) aggregate multiple observations into a single navigable output; and (5) produce an output interpretable by software developers. We piloted this method by filming live consultations (n = 22) by 4 general practitioners (GPs) using different EPR systems. We compared the time taken and variations during coded data entry, prescribing, and blood pressure (BP) recording. We used nonparametric tests to make statistical comparisons. We contrasted methods of BP recording using Unified Modeling Language (UML) sequence diagrams. RESULTS: We found that 4 channels of video were optimal. We identified an existing application for manual coding of video output. We developed in-house tools for capturing use of keyboard and mouse and to time stamp speech. The transcript is then typed within this time stamp. Although we managed to capture body language using pattern recognition software, we were unable to use this data quantitatively. We loaded these observational outputs into our aggregation tool, which allows simultaneous navigation and viewing of multiple files. This also creates a single exportable file in XML format, which we used to develop UML sequence diagrams. In our pilot, the GP using the EMIS LV (Egton Medical Information Systems Limited, Leeds, UK) system took the longest time to code data (mean 11.5 s, 95% CI 8.7-14.2). Nonparametric comparison of EMIS LV with the other systems showed a significant difference, with EMIS PCS (Egton Medical Information Systems Limited, Leeds, UK) (P = .007), iSoft Synergy (iSOFT, Banbury, UK) (P = .014), and INPS Vision (INPS, London, UK) (P = .006) facilitating faster coding. In contrast, prescribing was fastest with EMIS LV (mean 23.7 s, 95% CI 20.5-26.8), but nonparametric comparison showed no statistically significant difference. UML sequence diagrams showed that the simplest BP recording interface was not the easiest to use, as users spent longer navigating or looking up previous blood pressures separately. Complex interfaces with free-text boxes left clinicians unsure of what to add. CONCLUSIONS: The ALFA method allows the precise observation of the clinical consultation. It enables rigorous comparison of core elements of EPR systems. Pilot data suggests its capacity to demonstrate differences between systems. Its outputs could provide the evidence base for making more objective choices between systems.
Abstract: BACKGROUND AND OBJECTIVES: Lipid management in UK general practice targets the achievement of total cholesterol (TC) targets in high-risk individuals. Statins alone have a modest effect on non-LDL-C components of the lipid profile, leaving these patients at significant residual cardiovascular (CV) risk. Improving risk further would require the addition of non-statin therapies. This analysis explores what proportion of the UK population with cardiovascular disease (CVD) and TC levels at or below target may still be at risk because of residual dyslipidaemia. METHODS: CV risk profiles were extracted from a research database of 602,222 patients from 98 UK general practices. Patients were categorised according to their prior CV history and use of statins. Mean values and proportions achieving treatment targets were assessed for TC, low density lipoprotein (LDL-C), high density lipoprotein (HDL-C) and triglycerides (TG). RESULTS: In all, 48 499 patients with pre-existing CVD or diabetes were identified. 73% of statin-treated patients and 63% of untreated patients had a TC < or =5 mmol/L. 28.6% of patients treated to a TC target had LDL-C>3 mmol/L. Amongst those with both TC and LDL-C treated to target, 22.5% had low HDL-C and 37.2% had high triglyceride (TG). Within this group, more women than men had abnormal HDL-C (25.4 vs. 20.7%; p<0.0001). Patients with diabetes were more likely than non-diabetics to have abnormalities of both HDL-C (28.9 vs. 16.4%; p<0.0001) and triglyceride (44.9 vs. 29.5%; p<0.0001) despite normal TC and LDL-C. CONCLUSIONS: Around 60% of high-risk patients have residual dyslipidaemias despite achieving the Quality and Outcomes Framework (QOF) TC target. New patterns of treatment are required in order to extend lipid management beyond simple total cholesterol lowering.
Abstract: BACKGROUND AND OBJECTIVES: Reduction in total cholesterol (TC) and LDL-cholesterol (LDL-C) forms one of the principal objectives of most cardiovascular secondary prevention strategies. Many patients being treated with statins, however, have significant residual dyslipidaemia, with many having suboptimal HDL-cholesterol (HDL-C) levels. The addition of nicotinic acid to a statin has been shown to improve this profile, although clinical outcome evidence is currently lacking. This study set out to model the impact of nicotinic acid therapy on cardiovascular risk in these patients, based on Framingham risk assessments on a cohort of patients drawn from UK general practitioner records. METHODS: Cardiovascular risk profiles were extracted from a research database of 602,222 patients from 98 UK general practices. 23 262 statin-treated patients with established cardiovascular disease or diabetes were identified and their 4-year Framingham risk was estimated. Patients who had either TC or HDL-C outside the desirable range then had their lipid profile adjusted in accordance with the likely performance of nicotinic acid, and the Framingham risk was then re-assessed. RESULTS: Baseline 4-year coronary risk in the group as a whole was 11.5% (95%CI: 11.4-11.6). After adjustment of the lipid profile, this was reduced to 9.7% (95%CI: 9.6-9.8), a reduction in risk of 15.9% (95%CI: 15.1-16.6). When modelling was limited to those with diabetes or an abnormal treated lipid profile, the magnitude of change was increased to 23-29% depending on sex and subgroup. CONCLUSIONS: Risk factor modelling suggests that raising HDL-C levels using nicotinic acid in statin-treated patients is likely to yield significant incremental clinical benefits. The results of clinical trials currently under way are awaited with interest.
Abstract: BACKGROUND: UK general practitioners largely conduct computer-mediated consultations. Although historically there were many small general practice (GP) computer suppliers there are now around five widely used electronic patient record (EPR) systems. A new method has been developed for assessing the impact of the computer on doctor-patient interaction through detailed observation of the consultation and computer use. OBJECTIVE: To pilot the latest version of a method to measure the difference in coding and prescribing times on two different brands of general practice EPR system. METHOD: We compared two GP EPR systems by observing use in real life consultations. Three video cameras recorded the consultation and screen capture software recorded computer activity. We piloted semi-automated user action recording (UAR) software to record mouse and keyboard use, to overcome limitations in manual measurement. Six trained raters analysed the videos using data capture software to measure the doctor-patient-computer interactions; we used interclass correlation coefficients (ICC) to measure reliability. RESULTS: Raters demonstrated high inter-rater reliability for verbal interactions and prescribing (ICC 0.74 to 0.99), but for measures of computer use they were not reliable. We used UAR to capture computer use and found it more reliable. Coded data entry time varied between the systems: 6.8 compared with 11.5 seconds (P = 0.006). However, the EPR with the shortest coding time had a longer prescribing time: 27.5 compared with 23.7 seconds (P = 0.64). CONCLUSION: This methodological development improves the reliability of our method for measuring the impact of different computer systems on the GP consultation. UAR added more objectivity to the observation of doctor-computer interactions. If larger studies were to reproduce the differences between computer systems demonstrated in this pilot it might be possible to make objective comparisons between systems.
Abstract: BACKGROUND: UK primary care is highly computerized; initially led by enthusiastic general practitioners who developed their own systems. This preceded the development of a National Health Service information strategy and an ambitious National Programme for IT. MODEL: A 4-element model is proposed to explain the development of information technology: (1) individual clinician choice; (2) integration into the clinical task--usually an office visit; (3) technological developments; and (4) organizational factors. CONCLUSION: All 4 elements of this model have been tilted in favor of the utilization of information technology; lessons from the United Kingdom may help other health systems looking to implement information technology systems in primary care.
Abstract: The last few years have seen new developments to understand and tackle the significant public health issue posed by chronic kidney disease (CKD). Established renal disease currently consumes 2% of the UK National Health Service budget and predictions are that this figure will increase significantly due to the rising number of people requiring renal replacement therapy fuelled by the ageing population and the diabetes mellitus epidemic. This paper reviews the scale of CKD and discusses the new developments such as staging, referral guidelines and new Department of Health incentives brought about to improve awareness. The importance of Information Technology in assisting the management of renal disease is also outlined. We identify various types of intervention which might be used to do this: feedback in an educational context, the establishment of computerized decision support and enhancement of the patient journey. Many principles may be extended to the management of any chronic disease. While new developments are necessary to improve care, wider implementation is required to be able to see if improved outcomes are achieved.
Abstract: BACKGROUND: In the UK routinely collected computerized clinical data is used to assess progress towards financially incentivised quality targets for chronic disease management including hypertension. OBJECTIVE: To develop a method for assessing the impact of recording quality target data in the clinical consultation. METHODS: Raters were trained how to rate a multi-channel video of a simulated clinical consultation for interaction between actors, computer use, non-verbal communication. RESULTS: 25% of consultation time is computer use and a median of 4 to 5 items were coded per consultation mainly items related to the hypertension quality target. Intraclass correlation coefficient showed good inter-rater reliability (>0.9; p<0.001). CONCLUSION: We have successfully piloted a novel technique for observing the influence of the computer on the consultation. Despite increasing computer use to record quality target data the overwhelming proportion of the consultation remains doctor patient interaction.
Abstract: Single-channel video is an established method for assessing the clinical consultation; however, it has limitations. While previous research has concluded that three-channel video recording of clinical consultations offers advantages, using professional equipment made costs prohibitive. In this study we set out to establish whether the benefits of three-channel video could be achieved using low-budget consumer-level equipment. Using a kit assembled for around euro 1000, we produced three-channel video recordings of simulated consultations. We then showed single- and three-channel versions of the videos to a panel of health professionals and recorded their opinions regarding the quality of the material and the level of information presented. We found that our budget three-channel set-up provided the same advantages as professional three-channel video, while the cost and complexity of the process was minimal. It is now affordable as well as feasible to use a budget set-up three-channel video system for training clinicians and assessing the impact of the computer on the consultation.
Abstract: BACKGROUND: Routinely collected general practice computer data are used for quality improvement; poor data quality including inconsistent coding can reduce their usefulness. OBJECTIVE: To document the diversity of data entry systems currently in use in UK general practice and highlight possible implications for data quality. METHOD: General practice volunteers provided screen shots of the clinical coding screen they would use to code a diagnosis or problem title in the clinical consultation. The six clinical conditions examined were: depression, cystitis, type 2 diabetes mellitus, sore throat, tired all the time, and myocardial infarction. We looked at the picking lists generated for these problem titles in EMIS, IPS, GPASS and iSOFT general practice clinical computer systems, using the Triset browser as a gold standard for comparison. RESULTS: A mean of 19.3 codes is offered in the picking list after entering a diagnosis or problem title. EMIS produced the longest picking lists and GPASS the shortest, with a mean number of choices of 35.2 and 12.7, respectively. Approximately three-quarters (73.5%) of codes are diagnoses, one-eighth (12.5%) symptom codes, and the remainder come from a range of Read chapters. There was no readily detectable consistent order in which codes were displayed. Velocity coding, whereby commonly-used codes are placed higher in the picking list, results in variation between practices even where they have the same brand of computer system. CONCLUSIONS: Current systems for clinical coding promote diversity rather than consistency of clinical coding. As the UK moves towards an integrated health IT system consistency of coding will become more important. A standardised, limited list of codes for primary care might help address this need.
Abstract: BACKGROUND: UK general practice is universally computerised, with computers used in the consulting room at the point of care. Practices use a range of different brands of computer system, which have developed organically to meet the needs of general practitioners and health service managers. Unified Modelling Language (UML) is a standard modelling and specification notation widely used in software engineering. OBJECTIVE: To examine the feasibility of UML notation to compare the impact of different brands of general practice computer system on the clinical consultation. METHOD: Multi-channel video recordings of simulated consultation sessions were recorded on three different clinical computer systems in common use (EMIS, iSOFT Synergy and IPS Vision). User action recorder software recorded time logs of keyboard and mouse use, and pattern recognition software captured non-verbal communication. The outputs of these were used to create UML class and sequence diagrams for each consultation. We compared 'definition of the presenting problem' and 'prescribing', as these tasks were present in all the consultations analysed. RESULTS: Class diagrams identified the entities involved in the clinical consultation. Sequence diagrams identified common elements of the consultation (such as prescribing) and enabled comparisons to be made between the different brands of computer system. The clinician and computer system interaction varied greatly between the different brands. CONCLUSIONS: UML sequence diagrams are useful in identifying common tasks in the clinical consultation, and for contrasting the impact of the different brands of computer system on the clinical consultation. Further research is needed to see if patterns demonstrated in this pilot study are consistently displayed.
Abstract: BACKGROUND: Croatia and the UK have list-based general practice systems: patients register with a single practice. They are also progressively computerising family practice. We set out to identify and report where these countries might learn from each other's experience. METHOD: Experiences, similarities and differences were derived from a literature review and visits to practices in Croatia and the UK. RESULTS: Both countries had developed unique but sophisticated paper-based primary care record systems. They have now moved to promote the computerisation of primary care; both countries see this as integral to patient safety, quality improvement and derivation of data for health service management. However, the development of primary care computing has been an organic process with small suppliers producing trial systems with natural selection of the more effective system. CONCLUSIONS: IT has the potential to improve patient safety and the quality and efficiency of primary care. The lack of a theoretical framework for the comparison of systems hampers the development and selection of an optimum system.
Abstract: OBJECTIVES: Benchmarking statements provide a mechanism for making academic standards explicit within a subject area. They allow comparisons between courses to be based on learning outcomes rather than by defining a curriculum. No such statement has been produced for informatics. In the absence of any established benchmarking statements for informatics a new biomedical informatics course at St. George's has developed a first benchmarking statement - which defines the skills knowledge and understanding a biomedical informatics student should acquire by the time they complete the course. METHODS: Review of national biomedical science and computing subject benchmarking statements and academic educational objectives and national occupational competencies in informatics. RESULTS: We have developed a twenty-item benchmarking statement and this is available on-line at: http://www.gpinformatics.org/benchmark2006/. This benchmarking statement includes a definition and justification for all twenty statements. We found international educational objectives and national informatics competencies useful and these are mapped to each one. National subject benchmarks for computing and biomedical science were less useful and have not been systematically mapped. CONCLUSIONS: Benchmarking the skills, knowledge and understanding that a student should acquire during their course of study may be more useful than setting a standard curriculum. This benchmarking statement is a first step towards defining the learning outcomes and competencies a student of this discipline should acquire. The international informatics community should consider moving from a standard curriculum to an agreed subject benchmarking statement for medical, health and biomedical informatics.
Abstract: The Primary Care Data Quality programme (PCDQ) is a quality-improvement programme which processes routinely collected general practice computer data. Patient data collected from a wide range of different brands of clinical computer systems are aggregated, processed, and fed back to practices in an educational context to improve the quality of care. Process modelling is a well-established approach used to gain understanding and systematic appraisal, and identify areas of improvement of a business process. Unified modelling language (UML) is a general purpose modelling technique used for this purpose. We used UML to appraise the PCDQ process to see if the efficiency and predictability of the process could be improved. Activity analysis and thinking-aloud sessions were used to collect data to generate UML diagrams. The UML model highlighted the sequential nature of the current process as a barrier for efficiency gains. It also identified the uneven distribution of process controls, lack of symmetric communication channels, critical dependencies among processing stages, and failure to implement all the lessons learned in the piloting phase. It also suggested that improved structured reporting at each stage - especially from the pilot phase, parallel processing of data and correctly positioned process controls - should improve the efficiency and predictability of research projects. Process modelling provided a rational basis for the critical appraisal of a clinical data processing system; its potential maybe underutilized within health care.
Abstract: OBJECTIVES: Benchmarking statements provide a mechanism for making academic standards explicit within a subject area. They allow comparisons between courses to be based on learning outcomes rather than by defining a curriculum. No such statement has been produced for informatics. In the absence of any established benchmarking statements for informatics a new biomedical informatics course at St. George's has developed a first benchmarking statement - which defines the skills knowledge and understanding a biomedical informatics student should acquire by the time they complete the course. METHODS: Review of national biomedical science and computing subject benchmarking statements and academic educational objectives and national occupational competencies in informatics. RESULTS: We have developed a twenty-item benchmarking statement and this is available on-line at: http://www.gpinformatics.org/benchmark2006/. This benchmarking statement includes a definition and justification for all twenty statements. We found international educational objectives and national informatics competencies useful and these are mapped to each one. National subject benchmarks for computing and biomedical science were less useful and have not been systematically mapped. CONCLUSIONS: Benchmarking the skills, knowledge and understanding that a student should acquire during their course of study may be more useful than setting a standard curriculum. This benchmarking statement is a first step towards defining the learning outcomes and competencies a student of this discipline should acquire. The international informatics community should consider moving from a standard curriculum to an agreed subject benchmarking statement for medical, health and biomedical informatics.
Abstract: Early identification of patients with chronic kidney disease (CKD) may allow health-care systems to implement interventions aimed at decreasing disease progression and eventual morbidity and mortality. Primary care in the United Kingdom is computerized suggesting a separate screening program for CKD may not be necessary because identifying data already populates primary care databases. Our study utilized a data set of 163 demographic, laboratory, diagnosis, and prescription variables from 130 226 adults in the regions of Kent, Manchester, and Surrey. The patients were 18 years of age and older in a 5-year study period culminating in November 2003. Estimated glomerular filtration rate was calculated from the four-variable Modification of Diet in Renal Disease equation using calibrated creatinine levels. A valid creatinine value was recorded in almost 30% of this cohort. The age-standardized prevalence of stage 3-5 CKD was 10.6% for females and 5.8% for males. In these patients, the odds ratio for hypertension was 2.1, for diabetes 1.33, and for cardiovascular disease 1.69. Only 20% of the diabetic people with stage 3-5 CKD had a blood pressure less than or equal to 130/80 mm Hg. The proportion of patients with anemia significantly rose as renal function declined. We suggest that stage 3-5 CKD is easily detected in existing computerized records. The associated comorbidity and management is readily available enabling intervention and targeting of specialist resources.
Abstract: AIMS: To compare rates of chronic kidney disease (CKD) in patients with diabetes and management of risk factors compared with people without diabetes using general practice computer records, and to assess the utility of serum creatinine and albuminuria as markers of impaired renal function. METHODS: The simplified Modification of Diet in Renal Disease (MDRD) equation was used to estimate glomerular filtration rate (eGFR) and stage of CKD. Further data were extracted to assess how effectively impaired renal function was being identified and how well potentially modifiable risk factors were being managed. The setting was 17 practices in Surrey, Kent and Greater Manchester (2003-2004). Participants were all patients with serum creatinine (SCr) recorded. RESULTS: Of the total population of 162 113, 5072 were recorded as having a diagnosis of diabetes, giving a prevalence of 3.1%. Of patients with diabetes, 31% had clinically significant CKD (defined as eGFR < 60 ml/min per 1.73 m(2); CKD stages 3-5) compared with 6.9% of those without diabetes. Only 33% of patients with diabetes at CKD stage 3 had serum creatinine > 120 micromol/l. Of patients with diabetes with eGFR < 60 ml/min per 1.73 m(2), 63% had normoalbuminuria. Considering those with eGFR 30-60 ml/min per 1.73 m(2), 42% of people with diabetes were on an ACE inhibitor compared with 25% of those without diabetes; 32% of patients with diabetes who had any record of micro- or macroalbuminuria at CKD stage 3 were taking an ACE inhibitor. Of people with diabetes and hypertension (BP > 140/80 mmHg), 26% were not prescribed any hypertensive medication, regardless of level of CKD. CONCLUSIONS: CKD is common in people with diabetes living in the community in the UK. The study found a similar rate of stage 3-5 CKD to that found previously in the USA. Currently used measures of renal function fail to identify CKD as effectively as eGFR. Risk factors for CKD and its progression are suboptimally managed.
Abstract: BACKGROUND: Chronic kidney disease (CKD) is a major public health problem. In the UK, guidelines have been developed to facilitate case identification and management. Our aim was to estimate the annualized cost of implementation of the guidelines on newly identified CKD cases. METHODS: We interrogated the New Opportunities for Early Renal Intervention by Computerised Assessment (NEOERICA) database using a Java program created to recompile the CKD guidelines into rule-based decision trees. This categorized all patients with a serum creatinine recorded over a 1-year period into those requiring more tests or referral. A 12-month cost analysis for following the guidelines was performed. RESULTS: In the first year, a practice of 10,000 would identify 147.5 patients with stages 3-5 CKD over and above those already known. All stages 4-5 CKD cases would require nephrology referral. Of those with stage 3 CKD (143.85), 126.27 stable patients would require more tests. The following would require referral: 14.8 with estimated glomerular filtration rate decline>or=5 ml/min/1.73 m2/year, 1.11 with haemoglobin<11 g/dl and 1.67 with blood pressure>150/90 on three anti-hypertensives. The projected cost per practice of investigating stable stage 3 CKD was euro 6111; and euro 7836 for nephrology referral. Total costs of euro 17 133 in the first year were increased to euro 29,790 through the effect of creatinine calibration. CONCLUSIONS: CKD guideline implementation results in significant increases in nephrology referral and additional investigation. These costs could be recouped by delaying dialysis requirement by 1 year in one individual per 10,000 patients managed according to guidelines.
Abstract: BACKGROUND: Chronic kidney disease (CKD) is a major public health problem. In the UK, guidelines have been developed to facilitate case identification and management. Our aim was to estimate the annualized cost of implementation of the guidelines on newly identified CKD cases. METHODS: We interrogated the New Opportunities for Early Renal Intervention by Computerised Assessment (NEOERICA) database using a Java program created to recompile the CKD guidelines into rule-based decision trees. This categorized all patients with a serum creatinine recorded over a 1-year period into those requiring more tests or referral. A 12-month cost analysis for following the guidelines was performed. RESULTS: In the first year, a practice of 10,000 would identify 147.5 patients with stages 3-5 CKD over and above those already known. All stages 4-5 CKD cases would require nephrology referral. Of those with stage 3 CKD (143.85), 126.27 stable patients would require more tests. The following would require referral: 14.8 with estimated glomerular filtration rate decline>or=5 ml/min/1.73 m2/year, 1.11 with haemoglobin<11 g/dl and 1.67 with blood pressure>150/90 on three anti-hypertensives. The projected cost per practice of investigating stable stage 3 CKD was euro 6111; and euro 7836 for nephrology referral. Total costs of euro 17 133 in the first year were increased to euro 29,790 through the effect of creatinine calibration. CONCLUSIONS: CKD guideline implementation results in significant increases in nephrology referral and additional investigation. These costs could be recouped by delaying dialysis requirement by 1 year in one individual per 10,000 patients managed according to guidelines.
Abstract: AIMS: To compare rates of chronic kidney disease (CKD) in patients with diabetes and management of risk factors compared with people without diabetes using general practice computer records, and to assess the utility of serum creatinine and albuminuria as markers of impaired renal function. METHODS: The simplified Modification of Diet in Renal Disease (MDRD) equation was used to estimate glomerular filtration rate (eGFR) and stage of CKD. Further data were extracted to assess how effectively impaired renal function was being identified and how well potentially modifiable risk factors were being managed. The setting was 17 practices in Surrey, Kent and Greater Manchester (2003-2004). Participants were all patients with serum creatinine (SCr) recorded. RESULTS: Of the total population of 162 113, 5072 were recorded as having a diagnosis of diabetes, giving a prevalence of 3.1%. Of patients with diabetes, 31% had clinically significant CKD (defined as eGFR < 60 ml/min per 1.73 m(2); CKD stages 3-5) compared with 6.9% of those without diabetes. Only 33% of patients with diabetes at CKD stage 3 had serum creatinine > 120 micromol/l. Of patients with diabetes with eGFR < 60 ml/min per 1.73 m(2), 63% had normoalbuminuria. Considering those with eGFR 30-60 ml/min per 1.73 m(2), 42% of people with diabetes were on an ACE inhibitor compared with 25% of those without diabetes; 32% of patients with diabetes who had any record of micro- or macroalbuminuria at CKD stage 3 were taking an ACE inhibitor. Of people with diabetes and hypertension (BP > 140/80 mmHg), 26% were not prescribed any hypertensive medication, regardless of level of CKD. CONCLUSIONS: CKD is common in people with diabetes living in the community in the UK. The study found a similar rate of stage 3-5 CKD to that found previously in the USA. Currently used measures of renal function fail to identify CKD as effectively as eGFR. Risk factors for CKD and its progression are suboptimally managed.
Abstract: OBJECTIVES: To report the lessons learned from eight years of feeding back routinely collected cardiovascular data in an educational context METHODS: There are distinct educational and technical components. The educational component provides peer-led learning opportunities based on comparative analysis of quality of care, as represented in computer records. The technical part ensures that relevant evidence-based audit criteria are identified; an appropriate dataset is extracted and processed to facilitate quality improvement. Anonymised data are used to provide inter-practice comparisons, with lists of identifiable patients who need interventions left in individual practices. RESULTS: The progressive improvement in cholesterol management in ischaemic heart disease (IHD) is used as an exemplar of the changes achieved. Over three iterations of the cardiovascular programme the standardised prevalence of IHD recorded in GP computer systems rose from 3.8% to 4.0%. Cholesterol recording rose from 47.6% to 89.0%; and the mean cholesterol level fell from 5.18 to 4.67 mmol/L; while statin prescribing rose from 46% to 57% to 68%. The atrial fibrillation, heart failure and renal programmes (more people with chronic kidney disease go on to die from cardiovascular cause than from end-stage renal disease) are used to demonstrate the range of cardiovascular interventions amenable to this approach. CONCLUSIONS: Technical progress has meant that larger datasets can be extracted and processed. Feedback of routinely collected data in an educational context is acceptable to practitioners and results in quality improvement. Further research is needed to assess its utility as a strategy and cost-effectiveness compared with other methods.
Abstract: Early identification of patients with chronic kidney disease (CKD) may allow health-care systems to implement interventions aimed at decreasing disease progression and eventual morbidity and mortality. Primary care in the United Kingdom is computerized suggesting a separate screening program for CKD may not be necessary because identifying data already populates primary care databases. Our study utilized a data set of 163 demographic, laboratory, diagnosis, and prescription variables from 130 226 adults in the regions of Kent, Manchester, and Surrey. The patients were 18 years of age and older in a 5-year study period culminating in November 2003. Estimated glomerular filtration rate was calculated from the four-variable Modification of Diet in Renal Disease equation using calibrated creatinine levels. A valid creatinine value was recorded in almost 30% of this cohort. The age-standardized prevalence of stage 3-5 CKD was 10.6% for females and 5.8% for males. In these patients, the odds ratio for hypertension was 2.1, for diabetes 1.33, and for cardiovascular disease 1.69. Only 20% of the diabetic people with stage 3-5 CKD had a blood pressure less than or equal to 130/80 mm Hg. The proportion of patients with anemia significantly rose as renal function declined. We suggest that stage 3-5 CKD is easily detected in existing computerized records. The associated comorbidity and management is readily available enabling intervention and targeting of specialist resources.
Abstract: OBJECTIVES: To report the lessons learned from eight years of feeding back routinely collected cardiovascular data in an educational context METHODS: There are distinct educational and technical components. The educational component provides peer-led learning opportunities based on comparative analysis of quality of care, as represented in computer records. The technical part ensures that relevant evidence-based audit criteria are identified; an appropriate dataset is extracted and processed to facilitate quality improvement. Anonymised data are used to provide inter-practice comparisons, with lists of identifiable patients who need interventions left in individual practices. RESULTS: The progressive improvement in cholesterol management in ischaemic heart disease (IHD) is used as an exemplar of the changes achieved. Over three iterations of the cardiovascular programme the standardised prevalence of IHD recorded in GP computer systems rose from 3.8% to 4.0%. Cholesterol recording rose from 47.6% to 89.0%; and the mean cholesterol level fell from 5.18 to 4.67 mmol/L; while statin prescribing rose from 46% to 57% to 68%. The atrial fibrillation, heart failure and renal programmes (more people with chronic kidney disease go on to die from cardiovascular cause than from end-stage renal disease) are used to demonstrate the range of cardiovascular interventions amenable to this approach. CONCLUSIONS: Technical progress has meant that larger datasets can be extracted and processed. Feedback of routinely collected data in an educational context is acceptable to practitioners and results in quality improvement. Further research is needed to assess its utility as a strategy and cost-effectiveness compared with other methods.
Abstract: The Primary Care Data Quality programme (PCDQ) is a quality-improvement programme which processes routinely collected general practice computer data. Patient data collected from a wide range of different brands of clinical computer systems are aggregated, processed, and fed back to practices in an educational context to improve the quality of care. Process modelling is a well-established approach used to gain understanding and systematic appraisal, and identify areas of improvement of a business process. Unified modelling language (UML) is a general purpose modelling technique used for this purpose. We used UML to appraise the PCDQ process to see if the efficiency and predictability of the process could be improved. Activity analysis and thinking-aloud sessions were used to collect data to generate UML diagrams. The UML model highlighted the sequential nature of the current process as a barrier for efficiency gains. It also identified the uneven distribution of process controls, lack of symmetric communication channels, critical dependencies among processing stages, and failure to implement all the lessons learned in the piloting phase. It also suggested that improved structured reporting at each stage - especially from the pilot phase, parallel processing of data and correctly positioned process controls - should improve the efficiency and predictability of research projects. Process modelling provided a rational basis for the critical appraisal of a clinical data processing system; its potential maybe underutilized within health care.
Abstract: OBJECTIVES: Benchmarking statements provide a mechanism for making academic standards explicit within a subject area. They allow comparisons between courses to be based on learning outcomes rather than by defining a curriculum. No such statement has been produced for informatics. In the absence of any established benchmarking statements for informatics a new biomedical informatics course at St. George's has developed a first benchmarking statement - which defines the skills knowledge and understanding a biomedical informatics student should acquire by the time they complete the course. METHODS: Review of national biomedical science and computing subject benchmarking statements and academic educational objectives and national occupational competencies in informatics. RESULTS: We have developed a twenty-item benchmarking statement and this is available on-line at: http://www.gpinformatics.org/benchmark2006/. This benchmarking statement includes a definition and justification for all twenty statements. We found international educational objectives and national informatics competencies useful and these are mapped to each one. National subject benchmarks for computing and biomedical science were less useful and have not been systematically mapped. CONCLUSIONS: Benchmarking the skills, knowledge and understanding that a student should acquire during their course of study may be more useful than setting a standard curriculum. This benchmarking statement is a first step towards defining the learning outcomes and competencies a student of this discipline should acquire. The international informatics community should consider moving from a standard curriculum to an agreed subject benchmarking statement for medical, health and biomedical informatics.
Abstract: Early identification of patients with chronic kidney disease (CKD) may allow health-care systems to implement interventions aimed at decreasing disease progression and eventual morbidity and mortality. Primary care in the United Kingdom is computerized suggesting a separate screening program for CKD may not be necessary because identifying data already populates primary care databases. Our study utilized a data set of 163 demographic, laboratory, diagnosis, and prescription variables from 130 226 adults in the regions of Kent, Manchester, and Surrey. The patients were 18 years of age and older in a 5-year study period culminating in November 2003. Estimated glomerular filtration rate was calculated from the four-variable Modification of Diet in Renal Disease equation using calibrated creatinine levels. A valid creatinine value was recorded in almost 30% of this cohort. The age-standardized prevalence of stage 3-5 CKD was 10.6% for females and 5.8% for males. In these patients, the odds ratio for hypertension was 2.1, for diabetes 1.33, and for cardiovascular disease 1.69. Only 20% of the diabetic people with stage 3-5 CKD had a blood pressure less than or equal to 130/80 mm Hg. The proportion of patients with anemia significantly rose as renal function declined. We suggest that stage 3-5 CKD is easily detected in existing computerized records. The associated comorbidity and management is readily available enabling intervention and targeting of specialist resources.
Abstract: The Primary Care Data Quality programme (PCDQ) is a quality-improvement programme which processes routinely collected general practice computer data. Patient data collected from a wide range of different brands of clinical computer systems are aggregated, processed, and fed back to practices in an educational context to improve the quality of care. Process modelling is a well-established approach used to gain understanding and systematic appraisal, and identify areas of improvement of a business process. Unified modelling language (UML) is a general purpose modelling technique used for this purpose. We used UML to appraise the PCDQ process to see if the efficiency and predictability of the process could be improved. Activity analysis and thinking-aloud sessions were used to collect data to generate UML diagrams. The UML model highlighted the sequential nature of the current process as a barrier for efficiency gains. It also identified the uneven distribution of process controls, lack of symmetric communication channels, critical dependencies among processing stages, and failure to implement all the lessons learned in the piloting phase. It also suggested that improved structured reporting at each stage - especially from the pilot phase, parallel processing of data and correctly positioned process controls - should improve the efficiency and predictability of research projects. Process modelling provided a rational basis for the critical appraisal of a clinical data processing system; its potential maybe underutilized within health care.
Abstract: AIMS: To compare rates of chronic kidney disease (CKD) in patients with diabetes and management of risk factors compared with people without diabetes using general practice computer records, and to assess the utility of serum creatinine and albuminuria as markers of impaired renal function. METHODS: The simplified Modification of Diet in Renal Disease (MDRD) equation was used to estimate glomerular filtration rate (eGFR) and stage of CKD. Further data were extracted to assess how effectively impaired renal function was being identified and how well potentially modifiable risk factors were being managed. The setting was 17 practices in Surrey, Kent and Greater Manchester (2003-2004). Participants were all patients with serum creatinine (SCr) recorded. RESULTS: Of the total population of 162 113, 5072 were recorded as having a diagnosis of diabetes, giving a prevalence of 3.1%. Of patients with diabetes, 31% had clinically significant CKD (defined as eGFR < 60 ml/min per 1.73 m(2); CKD stages 3-5) compared with 6.9% of those without diabetes. Only 33% of patients with diabetes at CKD stage 3 had serum creatinine > 120 micromol/l. Of patients with diabetes with eGFR < 60 ml/min per 1.73 m(2), 63% had normoalbuminuria. Considering those with eGFR 30-60 ml/min per 1.73 m(2), 42% of people with diabetes were on an ACE inhibitor compared with 25% of those without diabetes; 32% of patients with diabetes who had any record of micro- or macroalbuminuria at CKD stage 3 were taking an ACE inhibitor. Of people with diabetes and hypertension (BP > 140/80 mmHg), 26% were not prescribed any hypertensive medication, regardless of level of CKD. CONCLUSIONS: CKD is common in people with diabetes living in the community in the UK. The study found a similar rate of stage 3-5 CKD to that found previously in the USA. Currently used measures of renal function fail to identify CKD as effectively as eGFR. Risk factors for CKD and its progression are suboptimally managed.
Abstract: OBJECTIVES: To report the lessons learned from eight years of feeding back routinely collected cardiovascular data in an educational context METHODS: There are distinct educational and technical components. The educational component provides peer-led learning opportunities based on comparative analysis of quality of care, as represented in computer records. The technical part ensures that relevant evidence-based audit criteria are identified; an appropriate dataset is extracted and processed to facilitate quality improvement. Anonymised data are used to provide inter-practice comparisons, with lists of identifiable patients who need interventions left in individual practices. RESULTS: The progressive improvement in cholesterol management in ischaemic heart disease (IHD) is used as an exemplar of the changes achieved. Over three iterations of the cardiovascular programme the standardised prevalence of IHD recorded in GP computer systems rose from 3.8% to 4.0%. Cholesterol recording rose from 47.6% to 89.0%; and the mean cholesterol level fell from 5.18 to 4.67 mmol/L; while statin prescribing rose from 46% to 57% to 68%. The atrial fibrillation, heart failure and renal programmes (more people with chronic kidney disease go on to die from cardiovascular cause than from end-stage renal disease) are used to demonstrate the range of cardiovascular interventions amenable to this approach. CONCLUSIONS: Technical progress has meant that larger datasets can be extracted and processed. Feedback of routinely collected data in an educational context is acceptable to practitioners and results in quality improvement. Further research is needed to assess its utility as a strategy and cost-effectiveness compared with other methods.
Abstract: BACKGROUND: Routinely collected clinical data is increasingly used for health service management, audit, and research. Even apparently anonymised data are subject to data protection. The relevant principles were set out in a treaty of the Council of Europe and subsequent policy has been based on these. However, little has been written about implementing policy and the role of health informaticians in this process. OBJECTIVE: To define the elements of an effective implementation policy; the role of the health informatician in protecting processed clinical data. METHODS: We performed a literature review of bibliographic databases, a manual search of the major medical informatics associations' websites, relevant working groups and an affiliated journal. Fifty-four papers relevant to implementation were identified. RESULTS: The effective implementation of policy requires consideration of technical, organisational, personnel and professional issues. However, there is no clearly defined formula for successful implementation of data protection policy. CONCLUSIONS: Patients and professionals need a system they can trust, and processes that can be easily incorporated into everyday practice. The lack of a core generalisable theory or strong professional code in health informatics limits the ability of the health informaticians to implement policy.
Abstract: BACKGROUND: Statins are recommended for the secondary prevention of cardiovascular disease, although they are often used in suboptimal doses and some patients may not receive lipid-lowering therapy. The Primary Care Data Quality (PCDQ) programme is an audit-based educational intervention. OBJECTIVE: To report the PCDQ programme's effect on the cholesterol management in cardiovascular disease. Subjects and methods Anonymized general practice data from 99 practices; 5% (n = 29 915) had cardiovascular diagnoses. RESULTS: Mean cholesterol fell from 4.75 to 4.64 mmol l(-1); patients achieving cholesterol target (< 5 mmol l(-1)) rose from 45.3 to 53.2%. Coronary heart disease patients achieved better control (mean 4.57 mmol l(-1)) than those with stroke (4.87 mmol l(-1)) or peripheral vascular disease (4.93 mmol l(-1)). Statin prescribing increased from 57.5 to 62.7%. Patients with diabetes [odds ratio (OR) 2.06, 95% confidence interval (95% CI) 1.91-2.21], prior myocardial infarction (MI) (OR 1.93, 95% CI 1.80-2.07), revascularization (OR 1.52, 95% CI 1.33-1.73) and smokers (OR 1.31, 95% CI 1.23-1.39) were more likely to receive statins, whereas people aged 75+ (OR 0.48, 95% CI 0.45-0.50), females (OR 0.90, 95% CI 0.86-0.94) and non-CHD-diagnosed (OR 0.36, 95% CI 0.34-0.38) were less likely. CONCLUSIONS: Diagnostic coding and number of patients who had their cholesterol measured and treated increased. There was no significant change in dosage used or inequity between the different groups prescribed statins.
Abstract: BACKGROUND: National guidelines recommend bisphosphonates for secondary prevention of osteoporotic fractures; however, poor compliance may result in sub-optimal prevention. OBJECTIVE: This study reports the feasibility of using GP electronic records to identify poorly compliant post-menopausal women who may be at increased risk of fragility fractures. DESIGN: Cross-sectional study of general practice computer records. SUBJECTS: Women over 45 years, registered in 29 practices across England with a total population of approximately 200,000. METHODS: MIQUEST (Morbidity Information Query and Export Syntax) a data extraction application was used to extract prescription, diagnostic data and probable fragility fractures (hip, vertebral, wrist). All women >45 years who received a first prescription for a weekly bisphosphonate (alendronate or risedronate) at least a year before data extraction were identified. Each record was examined to determine the number of days of prescribed treatment. RESULTS: Of 97992 registered women, 44% (42734) were >45 years. Prevalence of likely fragility fractures in women over 45 was 5.1% (2195/42734). 3.0% (1286/42734, mean age 72 years) received a prescription for a bisphosphonate in the 360 day period prior to data extraction with a median duration of treatment of 267 days. 45% (584/1286) received prescriptions covering >288/360 days (Medicine Possession Ratio >80%); 13% (161/1286) collected prescriptions covering >360 days. In those prescribed bisphosphonates, 23% (294/1286) had a likely fragility fracture. CONCLUSIONS: Women >45 years with probable fragility fractures are more likely to be prescribed bisphosphonates, though less than half will be actually taking them as prescribed. GPs should use computer technology to identify poorly compliant patients who are unnecessarily at risk of fracture.
Abstract: BACKGROUND: Ethnicity data in general practice (GP) computerized medical records can be utilized to audit equity in health care. METHODS: We evaluated a patient profiling project targeted to improve ethnicity recording. RESULTS: Data extracted from 16 practices showed an increase in ethnicity recording from <1% before the intervention to 48% after. Recorded codes could be mapped onto the basic national statistics six-category ethnicity classification headings, and their proportions were similar to the 2001 census values. CONCLUSION: Recording of data using multiple coding hierarchies has reduced the utility of data as clinically important ethnic subgroups cannot be identified. Practitioners should be encouraged to use the single recommended ethnicity coding hierarchy.
Abstract: BACKGROUND: Rich Site Summary (RSS) feeds are a method for disseminating and syndicating the contents of a website using extensible mark-up language (XML). The Primary Care Electronic Library (PCEL) distributes recent additions to the site in the form of an RSS feed. When new resources are added to PCEL, they are manually assigned medical subject headings (MeSH terms), which are then automatically mapped to SNOMED-CT terms using the Unified Medical Language System (UMLS) Metathesaurus. The library is thus searchable using MeSH or SNOMED-CT. Our syndicate partner wished to have remote access to PCEL coronary heart disease (CHD) information resources based on SNOMED-CT search terms. OBJECTIVE: To pilot the supply of relevant information resources in response to clinically coded requests, using RSS syndication for transmission between web servers. METHOD: Our syndicate partner provided a list of CHD SNOMED-CT terms to its end-users, a list which was coded according to UMLS specifications. When the end-user requested relevant information resources, this request was relayed from our syndicate partner's web server to the PCEL web server. The relevant resources were retrieved from the PCEL MySQL database. This database is accessed using a server side scripting language (PHP), which enables the production of dynamic RSS feeds on the basis of Source Asserted Identifiers (CODEs) contained in UMLS. RESULTS: Retrieving resources using SNOMED-CT terms using syndication can be used to build a functioning application. The process from request to display of syndicated resources took less than one second. CONCLUSION: The results of the pilot illustrate that it is possible to exchange data between servers using RSS syndication. This method could be utilised dynamically to supply digital library resources to a clinical system with SNOMED-CT data used as the standard of reference.
Abstract: BACKGROUND: National guidelines recommend bisphosphonates for secondary prevention of osteoporotic fractures; however, poor compliance may result in sub-optimal prevention. OBJECTIVE: This study reports the feasibility of using GP electronic records to identify poorly compliant post-menopausal women who may be at increased risk of fragility fractures. DESIGN: Cross-sectional study of general practice computer records. SUBJECTS: Women over 45 years, registered in 29 practices across England with a total population of approximately 200,000. METHODS: MIQUEST (Morbidity Information Query and Export Syntax) a data extraction application was used to extract prescription, diagnostic data and probable fragility fractures (hip, vertebral, wrist). All women >45 years who received a first prescription for a weekly bisphosphonate (alendronate or risedronate) at least a year before data extraction were identified. Each record was examined to determine the number of days of prescribed treatment. RESULTS: Of 97992 registered women, 44% (42734) were >45 years. Prevalence of likely fragility fractures in women over 45 was 5.1% (2195/42734). 3.0% (1286/42734, mean age 72 years) received a prescription for a bisphosphonate in the 360 day period prior to data extraction with a median duration of treatment of 267 days. 45% (584/1286) received prescriptions covering >288/360 days (Medicine Possession Ratio >80%); 13% (161/1286) collected prescriptions covering >360 days. In those prescribed bisphosphonates, 23% (294/1286) had a likely fragility fracture. CONCLUSIONS: Women >45 years with probable fragility fractures are more likely to be prescribed bisphosphonates, though less than half will be actually taking them as prescribed. GPs should use computer technology to identify poorly compliant patients who are unnecessarily at risk of fracture.
Abstract: BACKGROUND: Rich Site Summary (RSS) feeds are a method for disseminating and syndicating the contents of a website using extensible mark-up language (XML). The Primary Care Electronic Library (PCEL) distributes recent additions to the site in the form of an RSS feed. When new resources are added to PCEL, they are manually assigned medical subject headings (MeSH terms), which are then automatically mapped to SNOMED-CT terms using the Unified Medical Language System (UMLS) Metathesaurus. The library is thus searchable using MeSH or SNOMED-CT. Our syndicate partner wished to have remote access to PCEL coronary heart disease (CHD) information resources based on SNOMED-CT search terms. OBJECTIVE: To pilot the supply of relevant information resources in response to clinically coded requests, using RSS syndication for transmission between web servers. METHOD: Our syndicate partner provided a list of CHD SNOMED-CT terms to its end-users, a list which was coded according to UMLS specifications. When the end-user requested relevant information resources, this request was relayed from our syndicate partner's web server to the PCEL web server. The relevant resources were retrieved from the PCEL MySQL database. This database is accessed using a server side scripting language (PHP), which enables the production of dynamic RSS feeds on the basis of Source Asserted Identifiers (CODEs) contained in UMLS. RESULTS: Retrieving resources using SNOMED-CT terms using syndication can be used to build a functioning application. The process from request to display of syndicated resources took less than one second. CONCLUSION: The results of the pilot illustrate that it is possible to exchange data between servers using RSS syndication. This method could be utilised dynamically to supply digital library resources to a clinical system with SNOMED-CT data used as the standard of reference.
Abstract: BACKGROUND: Medical Subject Headings (MeSH) are a hierarchical taxonomy of over 42,000 descriptors designed to classify scientific literature; it is hierarchical with generic high order headings and specific low order headings. Over 1,000 resources in the Primary Care Electronic Library (PCEL - www.pcel.info) were classified with MeSH. METHODS: Each of the entries or resources in the primary care digital library was assigned up to five MeSH terms. We compared whether the most generic or specific MeSH term ascribed to each resource best predicted user preferences. RESULTS: over the four month period analysed statistically significant differences were found for resources according to specific key MeSH terms they were classified by. This result was not repeated for generic key MeSH terms. CONCLUSIONS: Analysis of the use of specific MeSH terms reveals user preferences that would have otherwise remained obscured. These preferences are not found if more generic MeSH terms are analysed.
Abstract: BACKGROUND: Statins are recommended for the secondary prevention of cardiovascular disease, although they are often used in suboptimal doses and some patients may not receive lipid-lowering therapy. The Primary Care Data Quality (PCDQ) programme is an audit-based educational intervention. OBJECTIVE: To report the PCDQ programme's effect on the cholesterol management in cardiovascular disease. Subjects and methods Anonymized general practice data from 99 practices; 5% (n = 29 915) had cardiovascular diagnoses. RESULTS: Mean cholesterol fell from 4.75 to 4.64 mmol l(-1); patients achieving cholesterol target (< 5 mmol l(-1)) rose from 45.3 to 53.2%. Coronary heart disease patients achieved better control (mean 4.57 mmol l(-1)) than those with stroke (4.87 mmol l(-1)) or peripheral vascular disease (4.93 mmol l(-1)). Statin prescribing increased from 57.5 to 62.7%. Patients with diabetes [odds ratio (OR) 2.06, 95% confidence interval (95% CI) 1.91-2.21], prior myocardial infarction (MI) (OR 1.93, 95% CI 1.80-2.07), revascularization (OR 1.52, 95% CI 1.33-1.73) and smokers (OR 1.31, 95% CI 1.23-1.39) were more likely to receive statins, whereas people aged 75+ (OR 0.48, 95% CI 0.45-0.50), females (OR 0.90, 95% CI 0.86-0.94) and non-CHD-diagnosed (OR 0.36, 95% CI 0.34-0.38) were less likely. CONCLUSIONS: Diagnostic coding and number of patients who had their cholesterol measured and treated increased. There was no significant change in dosage used or inequity between the different groups prescribed statins.
Abstract: BACKGROUND: Much of European primary care is computerised and many groups of practices pool data for research. Technology is making pooled general practice data widely available beyond the domain within which it is collected. OBJECTIVE: To explore the barriers and opportunities to exploiting routinely collected general practice data for research. METHOD: Workshop, led by primary care and informatics academics experienced at working with clinical data from large databases, involving 23 delegates from eight countries. Email comments about the write-up from participants. OUTPUTS: The components of an effective process are: the input of those who have a detailed understanding of the context in which the data were recorded; an assessment of the validity of these data and any denominator used; creation of anonymised unique identifiers for each patient which can be decoded within the contributing practices; data must be traceable back to the patient record from which it was extracted; archiving of the queries, the look-up tables of any coding systems used and the ethical constraints which govern the use of the data. CONCLUSIONS: Explicit statements are needed to explain the source, context of recording, validity check and processing method of any routinely collected data used in research. Data lacking detailed methodological descriptors should not be published.
Abstract: Nearly all general practice physicians (GPs) in the United Kingdom (UK) have electronic health record (EHR) systems in their practices compared with perhaps 15% of primary care physicians in the United States (U.S.). Based on interviews of 13 general GPs and review of current literature, the authors argue that the historical experience of widespread electronic health record uptake in the UK provides insight into features that might motivate broad adoption in the United States. These features include electronic prescribing, improved quality and consistency of care, practice efficiencies that have both timesaving and revenue generating effects, and potential shielding from malpractice claims.
Abstract: OBJECTIVES: To report current levels of obesity and associated cardiac risk using routinely collected primary care computer data. METHODS: 67 practices took part in an educational intervention to improve computer data quality and care in cardiovascular disease. Data were extracted from 435,102 general practice computer records. 64.3% (229,108/362,861) of people age 15 y and older had a body mass index (BMI) recording or a valid height and weight record that enabled BMI to be derived. Data about cardiovascular disease and risk factors were also extracted. The prevalence of disease and the control of risk factors in the overweight and obese population were compared with those of normal body weight. RESULTS: 56.8% of men and 69.3% of women aged over 15 y had a BMI record. 22% of men and 32.3% of women aged 15 to 24 y were overweight or obese; rising each decade to a peak of 65.6% of men and 57.5% of women aged 55 to 64 y. Thereafter, the proportion who were overweight or obese declined. The prevalence of ischaemic heart disease, diabetes mellitus and hypertension rose with increasing levels of obesity; their prevalence in those who are moderately obese was between two and three times that of the general population. Systolic and diastolic blood pressure, blood glucose even in non-diabetics, cholesterol and triglycerides were all elevated in the overweight and obese population. CONCLUSION: Based on the recorded data over half of men and nearly half of women are overweight or obese. They have increased cardiovascular risk, which is not adequately controlled by current practice.
Abstract: BACKGROUND: Ethnicity data in general practice (GP) computerized medical records can be utilized to audit equity in health care. METHODS: We evaluated a patient profiling project targeted to improve ethnicity recording. RESULTS: Data extracted from 16 practices showed an increase in ethnicity recording from <1% before the intervention to 48% after. Recorded codes could be mapped onto the basic national statistics six-category ethnicity classification headings, and their proportions were similar to the 2001 census values. CONCLUSION: Recording of data using multiple coding hierarchies has reduced the utility of data as clinically important ethnic subgroups cannot be identified. Practitioners should be encouraged to use the single recommended ethnicity coding hierarchy.
Abstract: BACKGROUND: Statins are recommended for the secondary prevention of cardiovascular disease, although they are often used in suboptimal doses and some patients may not receive lipid-lowering therapy. The Primary Care Data Quality (PCDQ) programme is an audit-based educational intervention. OBJECTIVE: To report the PCDQ programme's effect on the cholesterol management in cardiovascular disease. Subjects and methods Anonymized general practice data from 99 practices; 5% (n = 29 915) had cardiovascular diagnoses. RESULTS: Mean cholesterol fell from 4.75 to 4.64 mmol l(-1); patients achieving cholesterol target (< 5 mmol l(-1)) rose from 45.3 to 53.2%. Coronary heart disease patients achieved better control (mean 4.57 mmol l(-1)) than those with stroke (4.87 mmol l(-1)) or peripheral vascular disease (4.93 mmol l(-1)). Statin prescribing increased from 57.5 to 62.7%. Patients with diabetes [odds ratio (OR) 2.06, 95% confidence interval (95% CI) 1.91-2.21], prior myocardial infarction (MI) (OR 1.93, 95% CI 1.80-2.07), revascularization (OR 1.52, 95% CI 1.33-1.73) and smokers (OR 1.31, 95% CI 1.23-1.39) were more likely to receive statins, whereas people aged 75+ (OR 0.48, 95% CI 0.45-0.50), females (OR 0.90, 95% CI 0.86-0.94) and non-CHD-diagnosed (OR 0.36, 95% CI 0.34-0.38) were less likely. CONCLUSIONS: Diagnostic coding and number of patients who had their cholesterol measured and treated increased. There was no significant change in dosage used or inequity between the different groups prescribed statins.
Abstract: BACKGROUND: Single-channel video is an established method for assessing clinical consultation in training general practitioners; however, it is hard to infer the body language of the doctor or how information in the consultation is being integrated into the medical record. A three-channel video was developed combining the conventional view with a camera looking at the doctor's facial expression and copying the video output from the monitor. However, the choice of three channels and camera angles selected has not been critically appraised. OBJECTIVE: To develop criteria for comparing single and multi-channel approaches to video recording of the consultation. METHODS: Single channel and three-channel recordings of simulated consultations were shown to a panel of 12 health professionals and interviews were conducted to gather their opinions on the level of information presented, quality and assessment. The transcripts were analysed thematically. RESULTS: It was found that in providing visual information the three-channel video was superior to the single channel video. The major elements needed for comparison of the two techniques would be the ability of the video to pick up quantifiable non-verbal communication of the doctor and the patient, and the ability to qualitatively and quantitatively reflect the use and impact of the computer on the consultation. The information provided by the three-channel video could be further classified to essential, desirable and redundant to guide the future development of the multi-channel video. CONCLUSIONS: Multi-channel methods should be able to capture the following information: body language and facial expression of doctor and patient; and how the doctor's knowledge and information collected in the consultation are synthesized into the medical record.
Abstract: BACKGROUND: Single-channel video is an established method for assessing clinical consultation in training general practitioners; however, it is hard to infer the body language of the doctor or how information in the consultation is being integrated into the medical record. A three-channel video was developed combining the conventional view with a camera looking at the doctor's facial expression and copying the video output from the monitor. However, the choice of three channels and camera angles selected has not been critically appraised. OBJECTIVE: To develop criteria for comparing single and multi-channel approaches to video recording of the consultation. METHODS: Single channel and three-channel recordings of simulated consultations were shown to a panel of 12 health professionals and interviews were conducted to gather their opinions on the level of information presented, quality and assessment. The transcripts were analysed thematically. RESULTS: It was found that in providing visual information the three-channel video was superior to the single channel video. The major elements needed for comparison of the two techniques would be the ability of the video to pick up quantifiable non-verbal communication of the doctor and the patient, and the ability to qualitatively and quantitatively reflect the use and impact of the computer on the consultation. The information provided by the three-channel video could be further classified to essential, desirable and redundant to guide the future development of the multi-channel video. CONCLUSIONS: Multi-channel methods should be able to capture the following information: body language and facial expression of doctor and patient; and how the doctor's knowledge and information collected in the consultation are synthesized into the medical record.
Abstract: INTRODUCTION: Routinely collected primary care data has underpinned research that has helped define primary care as a specialty. In the early years of the discipline, data were collected manually, but digital data collection now makes large volumes of data readily available. Primary care informatics is emerging as an academic discipline for the scientific study of how to harness these data. This paper reviews how data are stored in primary care computer systems; current use of large primary care research databases; and, the opportunities and challenges for using routinely collected primary care data in research. OPPORTUNITIES: (1) Growing volumes of routinely recorded data. (2) Improving data quality. (3) Technological progress enabling large datasets to be processed. (4) The potential to link clinical data in family practice with other data including genetic databases. (5) An established body of know-how within the international health informatics community. CHALLENGES: (1) Research methods for working with large primary care datasets are limited. (2) How to infer meaning from data. (3) Pace of change in medicine and technology. (4) Integrating systems where there is often no reliable unique identifier and between health (person-based records) and social care (care-based records-e.g. child protection). (5) Achieving appropriate levels of information security, confidentiality, and privacy. CONCLUSION: Routinely collected primary care computer data, aggregated into large databases, is used for audit, quality improvement, health service planning, epidemiological study and research. However, gaps exist in the literature about how to find relevant data, select appropriate research methods and ensure that the correct inferences are drawn.
Abstract: BACKGROUND: Single-channel video is an established method for assessing clinical consultation in training general practitioners; however, it is hard to infer the body language of the doctor or how information in the consultation is being integrated into the medical record. A three-channel video was developed combining the conventional view with a camera looking at the doctor's facial expression and copying the video output from the monitor. However, the choice of three channels and camera angles selected has not been critically appraised. OBJECTIVE: To develop criteria for comparing single and multi-channel approaches to video recording of the consultation. METHODS: Single channel and three-channel recordings of simulated consultations were shown to a panel of 12 health professionals and interviews were conducted to gather their opinions on the level of information presented, quality and assessment. The transcripts were analysed thematically. RESULTS: It was found that in providing visual information the three-channel video was superior to the single channel video. The major elements needed for comparison of the two techniques would be the ability of the video to pick up quantifiable non-verbal communication of the doctor and the patient, and the ability to qualitatively and quantitatively reflect the use and impact of the computer on the consultation. The information provided by the three-channel video could be further classified to essential, desirable and redundant to guide the future development of the multi-channel video. CONCLUSIONS: Multi-channel methods should be able to capture the following information: body language and facial expression of doctor and patient; and how the doctor's knowledge and information collected in the consultation are synthesized into the medical record.
Abstract: BACKGROUND: The Royal College of Physicians (RCP) have produced guidelines for stroke management in primary care; this guidance is taken to be the gold standard for the care of people with stroke. UK general practitioners now have a quality-based contract which includes a Quality and Outcomes Framework (QOF). This consists of financially remunerated 'quality points' for specific disease areas, including stroke. Achievement of these quality points is measured by extracting a limited list of computer codes from practice computer systems. OBJECTIVES: To investigate whether a high stroke quality score is associated with adherence to RCP guidelines. DESIGN: Examination of computer and written medical records of all patients with a diagnosis of stroke. SETTING: Two general practices, one in southwest London, one in Surrey, with a combined practice population of over 20 000. Both practices had a similar age-sex profile and prevalence of stroke. RESULTS: One practice scored 93.5% (29/31) of the available stroke quality points. The other practice achieved 73.4% (22.75/31), and only did better in one stroke quality target. However, the practice scoring fewer quality points had much better adherence to RCP guidance: 96% of patients were assessed in secondary care compared with 79% (P=0.001); 64% of stroke patients were seen the same day, compared with 44%; 56% received rehabilitation compared with 37%. CONCLUSIONS: Higher quality points did not reflect better adherence to RCP guidance. This audit highlights a gap between relatively simplistic measures of quality in the QOF, dependent on the recording of a narrow range of computer codes, and the actual standard of care being delivered. Research is needed to see whether this finding is generalisable and how the Quality and Outcomes Framework might be better aligned with delivering best practice.
Abstract: BACKGROUND: National guidelines recommend bisphosphonates for secondary prevention of osteoporotic fractures; however, poor compliance may result in sub-optimal prevention. OBJECTIVE: This study reports the feasibility of using GP electronic records to identify poorly compliant post-menopausal women who may be at increased risk of fragility fractures. DESIGN: Cross-sectional study of general practice computer records. SUBJECTS: Women over 45 years, registered in 29 practices across England with a total population of approximately 200,000. METHODS: MIQUEST (Morbidity Information Query and Export Syntax) a data extraction application was used to extract prescription, diagnostic data and probable fragility fractures (hip, vertebral, wrist). All women >45 years who received a first prescription for a weekly bisphosphonate (alendronate or risedronate) at least a year before data extraction were identified. Each record was examined to determine the number of days of prescribed treatment. RESULTS: Of 97992 registered women, 44% (42734) were >45 years. Prevalence of likely fragility fractures in women over 45 was 5.1% (2195/42734). 3.0% (1286/42734, mean age 72 years) received a prescription for a bisphosphonate in the 360 day period prior to data extraction with a median duration of treatment of 267 days. 45% (584/1286) received prescriptions covering >288/360 days (Medicine Possession Ratio >80%); 13% (161/1286) collected prescriptions covering >360 days. In those prescribed bisphosphonates, 23% (294/1286) had a likely fragility fracture. CONCLUSIONS: Women >45 years with probable fragility fractures are more likely to be prescribed bisphosphonates, though less than half will be actually taking them as prescribed. GPs should use computer technology to identify poorly compliant patients who are unnecessarily at risk of fracture.
Abstract: INTRODUCTION: The EFMI Primary Care Informatics Working Group held a workshop to explore interventions used across Europe to improve the data quality in primary care computerised medical records. METHOD: A plenary session reviewed the UK literature about improving data quality and then the session split into three small groups. Fifteen delegates from nine countries contributed to the workshop. These groups reported back at the end of the session. RESULTS: The groups defined what they meant by data quality. The principal requirement was that data must be 'fit for purpose'. The participants felt this was particularly important for diagnostic data, while recognising that the purpose might not be known at the point of data recording. They also described the barriers to recording structured and coded data. The most important were an inappropriate interface with the coding system and inappropriate granularity of codes. There was a wide range of suggestions as to how to overcome these barriers, including providing feedback, links to expert systems, education and training, use of the data for care elsewhere in the health system and mandation of electronic data recording. CONCLUSIONS: The workshop developed a new characteristic of data quality: 'fit for purpose'. This is different from definitions that focus on completeness, accuracy, currency, or its positive predictive value and sensitivity. The group also highlighted the importance of data quality of diagnoses, as these data are important throughout the health system as well as acting as a prompt for other interventions within the individual consultation. More research is needed into appropriate levels of granularity for diagnostic recording in primary care.
Abstract: BACKGROUND: UK general practice is computerised, and quality targets based on computer data provide a further incentive to improve data quality. A National Programme for Information Technology is standardising the technical infrastructure and removing some of the barriers to data aggregation. Routinely collected data is an underused resource, yet little has been written about the wide range of factors that need to be taken into account if we are to infer meaning from general practice data. OBJECTIVE: To report the complexity of general practice computer data and factors that need to be taken into account in its processing and interpretation. METHOD: We run clinically focused programmes that provide clinically relevant feedback to clinicians, and overview statistics to localities and researchers. However, to take account of the complexity of these data we have carefully devised a system of process stages and process controls to maintain referential integrity, and improve data quality and error reduction. These are integrated into our design and processing stages. Our systems document the query, reference code set and create unique patient ID. The design stage is followed by appraisal of: data entry issues, how concepts might be represented in clinical systems, coding ambiguities, using surrogates where needed, validation and pilot-ing. The subsequent processing of data includes extraction, migration and integration of data from different sources, cleaning, processing and analysis. RESULTS: Results are presented to illustrate issues with the population denominator, data entry problems, identification of people with unmet needs, and how routine data can be used for real-world testing of pharmaceuticals. CONCLUSIONS: Routinely collected primary care data could contribute more to the process of health improvement; however, those working with these data need to understand fully the complexity of the context within which data entry takes place.
Abstract: BACKGROUND: Ethnicity data in general practice (GP) computerized medical records can be utilized to audit equity in health care. METHODS: We evaluated a patient profiling project targeted to improve ethnicity recording. RESULTS: Data extracted from 16 practices showed an increase in ethnicity recording from <1% before the intervention to 48% after. Recorded codes could be mapped onto the basic national statistics six-category ethnicity classification headings, and their proportions were similar to the 2001 census values. CONCLUSION: Recording of data using multiple coding hierarchies has reduced the utility of data as clinically important ethnic subgroups cannot be identified. Practitioners should be encouraged to use the single recommended ethnicity coding hierarchy.
Abstract: The Metathesaurus of the Unified Medical Language System (UMLS) offers the possibility of mapping between various medical vocabularies. The Primary Care Electronic Library (PCEL) contains a database of over six thousand Medical Subject Headings (MeSH terms) describing the resources of the electronic library. We were interested to know if it was possible to map from MeSH to the Systemized Nomenclature of Medicine Clinical Terms (SNOMED CT). Such a mapping would aid healthcare professionals to retrieve relevant data from our digital library as it would enable links between clinical systems and indexed material.
Abstract: OBJECTIVES: Cardiovascular disease is the major cause of morbidity and mortality in people with diabetes. The management of cardiovascular risk factors in people with diabetes in primary care was compared with National Institute of Clinical Excellence guidelines. DESIGN: A cross-sectional study in 26 general practices, with a combined list size of 256,188 patients, participating in the Kent, Surrey and Sussex Primary Care Research Network. Primary outcomes were process of care measures. METHODS: Analysis of general practice computer data on the management of 5980 patients with diabetes, of whom 86% were aged 45 years and over. RESULTS: The prevalence of diabetes was 2.0% in women and 2.6% in men, much lower than the estimated expected prevalence of 4.8% for women and 3.3% in men. Blood pressure was well recorded (96% in both sexes), cholesterol levels less well (79% of women, 84% of men). Hypertension (78% of women, 72% of men) was common. Twenty-one percent of women and 16% of men had a blood pressure above 160/100 mmHg, suggesting under use of antihypertensive therapy. Cholesterol levels were >or=5 mmol/l in 46% of women and 38% of men. Lipid-lowering drugs were prescribed in 38% of women and men. Aspirin was prescribed in 38% of women and 40% of men. CONCLUSIONS: There is an under-diagnosis of diabetes and an under-treatment of blood pressure and blood cholesterol, more marked in women than in men. There is scope for improved management within general practice, including addressing sex inequalities.
Abstract: Technology has provided improved access to the rapidly expanding evidence base and to computerized clinical data recorded as part of routine care. A knowledge audit identifies from within this mass of information the knowledge requirements of a professional group or organization, enabling implementation of an appropriately tailored knowledge-management strategy. The objective of the study is to describe perceived knowledge gaps and recommend an appropriate knowledge-management strategy for primary care. The sample comprised 18 senior managers of Primary Care Trusts: the Chairman, Chief Executive Officer, or Research and Development Lead. A series of interviews were recorded verbatim, transcribed and analysed. Knowledge requirements were broad, suggesting that a broadly based knowledge-management strategy is needed in primary care. The biggest gap in current knowledge identified is how to perform needs assessment and quality improvement using aggregated routinely collected, general practice computer data.
Abstract: Technology has provided improved access to the rapidly expanding evidence base and to computerized clinical data recorded as part of routine care. A knowledge audit identifies from within this mass of information the knowledge requirements of a professional group or organization, enabling implementation of an appropriately tailored knowledge-management strategy. The objective of the study is to describe perceived knowledge gaps and recommend an appropriate knowledge-management strategy for primary care. The sample comprised 18 senior managers of Primary Care Trusts: the Chairman, Chief Executive Officer, or Research and Development Lead. A series of interviews were recorded verbatim, transcribed and analysed. Knowledge requirements were broad, suggesting that a broadly based knowledge-management strategy is needed in primary care. The biggest gap in current knowledge identified is how to perform needs assessment and quality improvement using aggregated routinely collected, general practice computer data.
Abstract: BACKGROUND: Chronic kidney disease (CKD) is an important predictor of end-stage renal disease, as well as a marker of increased mortality. The New Opportunities for Early Renal Intervention by Computerised Assessment (NEOERICA) project aimed to assess whether people with undiagnosed CKD who might benefit from early intervention could be identified from GP computer records. METHODS: The simplified Modification of Diet in Renal Disease (MDRD) equation was used to estimate glomerular filtration rate (GFR) and determine stage of CKD in patients from 12 practices in Surrey, Kent and Greater Manchester with SCr recorded in their notes. Further data were extracted on associated co-morbidities and potentially modifiable risk factors. RESULTS: One quarter (25.7%; 28,862/112,215) had an SCr recorded and one in five (18.9%) of them had a GFR <60 ml/min/1.73 m2 (equivalent to Stage 3-5 CKD), representing 4.9% of the population. Only 3.6% of these were recorded as having renal disease. Three-quarters (74.6%; 4075/5449) of those with Stage 3-5 CKD had one or more circulatory diseases; 346 were prescribed potentially nephrotoxic drugs and over 4000 prescriptions were issued for drugs recommended to be used with caution in renal impairment. CONCLUSIONS: Patients with CKD can be identified by searching GP computer databases; along with associated co-morbidities and treatment. Results revealed a similar rate of Stage 3-5 CKD to that found previously in the USA. The very low rate of recording of renal disease in patients found to have CKD indicates scope for improving detection and early intervention.
Abstract: Background: There are large numbers of schemes that collect and aggregate data from primary care computer systems into large databases. These data are then used for market and academic research. How the data is aggregated, cleaned and processed is usually opaque. Making the method transparent allows researchers to compare methods, and users of the output to better understand the strengths and weaknesses of the data.Objectives To define the stages of the process of aggregating, processing and cleaning clinical data from multiple data sources.Methods: Identify errors in design, collection, staging, integration and analysis.Results: An eight step process defined: (1) Design (2) Data: entry, (3) Extraction, (4) Migration, (5) Integration, (6) Cleaning, (7) Processing, and (8) Analysis. Conclusions: This eight step method provides a taxonomy to enable researchers to compare their methods of data process and aggregation.
Abstract: BACKGROUND: The Primary Care Electronic Library (PCEL) is a collection of indexed and abstracted internet resources. PCEL contains a directory of quality-assured internet material with associated search facilities. PCEL has been indexed, using metadata and established taxonomies. Site development requires an understanding of usage; this paper reports the use of open source tools to evaluate usage. This evaluation was conducted during a six-month period of development of PCEL. OBJECTIVE: To use open source to evaluate changes in usage of an electronic library. METHOD: We defined data we needed for analysis; this included: page requests, visits, unique visitors, page requests per visit, geographical location of users, NHS users, chronological information about users and resources used. RESULTS: During the evaluation period, page requests increased from 3500 to 10,000; visits from 1250 to 2300; and unique visitors from 750 to 1500. Up to 83% of users come from the UK, 15% were NHS users. The page requests of NHS users are slowly increasing but not as fast as requests by other users in the UK. PCEL is primarily used Monday to Friday, 9 a.m. to 5 p.m. Monday is the busiest day with use lessening through the week. NHS users had a different list of top ten resources accessed than non-NHS users, with only four resources appearing in both. CONCLUSIONS: Open source tools provide useful data which can be used to evaluate online resources. Improving the functionality of PCEL has been associated with increased use.
Abstract: BACKGROUND: Metadata is data that describes other data or resources. It has a defined number of named elements that convey meaning. Medical data are complex to process. For example, in the Primary Care Data Quality (PCDQ) renal programme, we need to collect over 300 variables because there are so many possible causes of renal disease. These variables are not just single columns of data--all are extracted as code plus date, while others are code-date-value. Metadata has the potential to improve the reliability of processing large datasets. OBJECTIVE: To define unique and unambiguous metadata headings for clinical data and derived variables. METHOD: We defined the look-up tables we would use as a controlled vocabulary to name the core clinical concepts within the metadata. We added six other elements to describe data: (1) the study or audit name; (2) the query used to extract the data; (3) the data collection number; (4) the type of data, including specifying the units; (5) the repeat number (if the variable was extracted more than once); and (6) a processing suffix that defines how the data have been processed. RESULTS: The metadata system has enabled the development of a query library and an analysis syntax library that make data processing and analysis more efficient. Its stability means greater effort can be put into more complex data processing, and some semiautomation of processes. However, the system has had implementation problems. It has been particularly hard to stop clinicians using multiple synonyms for the same variable. CONCLUSIONS: The PCDQ metadata system provides an auditable method of data processing. It is a method that should improve the reliability, validity and efficiency of processing routinely collected clinical data. This paper sets out to demystify our data processing method and makes the PCDQ metadata system available to clinicians and data processors who might wish to adopt it.
Abstract: Background: Primary care is recognised as a medical specialty and its unique information needs justify the existence of its own health informatics sub-specialty: primary care informatics (PCI). A challenge for PCI is how to raise the standard of computerised medical records so that meaningful conclusions can be drawn from them. In the UK the Primary Care Data Quality (PCDQ) programme has eight years experience of using feedback in an educational context to improve data quality.Objective: This literature review set out to define the characteristics of a feedback process most likely to achieve change; the principles of which could be applied to PCDQ or to other data quality initiatives.Method: A literature review of the major medical bibliographical databases, and the websites and working groups of the international medical informatics associations. Results: There are generalisable lessons for primary care derived from the literature about implementing best evidence, feedback and the theory of diffusion of innovation. The principles identified are: (1) Engage and support local innovators - i.e. those most likely to adopt change, demonstrate the evidence-base for the intervention and the form of feedback most acceptable to them (2) Model the clinical context in which quality improvement is required; (3) Develop an understanding of the health system, its culture and management system; and, (4) Identify and address technical issues relating to computer use and coding.Conclusions: Feedback is most effective when: clinically relevant, educationally orientated, given by peers, and sensitive to the socio-technical context.
Abstract: Teamworking is a vital element in the delivery of primary healthcare. There is evidence that well organised multidisciplinary teams are more effective in developing quality of care. Personal Medical Services (PMS) is a health reform that allows general practices more autonomy and flexibility in delivering quality based primary care. Practices in the locality where this study was conducted were offered resources to employ additional staff. Such arrangements provided the opportunity to expand and develop Primary Care Teams. In this qualitative study, semi-structured interviews were conducted with primary care professionals in 21 second wave PMS practices. Some participants felt they had used PMS to build their teams and develop quality based patient care. For other practices teamworking was limited by the absence of a common goal, recruitment difficulties, inadequate communication and hierarchical structures, and prevented practices from moving forward with clear direction. The study indicates that changing the contractual arrangements does not necessarily improve teamworking. It highlights the need for more sustained educational and quality improvement initiatives to encourage greater collaboration and understanding between healthcare professionals.
Abstract: Much of the knowledge management (KM) literature suggests that organizations should adopt either a "personalization" or "codification" strategy and that to mix the two is unwise. Two European schools have come to the conclusion that a broad strategy is needed. Its key conceptual elements are in three dimensions: the type (explicit - tacit), focus (information - learning) and organization (digital - social) of knowledge. Without this broad approach it is impossible to reconcile the wish to provide (codified) evidence-based solutions to populations at the same time as personalized care for individuals.
Abstract: The Primary Care Informatics Working Group of EFMI is working to help develop the core theory of primary care informatics (PCI). Codes, classifications, terminologies and nomenclatures form an important part of the science of PCI, as they allow clinical information to be readily stored and processed in information systems. This article provides definitions and a history of the International Classification for Primary Care (ICPC), and of the Read code and the Systematized Nomenclature for Medicine (SNOMED). The Working Group wishes to encourage shared definitions and an understanding of the practical application of structured data to improve quality in clinical practice.
Abstract: BACKGROUND: We conducted a search of 12 practices' routinely collected computer data in three localities across the UK and found that 4.9% of the registered population had an estimated glomerular filtration rate (GFR) of <60 ml/min/1.73 m(2) (equivalent to stages 3-5 CKD). Only 3.6% of these were known to have renal disease. Although UK general practice is computerized, important clinical data might be recorded in letters or free-text computer entries and might therefore be invisible to the standard computer search tools. We therefore manually searched through all the records of patients with stages 3-5 CKD in one practice, to test the validity of the computer generated diagnosis and to see if other relevant information was missed by the computer search. METHODS: We identified 492 people with stages 3-5 CKD using computer searching and then manually searched their computer records and written notes for any missed data. The dataset included cardiovascular morbidities and risk factors including diabetes; drugs which may impair renal function; known renal disease; and terminal diagnoses and dementia. RESULTS: The manual searches only added four renal diagnoses to the 36 already identified. Although heart failure and stroke appear to be over-estimated by computer searches, other cardiovascular diagnoses were reliably recorded. Cardiovascular risk factors and drug recording is a strength of general practice computer data. It is complete and contemporary, though most patients had scope to have their cardiovascular risk reduced further. Eighty-four percent had a haemoglobin estimation, and a higher proportion with reduced renal function were anaemic (P<0.001). Testing for proteinuria was less well recorded; negative stick tests were not recorded. Clinical diagnoses of prostatism and bladder outflow problems made these data hard to interpret. CONCLUSIONS: Automated searching of general practice computer records could provide a reliable and valid way of identifying people with stages 3-5 CKD who could benefit from interventions readily available in primary care.
Abstract: BACKGROUND: The annual stroke rate in atrial fibrillation is around 5 per cent with increased risk in those with hypertension, diabetes, left ventricular dysfunction and other cardiovascular risk factors. This study set out to identify the patients with atrial fibrillation and modifiable risk factors for stroke. METHOD: Analysis of practice computer data taken from eight general practices (81 811 patients) in the south of England. 944 patients with a diagnosis of atrial fibrillation, of whom 782 (82.8 percent) were aged 65 years and over. RESULTS: The age standardised prevalence of diagnosed atrial fibrillation was 1.23 per cent (1.28 percent for men and 1.18 percent for women). It was much more prevalent in the older population, 8.28 percent and 6.66 percent for males and females over 65, respectively. Cardiovascular co-morbidities were more frequent with increasing age. Blood pressure (BP) was recorded in over 95 per cent of patients with atrial fibrillation though there was scope for improving control; 25 per cent of men and 31 per cent women had a BP over 150/90. Inconsistent recording of ECG and echocardiography made it hard to identify patients with left ventricular dysfunction. Forty six percent of men and 37 percent of women were either being prescribed Warfarin, or had contraindications to its use; of those on Warfarin 75.9 percent have an international normalized ratio in range. Forty four per cent were treated with aspirin. People at high risk of stroke were no more likely to be treated with Warfarin or aspirin than those at moderate risk. CONCLUSIONS: The rate of use of Warfarin remains low, and there is scope for better recording and management of risk factors particularly BP.
Abstract: BACKGROUND: A growing number of patients are taking multiple medications. Unfortunately, adherence may fall as drug numbers and procedural complexity increase. While there are plausible theoretical reasons why combining pills might improve non-adherence, patients' attitudes are unknown. AIM: To explore attitudes and practices to medication regimens among patients already in receipt of multiple medications, and to assess whether a combined tablet would be perceived as advantageous. DESIGN: Qualitative study. METHODS: Ninety-two men and women aged >40 years currently receiving both antihypertensive and cholesterol-lowering medications took part in 14 focus groups. RESULTS: Drugs were seen as unwelcome but necessary. Some took drugs flexibly by changing dose timing, thereby increasing the complexity of their regimen. A routine was seen as the key to coping with multiple medications, although it was sometimes threatened by changes in prescriptions and life circumstances. While some participants welcomed a combined pill, there was uncertainty about whether a combination that mirrored their current doses would be available. There were also concerns about tablet size, allergies, the attribution of side-effects, timing of tablets throughout the day, and the ability to alter dose levels. CONCLUSION: While some patients would be willing to try a combined pill and would appreciate the associated convenience, they are likely to have a number of concerns that prescribers should address. Willingness to move to combined therapy may be hindered if drug combinations that mirror personalized and trusted regimens are not available.
Abstract: BACKGROUND: A growing number of patients are taking multiple medications. Unfortunately, adherence may fall as drug numbers and procedural complexity increase. While there are plausible theoretical reasons why combining pills might improve non-adherence, patients' attitudes are unknown. AIM: To explore attitudes and practices to medication regimens among patients already in receipt of multiple medications, and to assess whether a combined tablet would be perceived as advantageous. DESIGN: Qualitative study. METHODS: Ninety-two men and women aged >40 years currently receiving both antihypertensive and cholesterol-lowering medications took part in 14 focus groups. RESULTS: Drugs were seen as unwelcome but necessary. Some took drugs flexibly by changing dose timing, thereby increasing the complexity of their regimen. A routine was seen as the key to coping with multiple medications, although it was sometimes threatened by changes in prescriptions and life circumstances. While some participants welcomed a combined pill, there was uncertainty about whether a combination that mirrored their current doses would be available. There were also concerns about tablet size, allergies, the attribution of side-effects, timing of tablets throughout the day, and the ability to alter dose levels. CONCLUSION: While some patients would be willing to try a combined pill and would appreciate the associated convenience, they are likely to have a number of concerns that prescribers should address. Willingness to move to combined therapy may be hindered if drug combinations that mirror personalized and trusted regimens are not available.
Abstract: OBJECTIVE: To determine the extent to which routinely collected general practitioner computer data could be used to create disease registers of patients with osteoporosis, and to report any improvement in data quality since previous studies. STUDY DESIGN: Audit using anonymized data extracted from general practice computer records from across England. METHODS: Morbidity Query Information and Export Syntax (MIQUEST) software was used to extract structured data from the 78 volunteer practices that participated in the study. The data were aggregated and analysed. RESULTS: There were 100-fold differences in the rates of recording of relevant data. Many patients receiving treatment had no diagnostic codes. Data about secondary causes of osteoporosis and fractures were more consistently recorded than data relating to falls. There were no data to indicate whether fractures were low impact. T-scores, the gold-standard measure of bone density, were very infrequently recorded. CONCLUSIONS: Sufficient data about secondary causes of osteoporosis exist, and these could be searched to identify patients at risk. Meanwhile, fracture recoding could be improved, including likely fragility fractures, and T-scores could be added to computer records. A systematic approach is needed to raise the computer records to a standard where they can be used as valid and reliable disease registers.
Abstract: OBJECTIVES: To compare the management of heart failure with the standards set out in the National Service Framework for Coronary Heart Disease. STUDY DESIGN: A cross-sectional study in 26 general practices, with a combined list size of 256,188, that are members of the Kent, Surrey and Sussex Primary Care Research Network. METHODS: Information was extracted on the management of 2129 patients with heart failure, of whom 2097 were aged 45 years and over. RESULTS: The prevalence of heart failure was 8.3 per 1000. Prevalence rates increased with age, from 0.2 per 1000 in people aged under 35 years of age to 125 per 1000 in those aged 85 years and over. Coronary heart disease (present in 47%) was the most common comorbid condition in men with heart failure, whereas hypertension (present in 46%) was the most common condition in women. Recording of cardiovascular risk factors was generally higher in younger patients than in older patients, and in men than in women. Blood pressure (92% of men and 90% of women) and smoking status (84% of men and 77% of women) were generally the best-recorded cardiovascular risk factors. Blood electrolytes were recorded in about 83% of men and 75% of women. Only 17% of men and 11% of women with heart failure had a record of undergoing an echocardiogram. Use of angiotensin-converting enzyme (ACE) inhibitors or antagonists was 76% in men with heart failure and 68% in women; lowest rates were seen in older patients. Uptake of influenza immunization was generally high, at 85% in men and 84% in women. CONCLUSIONS: The use of ACE inhibitors in patients with heart failure was higher than in some previous studies. However, many patients have no documentation in their computerized medical records of having undergone key investigations, such as echocardiography.
Abstract: OBJECTIVE: To determine the extent to which routinely collected general practitioner computer data could be used to create disease registers of patients with osteoporosis, and to report any improvement in data quality since previous studies. STUDY DESIGN: Audit using anonymized data extracted from general practice computer records from across England. METHODS: Morbidity Query Information and Export Syntax (MIQUEST) software was used to extract structured data from the 78 volunteer practices that participated in the study. The data were aggregated and analysed. RESULTS: There were 100-fold differences in the rates of recording of relevant data. Many patients receiving treatment had no diagnostic codes. Data about secondary causes of osteoporosis and fractures were more consistently recorded than data relating to falls. There were no data to indicate whether fractures were low impact. T-scores, the gold-standard measure of bone density, were very infrequently recorded. CONCLUSIONS: Sufficient data about secondary causes of osteoporosis exist, and these could be searched to identify patients at risk. Meanwhile, fracture recoding could be improved, including likely fragility fractures, and T-scores could be added to computer records. A systematic approach is needed to raise the computer records to a standard where they can be used as valid and reliable disease registers.
Abstract: Clinical coding is variable in UK general practice. The reasons for this remain undefined. This review explains why there are no readily available alternatives to recording structured clinical data and reviews the barriers to recording structured clinical data. Methods used included a literature review of bibliographic databases, university health informatics departments, and national and international medical informatics associations. The results show that the current state of development of computers and data processing means there is no practical alternative to coding data. The identified barriers to clinical coding are: the limitations of the coding systems and terminologies and the skill gap in their use; recording structured data in the consultation takes time and is distracting; the level of motivation of primary care professionals; and the priority within the organization. A taxonomy is proposed to describe the barriers to clinical coding. This can be used to identify barriers to coding and facilitate the development of strategies to overcome them.
Abstract: Clinical coding is variable in UK general practice. The reasons for this remain undefined. This review explains why there are no readily available alternatives to recording structured clinical data and reviews the barriers to recording structured clinical data. Methods used included a literature review of bibliographic databases, university health informatics departments, and national and international medical informatics associations. The results show that the current state of development of computers and data processing means there is no practical alternative to coding data. The identified barriers to clinical coding are: the limitations of the coding systems and terminologies and the skill gap in their use; recording structured data in the consultation takes time and is distracting; the level of motivation of primary care professionals; and the priority within the organization. A taxonomy is proposed to describe the barriers to clinical coding. This can be used to identify barriers to coding and facilitate the development of strategies to overcome them.
Abstract: BACKGROUND: A growing number of patients are taking multiple medications. Unfortunately, adherence may fall as drug numbers and procedural complexity increase. While there are plausible theoretical reasons why combining pills might improve non-adherence, patients' attitudes are unknown. AIM: To explore attitudes and practices to medication regimens among patients already in receipt of multiple medications, and to assess whether a combined tablet would be perceived as advantageous. DESIGN: Qualitative study. METHODS: Ninety-two men and women aged >40 years currently receiving both antihypertensive and cholesterol-lowering medications took part in 14 focus groups. RESULTS: Drugs were seen as unwelcome but necessary. Some took drugs flexibly by changing dose timing, thereby increasing the complexity of their regimen. A routine was seen as the key to coping with multiple medications, although it was sometimes threatened by changes in prescriptions and life circumstances. While some participants welcomed a combined pill, there was uncertainty about whether a combination that mirrored their current doses would be available. There were also concerns about tablet size, allergies, the attribution of side-effects, timing of tablets throughout the day, and the ability to alter dose levels. CONCLUSION: While some patients would be willing to try a combined pill and would appreciate the associated convenience, they are likely to have a number of concerns that prescribers should address. Willingness to move to combined therapy may be hindered if drug combinations that mirror personalized and trusted regimens are not available.
Abstract: OBJECTIVE: To determine the extent to which routinely collected general practitioner computer data could be used to create disease registers of patients with osteoporosis, and to report any improvement in data quality since previous studies. STUDY DESIGN: Audit using anonymized data extracted from general practice computer records from across England. METHODS: Morbidity Query Information and Export Syntax (MIQUEST) software was used to extract structured data from the 78 volunteer practices that participated in the study. The data were aggregated and analysed. RESULTS: There were 100-fold differences in the rates of recording of relevant data. Many patients receiving treatment had no diagnostic codes. Data about secondary causes of osteoporosis and fractures were more consistently recorded than data relating to falls. There were no data to indicate whether fractures were low impact. T-scores, the gold-standard measure of bone density, were very infrequently recorded. CONCLUSIONS: Sufficient data about secondary causes of osteoporosis exist, and these could be searched to identify patients at risk. Meanwhile, fracture recoding could be improved, including likely fragility fractures, and T-scores could be added to computer records. A systematic approach is needed to raise the computer records to a standard where they can be used as valid and reliable disease registers.
Abstract: OBJECTIVES: To compare the management of heart failure with the standards set out in the National Service Framework for Coronary Heart Disease. STUDY DESIGN: A cross-sectional study in 26 general practices, with a combined list size of 256,188, that are members of the Kent, Surrey and Sussex Primary Care Research Network. METHODS: Information was extracted on the management of 2129 patients with heart failure, of whom 2097 were aged 45 years and over. RESULTS: The prevalence of heart failure was 8.3 per 1000. Prevalence rates increased with age, from 0.2 per 1000 in people aged under 35 years of age to 125 per 1000 in those aged 85 years and over. Coronary heart disease (present in 47%) was the most common comorbid condition in men with heart failure, whereas hypertension (present in 46%) was the most common condition in women. Recording of cardiovascular risk factors was generally higher in younger patients than in older patients, and in men than in women. Blood pressure (92% of men and 90% of women) and smoking status (84% of men and 77% of women) were generally the best-recorded cardiovascular risk factors. Blood electrolytes were recorded in about 83% of men and 75% of women. Only 17% of men and 11% of women with heart failure had a record of undergoing an echocardiogram. Use of angiotensin-converting enzyme (ACE) inhibitors or antagonists was 76% in men with heart failure and 68% in women; lowest rates were seen in older patients. Uptake of influenza immunization was generally high, at 85% in men and 84% in women. CONCLUSIONS: The use of ACE inhibitors in patients with heart failure was higher than in some previous studies. However, many patients have no documentation in their computerized medical records of having undergone key investigations, such as echocardiography.
Abstract: OBJECTIVES: To compare the management of heart failure with the standards set out in the National Service Framework for Coronary Heart Disease. STUDY DESIGN: A cross-sectional study in 26 general practices, with a combined list size of 256,188, that are members of the Kent, Surrey and Sussex Primary Care Research Network. METHODS: Information was extracted on the management of 2129 patients with heart failure, of whom 2097 were aged 45 years and over. RESULTS: The prevalence of heart failure was 8.3 per 1000. Prevalence rates increased with age, from 0.2 per 1000 in people aged under 35 years of age to 125 per 1000 in those aged 85 years and over. Coronary heart disease (present in 47%) was the most common comorbid condition in men with heart failure, whereas hypertension (present in 46%) was the most common condition in women. Recording of cardiovascular risk factors was generally higher in younger patients than in older patients, and in men than in women. Blood pressure (92% of men and 90% of women) and smoking status (84% of men and 77% of women) were generally the best-recorded cardiovascular risk factors. Blood electrolytes were recorded in about 83% of men and 75% of women. Only 17% of men and 11% of women with heart failure had a record of undergoing an echocardiogram. Use of angiotensin-converting enzyme (ACE) inhibitors or antagonists was 76% in men with heart failure and 68% in women; lowest rates were seen in older patients. Uptake of influenza immunization was generally high, at 85% in men and 84% in women. CONCLUSIONS: The use of ACE inhibitors in patients with heart failure was higher than in some previous studies. However, many patients have no documentation in their computerized medical records of having undergone key investigations, such as echocardiography.
Abstract: Clinical coding is variable in UK general practice. The reasons for this remain undefined. This review explains why there are no readily available alternatives to recording structured clinical data and reviews the barriers to recording structured clinical data. Methods used included a literature review of bibliographic databases, university health informatics departments, and national and international medical informatics associations. The results show that the current state of development of computers and data processing means there is no practical alternative to coding data. The identified barriers to clinical coding are: the limitations of the coding systems and terminologies and the skill gap in their use; recording structured data in the consultation takes time and is distracting; the level of motivation of primary care professionals; and the priority within the organization. A taxonomy is proposed to describe the barriers to clinical coding. This can be used to identify barriers to coding and facilitate the development of strategies to overcome them.
Abstract: End-digit preference describes the disproportionate selection of specific end digits. The rounding of figures might lead to either an under- or over-recording of blood pressure (BP) and a lack of accuracy and reliability in treatment decisions. A total of 85 000 BP values taken from computerised general practice records of ischaemic heart disease patients in England between 2001 and 2003 were examined. Zero preference accounts for 64% of systolic and 59% of diastolic readings, compared with an expected frequency of 10% (P<0.000001). Even numbers are more frequently seen than odd numbers. In all, 64% of nonzero systolic recordings and 65% of diastolic recordings ended in even numbers, compared with expected proportions of 44% (P<0.0001). Among the nonzero even numbers, eight is the most frequently observed: 28% of systolic and 31% of diastolic recordings compared with an expected proportion of 25% (P<0.0001). Among the five nonzero odd numbers, five is the most frequently observed end digit, representing 59% systolic and 62% of diastolic compared with an expected level of 20% (P<0.00001). English general practice displays marked end-digit preference. This is strongly for the end-digit zero. However, there is more use of other end-digits, notably 8 and 5. This bias potentially carries important treatment consequences for this high-risk population.
Abstract: OBJECTIVE: To evaluate the implementation of a primary care, nurse-led, near patient anticoagulant monitoring service. DESIGN: Action research workshops, supported by questionnaires and clinical audit, to define the strengths and weaknesses of the service and the effectiveness of the computerised decision support system used to set the dosage of anticoagulant and time interval to the next appointment. SETTING: 13 general practices that implemented anticoagulant monitoring in a primary care organisation in south east England. PARTICIPANTS: 18 practice nurses, 72% of whom had over 20 years' clinical experience; the university-based investigators and managers from the primary care organisation. MAIN OUTCOME MEASURE: The nurses felt that the patients preferred the practice-based service, finding it more personal and accessible. However, circumstances arose where the nurse's intuition had to override the software's advice. The nurses found it stressful when they were unclear whether their decision making represented acceptable variation or dangerous practice. An audit tool was developed to measure the extent to which there was variation from the software's recommendation, and patterns of variation emerged. Most evident was that nurses responded to uncertainty by practising cautiously, shortening the interval until the next visit and slightly reducing the recommended dose of warfarin. CONCLUSIONS: The group, by sharing their experiences through a structured series of workshops, developed an understanding of when it might be appropriate to vary from the decision support software's recommendations and how this could be audited. The technological solution modelled on hospital practice proved hard to implement in primary care.
Abstract: A survey investigated the use of information technology among community nurses and other staff in one primary care trust. Provision of IT was poor across all the staff studied, with health visitors and community nurses lagging slightly behind others. The reasons for the low levels of use need further research so that barriers to using IT can be overcome.
Abstract: End-digit preference describes the disproportionate selection of specific end digits. The rounding of figures might lead to either an under- or over-recording of blood pressure (BP) and a lack of accuracy and reliability in treatment decisions. A total of 85 000 BP values taken from computerised general practice records of ischaemic heart disease patients in England between 2001 and 2003 were examined. Zero preference accounts for 64% of systolic and 59% of diastolic readings, compared with an expected frequency of 10% (P<0.000001). Even numbers are more frequently seen than odd numbers. In all, 64% of nonzero systolic recordings and 65% of diastolic recordings ended in even numbers, compared with expected proportions of 44% (P<0.0001). Among the nonzero even numbers, eight is the most frequently observed: 28% of systolic and 31% of diastolic recordings compared with an expected proportion of 25% (P<0.0001). Among the five nonzero odd numbers, five is the most frequently observed end digit, representing 59% systolic and 62% of diastolic compared with an expected level of 20% (P<0.00001). English general practice displays marked end-digit preference. This is strongly for the end-digit zero. However, there is more use of other end-digits, notably 8 and 5. This bias potentially carries important treatment consequences for this high-risk population.
Abstract: BACKGROUND: Irritable bowel syndrome is a common condition in general practice. It occurs in 10 to 20% of the population, but less than half seek medical assistance with the complaint. METHODS: A questionnaire was sent to the 406 GPs listed on the West Sussex Health Authority Medical List to investigate their views of this condition and whether they felt hypnotherapy had a place in its management RESULTS: 38% of general practitioners responded. The achieved sample shared the characteristics of target sample.Nearly half thought that irritable bowel syndrome (IBS) was a "nervous complaint" and used a combination of "the placebo effect of personal care," therapeutic, and dietary advice. There is considerable divergence in the perceived effectiveness of current approaches. Over 70% thought that hypnotherapy may have a role in the management of patients with IBS; though the majority (68%) felt that this should not be offered by general practitioners. 84% felt that this should be offered by qualified hypnotherapist, with 40% feeling that this should be offered outside the health service. CONCLUSIONS: General practitioners vary in their perceptions of what constitutes effective therapy in IBS. They are willing to consider referral to a qualified hypnotherapist.
Abstract: OBJECTIVE: To report problems implementing a data quality programme in osteoporosis. DESIGN: Analysis of data extracted using Morbidity Information Query and Export Syntax (MIQUEST) from participating general practices' systems and recommendations of practitioners who attended an action research workshop. SETTING: Computerised general practices using different Read code versions to record structured data. PARTICIPANTS: 78 practices predominantly from London and the south east, with representation from north east, north west and south west England. MAIN OUTCOME MEASURES: Patients at risk can be represented in many ways within structured data. Although fracture data exists, it is unclear which are fragility fractures. T-scores, the gold standard for measuring bone density, cannot be extracted using the UK's standard data extraction tool, MIQUEST; instead manual searches had to be implemented. There is a hundredfold variation in data recording levels between practices. Therapy is more frequently recorded than diagnosis. A multidisciplinary forum of experienced practitioners proposed that a limited list of codes should be used. CONCLUSIONS: There is variability in inter-practice data quality. Some clinically important codes are lacking, and there are multiple ways that the same clinical concept can be represented. Different practice computer systems have different versions of Read code, making some data incompatible. Manual searching is still required to find data. Clinicians with an understanding of what data are clinically relevant need to have a stronger voice in the production of codes, and in the creation of recommended lists.
Abstract: BACKGROUND: Gaps in computerized medical records and a lack of a systematic approach to data recording make progress towards achieving quality standards in primary care difficult to demonstrate. The aim of this study was to examine the effect of an educational intervention on data quality in primary care. METHODS: A before-and-after study of key data quality measures was carried out in 87 general practices in eight primary care organizations in England in phase 1 and 84 general practices in phase 2. The subjects were 19,470 patients with ischaemic heart disease in phase 1 and 19,784 patients in phase 2. The main outcome measures were improvement in the completeness and quality of the computerized medical record. Anonymized data were extracted from clinical information systems and processed to produce comparative information on each practice. Data quality workshops were arranged, in which reflection can take place, backed up by summary statistics. Practice visits provided training and personalized feedback of patients needing intervention. RESULTS: In the patients with heart disease, nearly 16,000 new clinical entries were made in the key improvement areas. The percentage of patients advised to quit smoking increased by 49.3 per cent, from 23.6 per cent to 61.9 per cent. There were also significant improvements in many other aspects of management. CONCLUSION: Focused interventions that provide targeted and relevant clinical information can be implemented in primary care. Such interventions can lead to a rise in data quality in primary care, but their effectiveness needs to be further tested in more rigorous research settings such as randomized controlled trials.
Abstract: End-digit preference describes the disproportionate selection of specific end digits. The rounding of figures might lead to either an under- or over-recording of blood pressure (BP) and a lack of accuracy and reliability in treatment decisions. A total of 85 000 BP values taken from computerised general practice records of ischaemic heart disease patients in England between 2001 and 2003 were examined. Zero preference accounts for 64% of systolic and 59% of diastolic readings, compared with an expected frequency of 10% (P<0.000001). Even numbers are more frequently seen than odd numbers. In all, 64% of nonzero systolic recordings and 65% of diastolic recordings ended in even numbers, compared with expected proportions of 44% (P<0.0001). Among the nonzero even numbers, eight is the most frequently observed: 28% of systolic and 31% of diastolic recordings compared with an expected proportion of 25% (P<0.0001). Among the five nonzero odd numbers, five is the most frequently observed end digit, representing 59% systolic and 62% of diastolic compared with an expected level of 20% (P<0.00001). English general practice displays marked end-digit preference. This is strongly for the end-digit zero. However, there is more use of other end-digits, notably 8 and 5. This bias potentially carries important treatment consequences for this high-risk population.
Abstract: AIM: To identify any barriers to the use of information technology by community nurses, such as poor access, insufficient time and a lack of appropriate skills. METHODS: Literature review and questionnaire. RESULTS: The study showed that a large majority of community nurses had access to IT. However, sharing facilities and varying clinical systems meant that, with the exception of e-mail, they made infrequent use of the applications provided. CONCLUSION: Despite some access difficulties, community nurses have a positive attitude to IT and would like to receive more training.
Abstract: In many countries, primary care informatics has developed to the point that it is recognised as an important enabler of quality improvement; this has not occurred to date in the United States.With this conference, we aimed to build an international consensus as to whether primary care has unique characteristics that require an informatics subspecialty; and, if so, to establish the role of primary care informatics in improving patient care, and to enable its recognition in the national strategy.The conference was organised by the primary care informatics working groups of AMIA, EFMI, IMIA and Wonca and took place at Medinfo 2004 in San Francisco. It consisted of two plenary lectures, two small-group work sessions and a panel discussion to summarise the day. It was attended by an international audience of 53 health informaticians, mostly working in primary care.There was consensus among the participants that primary care has many unique characteristics that justify the existence of an informatics subspecialty: primary care informatics (PCI). The conference identified principles and practical examples of: (1) the effective deployment of information technology to underpin the provision of records, communication and access to information; (2) the need to harness the extensive knowledge base about the practice of PCI; and (3) the contribution of the experimental work and theory that underpins the science of PCI. These principles and examples of their practical application were largely derived from the extensive knowledge base which has been built up in countries that have developed PCI over the last one to two decades.
Abstract: BACKGROUND: Chronic obstructive pulmonary disease (COPD) is an important cause of mortality and morbidity. Its management is shifting from the secondary to the primary care setting. The quality of data is known to vary between practices, and individual practices need to be able to assess their data quality. OBJECTIVES: To measure the quality of diagnostic data in COPD. SUBJECTS: 10 975 patients registered with a computerised general practice in the south of England, and 190 patients likely to have COPD. METHODS: An eight-step method was developed: (1) research the expected prevalence of the diagnosis and define audit criteria; (2) find out how the diagnosis might be coded--look at the terminology and the codes presented by the computer interface; (3) examine the characteristics of the practice population; (4) calculate the prevalence and infer its reliability; (5) investigate the completeness; (6) accuracy; (7) currency and consistency; and (8) calculate sensitivity and positive predictive value of the data. RESULTS: The prevalence of COPD in the literature ranges between 3% and 10%. The coding for bronchitis and COPD is complex and it is easy to select an incorrect code. The test population is younger but of similar social class to the national average. The prevalence of COPD in this study was 1.3%. The data were incomplete and some were inaccurate; patients with COPD had to be identified from additional searches. The sensitivity of the use of the diagnostic code was 79%, and the positive predictive value 75.3%. CONCLUSIONS: The method provides a tool to help practices and localities assess their diagnostic data quality.
Abstract: BACKGROUND: The quality of data in general practice clinical information systems varies enormously. This variability jeopardizes the proposed national strategy for an integrated care records service and the capacity of primary care organisations to respond coherently to the demands of clinical governance and the proposed quality-based general practice contract. This is apparent in the difficulty in automating the audit process and in comparing aggregated data from different practices. In an attempt to provide data of adequate quality to support such operational needs, increasing emphasis is being placed on the standardisation of data recording. OBJECTIVE: To develop a conceptual framework to facilitate the recording of standardised data within primary care. METHOD: A multiprofessional group of primary care members from the South Thames Research Network examined leading guidelines for best practice. Using the nominal group technique the group prioritized the information needs of primary care organisations for managing coronary heart disease according to current evidence. RESULTS: Information needs identified were prioritized and stratified into a functional framework. CONCLUSION: It has been possible within the context of a primary care research network to produce a framework for standardising data collection. Motivation of front-line clinicians was achieved through the incorporation of their views into the synthesis of the dataset.
Abstract: OBJECTIVE: In UK general practice, the coding of clinical data (Read Coding) is far from universal. This study set out to examine the barriers to recording structured information in computerised medical records; and to explore whether managers and clinicians had different perspectives in how these barriers should be overcome. METHOD: A qualitative study, using semi-structured interviews of general practitioners, primary care nurses and practice managers. The interviews were recorded verbatim, and then underwent thematic analysis; additional interviews were conducted until thematic saturation was achieved. RESULTS: For clinicians the recording of structured data within a consultation is not a neutral activity, they are highly aware of diagnostic uncertainty and sensitive to the potential impact of both a correct and incorrect diagnostic label on their relationship with their patient. Clinicians accept that data has to be coded if they are to demonstrate that appropriate evidence based care has been provided to populations; but alongside this they require free-text as a more powerful reminder of the individual human encounter. Managers felt that they could encourage clinicians to code data for re-use as part of population data or as quality target indicators rather than as an enabler of the next consultation. CONCLUSIONS: The primary care consultation is a complex social interaction, and coding of the medical diagnosis in itself imposes the bio-medical model, carries assumptions about certainty, and is perceived by clinicians to potentially jeopardise their relationships with their patient. Further research to elicit patients' views may help clarify the magnitude of this barrier.
Abstract: Although UK general practice is highly computerized, comprehensive use of these computers is often limited to registration data and the issue of repeat prescriptions. The recording of diagnostic data is patchy. This study examines whether patients with, or at risk of, osteoporosis can be readily identified from general practice computer records. It reports the findings of a pilot study designed to show the variability of recording the diagnosis of osteoporosis and osteopenia, as well as how useful surrogate markers might be to identify these patients. The study also illustrates the difficulties that even skilled practitioners in a primary care research network experience in extracting clinical data from practice information systems. Computer searches were carried out across six practices in a general practice research network in the south-east of England. Two of these practices had previously undertaken research projects in osteoporosis and were consequently expected to have excellent data quality in osteoporosis. These two practices had a combined list size of 27,500 and the remaining practices had a combined practice population of 43,000 patients. The data were found to be variable with over 10-fold differences between practices in the recorded prevalence of osteoporosis diagnosis as well as its surrogate markers-such as fragility fractures, long-term steroid prescription, etc. There was no difference in data quality between the two practices that had conducted osteoporosis research and the rest of the group, other than in the areas of diagnostic recording and prescribing for osteoporosis and recording of fractures. Issues were raised by the practices that struggled to identify patients at risk of osteoporosis about the limitations of Read classification in this disease area. Practices need further assistance if the patients at risk are to be identified. Without urgent action, it will be difficult for practices to identify the patients who are likely to benefit from Standard 6-'Falls' of the National Service Framework for Older People. These findings also have broader implications as UK general practice moves towards the implementation of a quality-based contract.
Abstract: Although UK general practice is highly computerized, comprehensive use of these computers is often limited to registration data and the issue of repeat prescriptions. The recording of diagnostic data is patchy. This study examines whether patients with, or at risk of, osteoporosis can be readily identified from general practice computer records. It reports the findings of a pilot study designed to show the variability of recording the diagnosis of osteoporosis and osteopenia, as well as how useful surrogate markers might be to identify these patients. The study also illustrates the difficulties that even skilled practitioners in a primary care research network experience in extracting clinical data from practice information systems. Computer searches were carried out across six practices in a general practice research network in the south-east of England. Two of these practices had previously undertaken research projects in osteoporosis and were consequently expected to have excellent data quality in osteoporosis. These two practices had a combined list size of 27,500 and the remaining practices had a combined practice population of 43,000 patients. The data were found to be variable with over 10-fold differences between practices in the recorded prevalence of osteoporosis diagnosis as well as its surrogate markers-such as fragility fractures, long-term steroid prescription, etc. There was no difference in data quality between the two practices that had conducted osteoporosis research and the rest of the group, other than in the areas of diagnostic recording and prescribing for osteoporosis and recording of fractures. Issues were raised by the practices that struggled to identify patients at risk of osteoporosis about the limitations of Read classification in this disease area. Practices need further assistance if the patients at risk are to be identified. Without urgent action, it will be difficult for practices to identify the patients who are likely to benefit from Standard 6-'Falls' of the National Service Framework for Older People. These findings also have broader implications as UK general practice moves towards the implementation of a quality-based contract.
Abstract: BACKGROUND: A key feature of a good general practice consultation is that it is patient-centred. A number of verbal and non-verbal behaviours have been identified as important to establish a good relationship with the patient. However, the use of the computer detracts the doctor's attention away from the patient, compromising these essential elements of the consultation. Current methods to assess the consultation and the influence of the computer on them are time consuming and subjective. If it were possible to measure these quantitatively, it could provide the basis for the first truly objective way of studying the influence of the computer on the consultation.The aim was to assess whether pattern recognition software could be used to measure the influence and pattern of computer use in the consultation. If this proved possible it would provide, for the first time, an objective quantitative measure of computer use and a measure of the attention and responsiveness of the general practitioner towards the patient. METHODS: A feasibility study using pattern recognition software to analyse a consultation was conducted. A web camera, linked to a data-gathering node was used to film a simulated consultation in a standard office. Members of the research team enacted the role of the doctor and the patient, using pattern recognition software to try and capture patient-centred, non-verbal behaviour. As this was a feasibility study detailed results of the analysis are not presented. RESULTS: It was revealed that pattern recognition software could be used to analyse certain aspects of a simulated consultation. For example, trigger lines enabled the number of times the clinician's hand covered the keyboard to be counted and wrapping recorded the number of times the clinician nodded his head. It was also possible to measure time sequences and whether the movement was brief or lingering. CONCLUSION: Pattern recognition software enables movements associated with patient-centredness to be recorded. Pattern recognition software has the potential to provide an objective, quantitative measure of the influence of the computer on the consultation.
Abstract: Although UK general practice is highly computerized, comprehensive use of these computers is often limited to registration data and the issue of repeat prescriptions. The recording of diagnostic data is patchy. This study examines whether patients with, or at risk of, osteoporosis can be readily identified from general practice computer records. It reports the findings of a pilot study designed to show the variability of recording the diagnosis of osteoporosis and osteopenia, as well as how useful surrogate markers might be to identify these patients. The study also illustrates the difficulties that even skilled practitioners in a primary care research network experience in extracting clinical data from practice information systems. Computer searches were carried out across six practices in a general practice research network in the south-east of England. Two of these practices had previously undertaken research projects in osteoporosis and were consequently expected to have excellent data quality in osteoporosis. These two practices had a combined list size of 27,500 and the remaining practices had a combined practice population of 43,000 patients. The data were found to be variable with over 10-fold differences between practices in the recorded prevalence of osteoporosis diagnosis as well as its surrogate markers-such as fragility fractures, long-term steroid prescription, etc. There was no difference in data quality between the two practices that had conducted osteoporosis research and the rest of the group, other than in the areas of diagnostic recording and prescribing for osteoporosis and recording of fractures. Issues were raised by the practices that struggled to identify patients at risk of osteoporosis about the limitations of Read classification in this disease area. Practices need further assistance if the patients at risk are to be identified. Without urgent action, it will be difficult for practices to identify the patients who are likely to benefit from Standard 6-'Falls' of the National Service Framework for Older People. These findings also have broader implications as UK general practice moves towards the implementation of a quality-based contract.
Abstract: OBJECTIVE: In UK general practice, the coding of clinical data (Read Coding) is far from universal. This study set out to examine the barriers to recording structured information in computerised medical records; and to explore whether managers and clinicians had different perspectives in how these barriers should be overcome. METHOD: A qualitative study, using semi-structured interviews of general practitioners, primary care nurses and practice managers. The interviews were recorded verbatim, and then underwent thematic analysis; additional interviews were conducted until thematic saturation was achieved. RESULTS: For clinicians the recording of structured data within a consultation is not a neutral activity, they are highly aware of diagnostic uncertainty and sensitive to the potential impact of both a correct and incorrect diagnostic label on their relationship with their patient. Clinicians accept that data has to be coded if they are to demonstrate that appropriate evidence based care has been provided to populations; but alongside this they require free-text as a more powerful reminder of the individual human encounter. Managers felt that they could encourage clinicians to code data for re-use as part of population data or as quality target indicators rather than as an enabler of the next consultation. CONCLUSIONS: The primary care consultation is a complex social interaction, and coding of the medical diagnosis in itself imposes the bio-medical model, carries assumptions about certainty, and is perceived by clinicians to potentially jeopardise their relationships with their patient. Further research to elicit patients' views may help clarify the magnitude of this barrier.
Abstract: OBJECTIVE: The purpose of this study was to examine whether Internet-based surveys of health professionals can provide a valid alternative to traditional survey methods. METHODS: (i) Systematic review of published Internet-based surveys of health professionals focusing on criteria of external validity, specifically sample representativeness and response bias. (ii) Internet-based survey of GPs, exploring attitudes about using an Internet-based decision support system for the management of familial cancer. RESULTS: The systematic review identified 17 Internet-based surveys of health professionals. Whilst most studies sampled from professional e-directories, some studies drew on unknown denominator populations by placing survey questionnaires on open web sites or electronic discussion groups. Twelve studies reported response rates, which ranged from nine to 94%. Sending follow-up reminders resulted in a substantial increase in response rates. In our own survey of GPs, a total of 268 GPs participated (adjusted response rate = 52.4%) after five e-mail reminders. A further 72 GPs responded to a brief telephone survey of non-respondents. Respondents to the Internet survey were more likely to be male and had significantly greater intentions to use Internet-based decision support than non-respondents. CONCLUSIONS: Internet-based surveys provide an attractive alternative to postal and telephone surveys of health professionals, but they raise important technical and methodological issues which should be carefully considered before widespread implementation. The major obstacle is external validity, and specifically how to obtain a representative sample and adequate response rate. Controlled access to a national list of NHSnet e-mail addresses of health professionals could provide a solution.
Abstract: Primary care informatics is an emerging academic discipline that remains undefined. The unique nature of primary care necessitates the development of its own informatics discipline. A definition of primary care informatics is proposed, which encompasses the distinctive nature of primary care. The core concepts and theory that should underpin it are described. Primary care informatics is defined as a science and as a subset of health informatics. The proposed definition is intended to focus the development of a generalizable core theory for this informatics subspecialty.
Abstract: OBJECTIVE: In UK general practice, the coding of clinical data (Read Coding) is far from universal. This study set out to examine the barriers to recording structured information in computerised medical records; and to explore whether managers and clinicians had different perspectives in how these barriers should be overcome. METHOD: A qualitative study, using semi-structured interviews of general practitioners, primary care nurses and practice managers. The interviews were recorded verbatim, and then underwent thematic analysis; additional interviews were conducted until thematic saturation was achieved. RESULTS: For clinicians the recording of structured data within a consultation is not a neutral activity, they are highly aware of diagnostic uncertainty and sensitive to the potential impact of both a correct and incorrect diagnostic label on their relationship with their patient. Clinicians accept that data has to be coded if they are to demonstrate that appropriate evidence based care has been provided to populations; but alongside this they require free-text as a more powerful reminder of the individual human encounter. Managers felt that they could encourage clinicians to code data for re-use as part of population data or as quality target indicators rather than as an enabler of the next consultation. CONCLUSIONS: The primary care consultation is a complex social interaction, and coding of the medical diagnosis in itself imposes the bio-medical model, carries assumptions about certainty, and is perceived by clinicians to potentially jeopardise their relationships with their patient. Further research to elicit patients' views may help clarify the magnitude of this barrier.
Abstract: The aim of this study was to assess the feasibility of using three-channel video to explore the impact of the computer on general practitioner (GP) consultations. A previous study had highlighted the limitations of using single-channel video: firstly, there was a lack of information about exactly how the computer was being used, and secondly difficulty in interpreting the body language of the consulting clinician. More information was needed to understand the impact of the computer on the consultation, and in this pilot three-channel video was used to overcome these constraints. Four doctors consulted, with the patient's role played by an actor with a preset script and preloaded personal and family history record programmed into the computer. The output was analysed using the Roter Interaction Analysis System (RIAS) and observational methods were used to explore the effect of computers on aspects of verbal and non-verbal behaviour and the completeness of the computer data record. Three-channel video proved to be a feasible and valuable technique for the analysis of primary care GP consultations, with advantages over single-channel video. Interesting differences in non-verbal and verbal behaviour became apparent with different types of computer use during the consultation. Implications for the three-channel video technique for training, monitoring GP competence and providing feedback are discussed.
Abstract: OBJECTIVE: The purpose of this study was to examine whether Internet-based surveys of health professionals can provide a valid alternative to traditional survey methods. METHODS: (i) Systematic review of published Internet-based surveys of health professionals focusing on criteria of external validity, specifically sample representativeness and response bias. (ii) Internet-based survey of GPs, exploring attitudes about using an Internet-based decision support system for the management of familial cancer. RESULTS: The systematic review identified 17 Internet-based surveys of health professionals. Whilst most studies sampled from professional e-directories, some studies drew on unknown denominator populations by placing survey questionnaires on open web sites or electronic discussion groups. Twelve studies reported response rates, which ranged from nine to 94%. Sending follow-up reminders resulted in a substantial increase in response rates. In our own survey of GPs, a total of 268 GPs participated (adjusted response rate = 52.4%) after five e-mail reminders. A further 72 GPs responded to a brief telephone survey of non-respondents. Respondents to the Internet survey were more likely to be male and had significantly greater intentions to use Internet-based decision support than non-respondents. CONCLUSIONS: Internet-based surveys provide an attractive alternative to postal and telephone surveys of health professionals, but they raise important technical and methodological issues which should be carefully considered before widespread implementation. The major obstacle is external validity, and specifically how to obtain a representative sample and adequate response rate. Controlled access to a national list of NHSnet e-mail addresses of health professionals could provide a solution.
Abstract: One-fifth of smokers show accelerated decline in lung function. These are the patients that go on to develop chronic obstructive pulmonary disease (COPD), an illness characterized by cough, production of sputum, shortness of breath and premature death (Sethi and Rochester, 2000). If this group of smokers stopped smoking, their decline would slow and they might avoid developing COPD. This pilot study aimed to discover whether those with accelerated decline in lung function would quit if presented with the facts about their situation. Known smokers in their 50s were screened for signs of accelerated respiratory decline. Those with an accelerated decline in lung function were identified and given tailored smoking cessation advice. Of 141 eligible patients, 22 responded and six gave up smoking and remained non-smokers 1 year later. The results of this pilot suggest that screening smokers for accelerated respiratory decline by practice nurses is feasible and acceptable to those patients that respond. Further research is needed to discover whether such an intervention would be cost-effective.
Abstract: A model for patient-centred nurse consulting, developed in the context of secondary prevention of cardiovascular disease, is reported in this article. The model was created in the absence of any existing model for nurse consulting. Heart disease clinics are increasingly being used to implement the National Service Framework for Coronary Heart Disease and it is anticipated that this model will be of practical use to nurses running these clinics. The model consists of eight steps, broadly following the chronology of the consultation. Each step contains a question for the nurse to ask him/herself and a task to complete. The model was developed as part of a research project on the influence of customized computer software used on nurse consultations with patients with heart disease.
Abstract: BACKGROUND: The quality of data in general practice clinical information systems varies enormously. This variability jeopardizes the proposed national strategy for an integrated care records service and the capacity of primary care organisations to respond coherently to the demands of clinical governance and the proposed quality-based general practice contract. This is apparent in the difficulty in automating the audit process and in comparing aggregated data from different practices. In an attempt to provide data of adequate quality to support such operational needs, increasing emphasis is being placed on the standardisation of data recording. OBJECTIVE: To develop a conceptual framework to facilitate the recording of standardised data within primary care. METHOD: A multiprofessional group of primary care members from the South Thames Research Network examined leading guidelines for best practice. Using the nominal group technique the group prioritized the information needs of primary care organisations for managing coronary heart disease according to current evidence. RESULTS: Information needs identified were prioritized and stratified into a functional framework. CONCLUSION: It has been possible within the context of a primary care research network to produce a framework for standardising data collection. Motivation of front-line clinicians was achieved through the incorporation of their views into the synthesis of the dataset.
Abstract: This case study reports the reasons why this large, multi-site general practice decided to move towards paperless practice in late 2001, and describes the progress and lessons learned to date. The principal operational reasons for this decision were problems associated with moving paper medical records between surgeries, and the realisation that resources to improve the computerised medical record could only come from redeploying the time spent handling paper records. A comprehensive plan was put in place to shift toward paperlessness. Motivating and changing working practices for clinical and support staff was as a great a challenge as upgrading the technology. The practice upgraded its computer system, and has installed scanning and automated generation of referral and other letters. The support staff skills have evolved from moving records to scanning documents and coding data. All clinical staff now consult on their computer, and code diagnoses and key clinical data. A networked digital dictation system allows typing to be centralised at one location, with the networking allowing printing at any site. Audit and quality improvement activities have increased, as the output from computer searches increasingly represents the quality of care provided. The implications of this case study are that a committed general practice can achieve a largely paperless environment in approximately two years. The practice is now fit to be part of any move towards integration of records within its local health community, and can demonstrate from its computer records that it meets the quality targets for primary care.
Abstract: A rating scale was developed to assess the contribution made by computer software towards the delivery of a quality consultation, with the purpose of informing the development of the next generation of systems. Two software programmes were compared, using this scale to test their ability to enable or inhibit the delivery of an ideal consultation with a patient with heart disease. The context was a general practice based, nurse run clinic for the secondary prevention of heart disease. One of the programmes was customized for this purpose; the other was a standard general practice programme. Consultations were video-recorded, and then assessed by an expert panel using the new assessment tool. Both software programmes were oriented towards the implementation of the evidence, rather than facilitating patient-centred practice. The rating scale showed, not surprisingly, significantly greater support from the customized software in the consultation in five out of eight areas. However, the scale's reliability measured by Cronbach's Alpha, was sub-optimal. With further refinement, this rating scale may become a useful tool that will inform software developers of the effectiveness of their programmes in the consultation, and suggest where they need development.
Abstract: OBJECTIVE: The MediPlus database collects anonymized information from generalpractice computer systems in the United Kingdom, for research purposes. Data quality markers are collated and fed back to the participating general practitioners. The authors examined whether this feedback had a significant effect on data quality. METHODS: The data quality markers used since 1992 were examined. The authors determined whether the feedback of "useful" data quality markers led to a statistically significant improvement in these markers. Environmental influences on data quality from outside the scheme were controlled for by examination of the data quality scores of new entrants. RESULTS: Three quality markers improved significantly over the period of the study. These were the use of highly specific "lower-level" Read Codes (p=0.004) and the linkage of repeat prescriptions (p=0.03) and acute prescriptions (p=0.04) to diagnosis. Clinicians who fall below the target level for linkage of repeat prescriptions to diagnosis receive more detailed feedback; the effect of this was also statistically significant (p<0.01.) CONCLUSIONS: The feedback of four of the ten markers had a significant effect on data quality. The effect of more detailed feedback appears to have had a greater effect. The lessons learned from this approach may help improve the quality of electronic medical records in the United Kingdom and elsewhere.
Abstract: OBJECTIVE: The MediPlus database collects anonymized information from generalpractice computer systems in the United Kingdom, for research purposes. Data quality markers are collated and fed back to the participating general practitioners. The authors examined whether this feedback had a significant effect on data quality. METHODS: The data quality markers used since 1992 were examined. The authors determined whether the feedback of "useful" data quality markers led to a statistically significant improvement in these markers. Environmental influences on data quality from outside the scheme were controlled for by examination of the data quality scores of new entrants. RESULTS: Three quality markers improved significantly over the period of the study. These were the use of highly specific "lower-level" Read Codes (p=0.004) and the linkage of repeat prescriptions (p=0.03) and acute prescriptions (p=0.04) to diagnosis. Clinicians who fall below the target level for linkage of repeat prescriptions to diagnosis receive more detailed feedback; the effect of this was also statistically significant (p<0.01.) CONCLUSIONS: The feedback of four of the ten markers had a significant effect on data quality. The effect of more detailed feedback appears to have had a greater effect. The lessons learned from this approach may help improve the quality of electronic medical records in the United Kingdom and elsewhere.
Abstract: A rating scale was developed to assess the contribution made by computer software towards the delivery of a quality consultation, with the purpose of informing the development of the next generation of systems. Two software programmes were compared, using this scale to test their ability to enable or inhibit the delivery of an ideal consultation with a patient with heart disease. The context was a general practice based, nurse run clinic for the secondary prevention of heart disease. One of the programmes was customized for this purpose; the other was a standard general practice programme. Consultations were video-recorded, and then assessed by an expert panel using the new assessment tool. Both software programmes were oriented towards the implementation of the evidence, rather than facilitating patient-centred practice. The rating scale showed, not surprisingly, significantly greater support from the customized software in the consultation in five out of eight areas. However, the scale's reliability measured by Cronbach's Alpha, was sub-optimal. With further refinement, this rating scale may become a useful tool that will inform software developers of the effectiveness of their programmes in the consultation, and suggest where they need development.
Abstract: The National Service Framework for Older People requires a reduction in the number of falls that result in serious injury. Those most at risk need to be identified, investigated in line with the Royal College of Physicians Clinical Guidelines and receive appropriate treatment. This report looks at the results of investigation of postmenopausal women diagnosed as having osteoporosis in primary care by forearm Dexa scanner (DTX200) and questions whether the investigations suggested within the National Service Framework are justifiable. Scans were performed on 699 postmenopausal women aged 54 or over resulting in a new diagnosis of osteoporosis in 173 women. Complete blood tests were performed in 107 of the newly diagnosed patients. Only three of these patients (2.8%) had blood test results that revealed a potential secondary cause. The rates of positive findings are low; further research is needed to see if they are justified in postmenopausal women.
Abstract: BACKGROUND: General practice websites are an emerging phenomenon, but there have been few critical evaluations of their content. Previously developed rating instruments to assess medical websites have been criticized for failing to report their reliability and validity. OBJECTIVES: The purpose of this study was to develop a rating instrument for assessing UK general practice websites, and then to evaluate them critically. METHODS: The STaRNet Website Assessment Tool (SWAT) was developed listing criteria that general practice websites may meet, which was then used to evaluate a random sample of websites drawn from an electronic database. A second assessor rated a subsample of the sites to assess the tool's inter-rater reliability. The setting was an information technology group of a general practice research network using a random sample of 108 websites identified from the database. The main outcome measures were identification of rating criteria and frequency counts from the website rating instrument. RESULTS: Ninety (93.3%) sites were accessible, of which 84 were UK general practice websites. Criteria most frequently met were those describing the scope of the website and their functionality. Apart from e-mail to practices, criteria related to electronic communication were rarely met. Criteria relating to the quality of information were least often met. Inter-rater reliability kappa values for the items in the tool ranged from -0.06 to 1.0 (mean 0.59). Values were >0.6 for 15 out of 25 criteria assessed in 40 sites which were rated by two assessors. CONCLUSIONS: General practice websites offer a wide range of information. They are technically satisfactory, but do not exploit fully the potential for electronic doctor-patient communication. The quality of information they provide is poor. The instrument may be developed as a template for general practices producing or revising their own websites.
Abstract: A rating scale was developed to assess the contribution made by computer software towards the delivery of a quality consultation, with the purpose of informing the development of the next generation of systems. Two software programmes were compared, using this scale to test their ability to enable or inhibit the delivery of an ideal consultation with a patient with heart disease. The context was a general practice based, nurse run clinic for the secondary prevention of heart disease. One of the programmes was customized for this purpose; the other was a standard general practice programme. Consultations were video-recorded, and then assessed by an expert panel using the new assessment tool. Both software programmes were oriented towards the implementation of the evidence, rather than facilitating patient-centred practice. The rating scale showed, not surprisingly, significantly greater support from the customized software in the consultation in five out of eight areas. However, the scale's reliability measured by Cronbach's Alpha, was sub-optimal. With further refinement, this rating scale may become a useful tool that will inform software developers of the effectiveness of their programmes in the consultation, and suggest where they need development.
Abstract: Patients with a diagnosis of heart failure, registered at the study practice, were recruited into the study. First, they had a cardiologist's assessment. They were then randomised into telemonitored patients who measured pulse, BP, weight and video consulted, and controls. AIM: To examine the acceptability, effectiveness and reliability of home telemonitoring. RESULTS: A high proportion of those invited took part (n=20/24). Compliance with measuring weight, pulse and BP remained high throughout the study. The data collection system and secure web-server were reliable. The telemonitoring group complied better with collecting prescriptions for their cardiac drugs. Video consulting started with enthusiasm, but became less useful. There were no significant differences in the quality of life (GHQ) and Chronic Heart Failure (Guyatt) questionnaire scores between the telemonitored group and the controls. CONCLUSIONS: Home telemonitoring is an acceptable reliable intervention. Baseline rates for compliance with self-monitoring are set out in this study. Benefit in terms of compliance with medication and self-monitoring is still seen after 1 year. Video consulting over ordinary telephone lines did not show sustained benefit, and was not complied with.
Abstract: The diagnosis and management of increasing numbers of patients with chronic diseases in the community require new technologies and strategies of care. We have used a new wireless cardiorespiratory telemonitoring system to monitor 14 elderly patients with a variety of chronic diseases at home. The electrocardiogram (ECG), heart rate and variability, and breathing were recorded on two separate occasions for 24 h. There was no difference in the data recorded when a research nurse applied the monitoring system and when the patients applied it themselves. The ECG and heart rate were recorded for 98% of the monitored time, and the frequency and periodicities of breathing were recorded for 74% and 61% of sleep and rest time by visual and automatic analysis, respectively. The results show that 24 h activity and cardiorespiratory telemonitoring can be performed by elderly patients at home. Significant unsuspected abnormalities of breathing and heart rhythm, amenable to treatment, were also detected.
Abstract: INTRODUCTION: This is a survey to identify what clinical coding systems are currently in use across the European Union, and the states seeking membership to it. We sought to identify what systems are currently used and to what extent they were subject to local adaptation. BACKGROUND: Clinical coding should facilitate identifying key medical events in a computerised medical record, and aggregating information across groups of records. The emerging new driver is as the enabler of the life-long computerised medical record. A prerequisite for this level of functionality is the transfer of information between different computer systems. This transfer can be facilitated either by working on the interoperability problems between disparate systems or by harmonising the underlying data. This paper examines the extent to which the latter has occurred across Europe. METHOD: Literature and Internet search. Requests for information via electronic mail to pan-European mailing lists of health informatics professionals. RESULTS: Coding systems are now a de facto part of health information systems across Europe. There are relatively few coding systems in existence across Europe. ICD9 and ICD 10, ICPC and Read were the most established. However the local adaptation of these classification systems either on a by country or by computer software manufacturer basis; significantly reduces the ability for the meaning coded with patients computer records to be easily transferred from one medical record system to another. CONCLUSIONS: There is no longer any debate as to whether a coding or classification system should be used. Convergence of different classifications systems should be encouraged. Countries and computer manufacturers within the EU should be encouraged to stop making local modifications to coding and classification systems, as this practice risks significantly slowing progress towards easy transfer of records between computer systems.
Abstract: Patients with a diagnosis of heart failure, registered at the study practice, were recruited into the study. First, they had a cardiologist's assessment. They were then randomised into telemonitored patients who measured pulse, BP, weight and video consulted, and controls. AIM: To examine the acceptability, effectiveness and reliability of home telemonitoring. RESULTS: A high proportion of those invited took part (n=20/24). Compliance with measuring weight, pulse and BP remained high throughout the study. The data collection system and secure web-server were reliable. The telemonitoring group complied better with collecting prescriptions for their cardiac drugs. Video consulting started with enthusiasm, but became less useful. There were no significant differences in the quality of life (GHQ) and Chronic Heart Failure (Guyatt) questionnaire scores between the telemonitored group and the controls. CONCLUSIONS: Home telemonitoring is an acceptable reliable intervention. Baseline rates for compliance with self-monitoring are set out in this study. Benefit in terms of compliance with medication and self-monitoring is still seen after 1 year. Video consulting over ordinary telephone lines did not show sustained benefit, and was not complied with.
Abstract: The diagnosis and management of increasing numbers of patients with chronic diseases in the community require new technologies and strategies of care. We have used a new wireless cardiorespiratory telemonitoring system to monitor 14 elderly patients with a variety of chronic diseases at home. The electrocardiogram (ECG), heart rate and variability, and breathing were recorded on two separate occasions for 24 h. There was no difference in the data recorded when a research nurse applied the monitoring system and when the patients applied it themselves. The ECG and heart rate were recorded for 98% of the monitored time, and the frequency and periodicities of breathing were recorded for 74% and 61% of sleep and rest time by visual and automatic analysis, respectively. The results show that 24 h activity and cardiorespiratory telemonitoring can be performed by elderly patients at home. Significant unsuspected abnormalities of breathing and heart rhythm, amenable to treatment, were also detected.
Abstract: INTRODUCTION: This is a survey to identify what clinical coding systems are currently in use across the European Union, and the states seeking membership to it. We sought to identify what systems are currently used and to what extent they were subject to local adaptation. BACKGROUND: Clinical coding should facilitate identifying key medical events in a computerised medical record, and aggregating information across groups of records. The emerging new driver is as the enabler of the life-long computerised medical record. A prerequisite for this level of functionality is the transfer of information between different computer systems. This transfer can be facilitated either by working on the interoperability problems between disparate systems or by harmonising the underlying data. This paper examines the extent to which the latter has occurred across Europe. METHOD: Literature and Internet search. Requests for information via electronic mail to pan-European mailing lists of health informatics professionals. RESULTS: Coding systems are now a de facto part of health information systems across Europe. There are relatively few coding systems in existence across Europe. ICD9 and ICD 10, ICPC and Read were the most established. However the local adaptation of these classification systems either on a by country or by computer software manufacturer basis; significantly reduces the ability for the meaning coded with patients computer records to be easily transferred from one medical record system to another. CONCLUSIONS: There is no longer any debate as to whether a coding or classification system should be used. Convergence of different classifications systems should be encouraged. Countries and computer manufacturers within the EU should be encouraged to stop making local modifications to coding and classification systems, as this practice risks significantly slowing progress towards easy transfer of records between computer systems.
Abstract: INTRODUCTION: This is a survey to identify what clinical coding systems are currently in use across the European Union, and the states seeking membership to it. We sought to identify what systems are currently used and to what extent they were subject to local adaptation. BACKGROUND: Clinical coding should facilitate identifying key medical events in a computerised medical record, and aggregating information across groups of records. The emerging new driver is as the enabler of the life-long computerised medical record. A prerequisite for this level of functionality is the transfer of information between different computer systems. This transfer can be facilitated either by working on the interoperability problems between disparate systems or by harmonising the underlying data. This paper examines the extent to which the latter has occurred across Europe. METHOD: Literature and Internet search. Requests for information via electronic mail to pan-European mailing lists of health informatics professionals. RESULTS: Coding systems are now a de facto part of health information systems across Europe. There are relatively few coding systems in existence across Europe. ICD9 and ICD 10, ICPC and Read were the most established. However the local adaptation of these classification systems either on a by country or by computer software manufacturer basis; significantly reduces the ability for the meaning coded with patients computer records to be easily transferred from one medical record system to another. CONCLUSIONS: There is no longer any debate as to whether a coding or classification system should be used. Convergence of different classifications systems should be encouraged. Countries and computer manufacturers within the EU should be encouraged to stop making local modifications to coding and classification systems, as this practice risks significantly slowing progress towards easy transfer of records between computer systems.
Abstract: The diagnosis and management of increasing numbers of patients with chronic diseases in the community require new technologies and strategies of care. We have used a new wireless cardiorespiratory telemonitoring system to monitor 14 elderly patients with a variety of chronic diseases at home. The electrocardiogram (ECG), heart rate and variability, and breathing were recorded on two separate occasions for 24 h. There was no difference in the data recorded when a research nurse applied the monitoring system and when the patients applied it themselves. The ECG and heart rate were recorded for 98% of the monitored time, and the frequency and periodicities of breathing were recorded for 74% and 61% of sleep and rest time by visual and automatic analysis, respectively. The results show that 24 h activity and cardiorespiratory telemonitoring can be performed by elderly patients at home. Significant unsuspected abnormalities of breathing and heart rhythm, amenable to treatment, were also detected.
Abstract: Patients with a diagnosis of heart failure, registered at the study practice, were recruited into the study. First, they had a cardiologist's assessment. They were then randomised into telemonitored patients who measured pulse, BP, weight and video consulted, and controls. AIM: To examine the acceptability, effectiveness and reliability of home telemonitoring. RESULTS: A high proportion of those invited took part (n=20/24). Compliance with measuring weight, pulse and BP remained high throughout the study. The data collection system and secure web-server were reliable. The telemonitoring group complied better with collecting prescriptions for their cardiac drugs. Video consulting started with enthusiasm, but became less useful. There were no significant differences in the quality of life (GHQ) and Chronic Heart Failure (Guyatt) questionnaire scores between the telemonitored group and the controls. CONCLUSIONS: Home telemonitoring is an acceptable reliable intervention. Baseline rates for compliance with self-monitoring are set out in this study. Benefit in terms of compliance with medication and self-monitoring is still seen after 1 year. Video consulting over ordinary telephone lines did not show sustained benefit, and was not complied with.
Abstract: We describe a conceptual framework that we have developed for evaluating primary care research networks. The framework includes objectives, process indicators, and outcome indicators. We propose the framework as a provisional model that we hope will promote further research and debate.
Abstract: BACKGROUND: One of the most effective interventions that the primary health care team can make is that of secondary prevention in ischaemic heart disease (IHD). There is still a need to improve the uptake of effective interventions such as aspirin and statins in these patients. General Practice in the UK is 95% computerised, but many functions are under-utilised. In the majority of cases primary care clinicians use the keyboard rather than mouse for data entry. Methods of data entry using the keyboard or CHUI (Character User Interface) can be cumbersome and time consuming. This can limit data collection and its assimilation for patient care. The object of this study was to assess the feasibility and effectiveness of a new software programme, which provides computerised support to primary care staff in their preventive care of IHD patients. AIM: To demonstrate that a systematic computer facilitated secondary prevention programme for IHD was effective, feasible, and acceptable to patients and improved patient care. METHOD: Evidence-based guidelines and intervention levels for secondary prevention of IHD were agreed at practice level and embedded in the software. Patients aged 80 and under were identified by the use of Read codes and repeat prescribing. The nurse-run programme consisted of a detailed review of electronic and written records and then the clinical review of 141 patients. At follow-up patients were issued with a questionnaire to assess their satisfaction with the process. RESULTS: From a general practice computer search for ischaemic heart disease Read Code (G3) and/or nitrate prescription an initial cohort of 242 patients was established. 90 were excluded on clinical grounds (not IHD, deceased, over-riding other clinical problems), and eleven patients could not be recruited (eight declined and three had moved away). The final cohort consisted of 141 patients, of whom 101 patients suffered angina, 67 had a previous history of myocardial infarction, and 28 had had coronary artery bypass grafting. Hypertension had been diagnosed in 80 and hyperlipidaemia in 43. As a result of the study new diagnoses included: hyperlipidaemia where statins were indicated (38), congestive cardiac failure requiring treatment with ACE (Angiotensin Converting Enzyme) inhibitors (2) and carotid bruits requiring referral (4). In addition diabetes was diagnosed in three patients. The programme proved acceptable to patients, doctors and practice staff; follow-up continues. CONCLUSION: The use of this methodology, in a single practice, has improved the care of patients well beyond that achieved with established template-based secondary prevention programmes. The outcome has been measured in terms of increased diagnosis and active management of hyperlipidaemia and other risk factors.
Abstract: We have conducted a trial of a wireless device for continuous cardiopulmonary monitoring. Its performance, user acceptance and safety were assessed for monitoring in the patient's home. The study included 20 patients: six with chronic obstructive pulmonary disease, six with chronic heart failure, seven with atrial fibrillation and palpitations, and one with a snoring problem. The system recorded the heart rate and respiratory rate, blood pressure, electrocardiogram and body temperature. The results were transmitted automatically to a central monitoring station. The accuracy of the measurements was checked by a comparison system and also by conventional measurements performed by a nurse. The system was acceptable to patients and functioned satisfactorily in the home. An important facet of home telemonitoring may turn out to be its greater reliability in collecting objective data.
Abstract: OBJECTIVES: To compare the agreement between conventional measurement of blood pressure and measurements obtained using two automated devices; and to compare how comfortable each of the three methods of measurement were for patients. METHODS: Blood pressure measurements and patient comfort scores were recorded using three different devices in 125-surgery and 40-community patients. The devices used were a conventional aneroid sphygmomanometer, an automated device that measured blood pressure on the upper arm and an automated device that measured blood pressure at the wrist. In each patient, the difference between the conventional and automatic measurement was calculated. The limits of agreement of each device were then calculated as the mean difference +/-1.96 standard deviations. RESULTS: In surgery patients, the width of limits of agreement of wrist measurement were 20.0 mm Hg and 12.1 mm Hg for systolic and diastolic blood pressure respectively, compared with 26. 4 mm Hg and 27.7 mm Hg for automatic arm measurement. In community patients, the width of limits of agreement of wrist measurement were 11.6 mm Hg and 11.0 mm Hg for systolic and diastolic blood pressure respectively, compared with 19.5 mm Hg and 12.1 mm Hg for automatic arm measurement. Surgery patients also reported that wrist measurement of blood pressure was significantly more comfortable than either manual or automatic arm measurement (mean comfort scores 4.03 for automatic wrist and 2.13 for automatic arm measurement, Friedman's Test, P<0.001). CONCLUSIONS: Blood pressure measurements taken using the wrist device agreed more closely with those obtained using a conventional aneroid sphygmomanometer than the arm device. The wrist device was also more comfortable for patients than two other methods of blood pressure measurement. Public Health (2000) 114, 165-168
Abstract: We describe a conceptual framework that we have developed for evaluating primary care research networks. The framework includes objectives, process indicators, and outcome indicators. We propose the framework as a provisional model that we hope will promote further research and debate.
Abstract: BACKGROUND: One of the most effective interventions that the primary health care team can make is that of secondary prevention in ischaemic heart disease (IHD). There is still a need to improve the uptake of effective interventions such as aspirin and statins in these patients. General Practice in the UK is 95% computerised, but many functions are under-utilised. In the majority of cases primary care clinicians use the keyboard rather than mouse for data entry. Methods of data entry using the keyboard or CHUI (Character User Interface) can be cumbersome and time consuming. This can limit data collection and its assimilation for patient care. The object of this study was to assess the feasibility and effectiveness of a new software programme, which provides computerised support to primary care staff in their preventive care of IHD patients. AIM: To demonstrate that a systematic computer facilitated secondary prevention programme for IHD was effective, feasible, and acceptable to patients and improved patient care. METHOD: Evidence-based guidelines and intervention levels for secondary prevention of IHD were agreed at practice level and embedded in the software. Patients aged 80 and under were identified by the use of Read codes and repeat prescribing. The nurse-run programme consisted of a detailed review of electronic and written records and then the clinical review of 141 patients. At follow-up patients were issued with a questionnaire to assess their satisfaction with the process. RESULTS: From a general practice computer search for ischaemic heart disease Read Code (G3) and/or nitrate prescription an initial cohort of 242 patients was established. 90 were excluded on clinical grounds (not IHD, deceased, over-riding other clinical problems), and eleven patients could not be recruited (eight declined and three had moved away). The final cohort consisted of 141 patients, of whom 101 patients suffered angina, 67 had a previous history of myocardial infarction, and 28 had had coronary artery bypass grafting. Hypertension had been diagnosed in 80 and hyperlipidaemia in 43. As a result of the study new diagnoses included: hyperlipidaemia where statins were indicated (38), congestive cardiac failure requiring treatment with ACE (Angiotensin Converting Enzyme) inhibitors (2) and carotid bruits requiring referral (4). In addition diabetes was diagnosed in three patients. The programme proved acceptable to patients, doctors and practice staff; follow-up continues. CONCLUSION: The use of this methodology, in a single practice, has improved the care of patients well beyond that achieved with established template-based secondary prevention programmes. The outcome has been measured in terms of increased diagnosis and active management of hyperlipidaemia and other risk factors.
Abstract: We have conducted a trial of a wireless device for continuous cardiopulmonary monitoring. Its performance, user acceptance and safety were assessed for monitoring in the patient's home. The study included 20 patients: six with chronic obstructive pulmonary disease, six with chronic heart failure, seven with atrial fibrillation and palpitations, and one with a snoring problem. The system recorded the heart rate and respiratory rate, blood pressure, electrocardiogram and body temperature. The results were transmitted automatically to a central monitoring station. The accuracy of the measurements was checked by a comparison system and also by conventional measurements performed by a nurse. The system was acceptable to patients and functioned satisfactorily in the home. An important facet of home telemonitoring may turn out to be its greater reliability in collecting objective data.
Abstract: OBJECTIVES: To compare the agreement between conventional measurement of blood pressure and measurements obtained using two automated devices; and to compare how comfortable each of the three methods of measurement were for patients. METHODS: Blood pressure measurements and patient comfort scores were recorded using three different devices in 125-surgery and 40-community patients. The devices used were a conventional aneroid sphygmomanometer, an automated device that measured blood pressure on the upper arm and an automated device that measured blood pressure at the wrist. In each patient, the difference between the conventional and automatic measurement was calculated. The limits of agreement of each device were then calculated as the mean difference +/-1.96 standard deviations. RESULTS: In surgery patients, the width of limits of agreement of wrist measurement were 20.0 mm Hg and 12.1 mm Hg for systolic and diastolic blood pressure respectively, compared with 26. 4 mm Hg and 27.7 mm Hg for automatic arm measurement. In community patients, the width of limits of agreement of wrist measurement were 11.6 mm Hg and 11.0 mm Hg for systolic and diastolic blood pressure respectively, compared with 19.5 mm Hg and 12.1 mm Hg for automatic arm measurement. Surgery patients also reported that wrist measurement of blood pressure was significantly more comfortable than either manual or automatic arm measurement (mean comfort scores 4.03 for automatic wrist and 2.13 for automatic arm measurement, Friedman's Test, P<0.001). CONCLUSIONS: Blood pressure measurements taken using the wrist device agreed more closely with those obtained using a conventional aneroid sphygmomanometer than the arm device. The wrist device was also more comfortable for patients than two other methods of blood pressure measurement. Public Health (2000) 114, 165-168
Abstract: OBJECTIVES: To compare the agreement between conventional measurement of blood pressure and measurements obtained using two automated devices; and to compare how comfortable each of the three methods of measurement were for patients. METHODS: Blood pressure measurements and patient comfort scores were recorded using three different devices in 125-surgery and 40-community patients. The devices used were a conventional aneroid sphygmomanometer, an automated device that measured blood pressure on the upper arm and an automated device that measured blood pressure at the wrist. In each patient, the difference between the conventional and automatic measurement was calculated. The limits of agreement of each device were then calculated as the mean difference +/-1.96 standard deviations. RESULTS: In surgery patients, the width of limits of agreement of wrist measurement were 20.0 mm Hg and 12.1 mm Hg for systolic and diastolic blood pressure respectively, compared with 26. 4 mm Hg and 27.7 mm Hg for automatic arm measurement. In community patients, the width of limits of agreement of wrist measurement were 11.6 mm Hg and 11.0 mm Hg for systolic and diastolic blood pressure respectively, compared with 19.5 mm Hg and 12.1 mm Hg for automatic arm measurement. Surgery patients also reported that wrist measurement of blood pressure was significantly more comfortable than either manual or automatic arm measurement (mean comfort scores 4.03 for automatic wrist and 2.13 for automatic arm measurement, Friedman's Test, P<0.001). CONCLUSIONS: Blood pressure measurements taken using the wrist device agreed more closely with those obtained using a conventional aneroid sphygmomanometer than the arm device. The wrist device was also more comfortable for patients than two other methods of blood pressure measurement. Public Health (2000) 114, 165-168
Abstract: BACKGROUND: One of the most effective interventions that the primary health care team can make is that of secondary prevention in ischaemic heart disease (IHD). There is still a need to improve the uptake of effective interventions such as aspirin and statins in these patients. General Practice in the UK is 95% computerised, but many functions are under-utilised. In the majority of cases primary care clinicians use the keyboard rather than mouse for data entry. Methods of data entry using the keyboard or CHUI (Character User Interface) can be cumbersome and time consuming. This can limit data collection and its assimilation for patient care. The object of this study was to assess the feasibility and effectiveness of a new software programme, which provides computerised support to primary care staff in their preventive care of IHD patients. AIM: To demonstrate that a systematic computer facilitated secondary prevention programme for IHD was effective, feasible, and acceptable to patients and improved patient care. METHOD: Evidence-based guidelines and intervention levels for secondary prevention of IHD were agreed at practice level and embedded in the software. Patients aged 80 and under were identified by the use of Read codes and repeat prescribing. The nurse-run programme consisted of a detailed review of electronic and written records and then the clinical review of 141 patients. At follow-up patients were issued with a questionnaire to assess their satisfaction with the process. RESULTS: From a general practice computer search for ischaemic heart disease Read Code (G3) and/or nitrate prescription an initial cohort of 242 patients was established. 90 were excluded on clinical grounds (not IHD, deceased, over-riding other clinical problems), and eleven patients could not be recruited (eight declined and three had moved away). The final cohort consisted of 141 patients, of whom 101 patients suffered angina, 67 had a previous history of myocardial infarction, and 28 had had coronary artery bypass grafting. Hypertension had been diagnosed in 80 and hyperlipidaemia in 43. As a result of the study new diagnoses included: hyperlipidaemia where statins were indicated (38), congestive cardiac failure requiring treatment with ACE (Angiotensin Converting Enzyme) inhibitors (2) and carotid bruits requiring referral (4). In addition diabetes was diagnosed in three patients. The programme proved acceptable to patients, doctors and practice staff; follow-up continues. CONCLUSION: The use of this methodology, in a single practice, has improved the care of patients well beyond that achieved with established template-based secondary prevention programmes. The outcome has been measured in terms of increased diagnosis and active management of hyperlipidaemia and other risk factors.
Abstract: We describe a conceptual framework that we have developed for evaluating primary care research networks. The framework includes objectives, process indicators, and outcome indicators. We propose the framework as a provisional model that we hope will promote further research and debate.
Abstract: We have conducted a trial of a wireless device for continuous cardiopulmonary monitoring. Its performance, user acceptance and safety were assessed for monitoring in the patient's home. The study included 20 patients: six with chronic obstructive pulmonary disease, six with chronic heart failure, seven with atrial fibrillation and palpitations, and one with a snoring problem. The system recorded the heart rate and respiratory rate, blood pressure, electrocardiogram and body temperature. The results were transmitted automatically to a central monitoring station. The accuracy of the measurements was checked by a comparison system and also by conventional measurements performed by a nurse. The system was acceptable to patients and functioned satisfactorily in the home. An important facet of home telemonitoring may turn out to be its greater reliability in collecting objective data.
Abstract: This is a controlled pilot study of twenty patients to see if heart failure management can be optimised in the community using telemedicine. The study seeks to examine the feasibility, acceptability and reliability of using telemedicine in this context. Heart failure is a common condition. It is an important cause of mortality and morbidity and has large cost implications for the NHS. Most patients are managed in the UK in General Practice based on clinical assessment by the practitioner. Twenty patients with a mean age of 75.1 years and mean New York Heart Association grade of 1.75 were randomised in to two equal groups (telemonitoring and control) and observed for a period of three months. All twenty patients had a Cardiologist assessment and quality of life measurement at the beginning and end of the study. Patients in the telemedicine group had their blood pressure, pulse and weight data collected daily and undertook a weekly video conference with the nurse. Control patients had their blood pressure, weight and pulse measured at six weekly intervals. The study has been extended for a further six months beyond its initial three-month observation period to see if the initial short term benefit in the telemedicine group is maintained.
Abstract: This is a controlled pilot study of twenty patients to see if heart failure management can be optimised in the community using telemedicine. The study seeks to examine the feasibility, acceptability and reliability of using telemedicine in this context. Heart failure is a common condition. It is an important cause of mortality and morbidity and has large cost implications for the NHS. Most patients are managed in the UK in General Practice based on clinical assessment by the practitioner. Twenty patients with a mean age of 75.1 years and mean New York Heart Association grade of 1.75 were randomised in to two equal groups (telemonitoring and control) and observed for a period of three months. All twenty patients had a Cardiologist assessment and quality of life measurement at the beginning and end of the study. Patients in the telemedicine group had their blood pressure, pulse and weight data collected daily and undertook a weekly video conference with the nurse. Control patients had their blood pressure, weight and pulse measured at six weekly intervals. The study has been extended for a further six months beyond its initial three-month observation period to see if the initial short term benefit in the telemedicine group is maintained.
Abstract: This is a controlled pilot study of twenty patients to see if heart failure management can be optimised in the community using telemedicine. The study seeks to examine the feasibility, acceptability and reliability of using telemedicine in this context. Heart failure is a common condition. It is an important cause of mortality and morbidity and has large cost implications for the NHS. Most patients are managed in the UK in General Practice based on clinical assessment by the practitioner. Twenty patients with a mean age of 75.1 years and mean New York Heart Association grade of 1.75 were randomised in to two equal groups (telemonitoring and control) and observed for a period of three months. All twenty patients had a Cardiologist assessment and quality of life measurement at the beginning and end of the study. Patients in the telemedicine group had their blood pressure, pulse and weight data collected daily and undertook a weekly video conference with the nurse. Control patients had their blood pressure, weight and pulse measured at six weekly intervals. The study has been extended for a further six months beyond its initial three-month observation period to see if the initial short term benefit in the telemedicine group is maintained.
