The new agenda for general practice computing

Can general practice computer data be of use in assessing asthma service delivery and needs?

Objectives: To investigate the potential of general practice computer data in assessing asthma service delivery and need. To compare the epidemiology of coded asthmatics and those receiving asthma drugs with recognized patterns for asthma. To estimate asthma prevalence, preventer and reliever drug need and its possible cost in east London. Design: Descriptive study using asthma computer audits undertaken in June 1995 in five general practices selected for their interest in asthma.

Updating the Read Codes: user-interactive maintenance of a dynamic clinical vocabulary

The Read Codes are a hierarchically-arranged controlled clinical vocabulary introduced in the early 1980s and now consisting of three maintained versions of differing complexity. The code sets are dynamic, and are updated quarterly in response to requests from users including clinicians in both primary and secondary care, software suppliers, and advice from a network of specialist healthcare professionals. The codes' continual evolution of content, both across and within versions, highlights tensions between different users and uses of coded clinical data. Internal processes, external interactions and new structural features implemented by the NHS Centre for Coding and Classification (NHSCCC) for user interactive maintenance of the Read Codes are described, and over 2000 items of user feedback episodes received over a 15-month period are analysed.

Has general practitioner computing made a difference to patient care? A systematic review of published reports

OBJECTIVE

To review findings from studies of the influence of desktop computers on primary care consultations.

DESIGN

Systematic review of world reports from 1984 to 1994.

SETTING

The computerised catalogues of Medline, BIDS, and GPlit were searched, as well as conference proceedings, books, bibliographies, and references in books and journal articles.

SUBJECTS

30 papers met the inclusion criteria and were included for detailed review.

INTERVENTIONS

A validated scheme for assessing methodological adequacy was used to score each paper.

MAIN OUTCOME MEASURES

Papers were rated on sample formation, baseline differences, unit of allocation, outcome measures, and follow up. Differences in outcomes were also recorded.

RESULTS

Four of the six papers dealing with the consultation process showed that consultations took longer. Doctor initiated and "medical" content of consultations increased at the expense of a reduction in patient initiated and "social" content. Each of the 21 studies which looked at clinician performance showed an improvement when a computer was used (from 8% to 50%, with better results for single preventive measures). Only one of the three studies looking at patient outcomes showed an improvement (diastolic blood pressure control 5 mm Hg better after one year, with fewer doctor-patient consultations).

CONCLUSIONS

Using a computer in the consultation may help improve clinician performance but may increase the length of the consultation. More studies are needed to assess the effects on patient outcomes of using a computer in consultations.

Use of Read codes in development of a standard data set

General practice has a wealth of data that could be used for purposes such as assessing health needs, planning, and audit. If this potential is to be realised appropriate data must be easily accessible and of high quality. This article describes the experience of an information project team in developing and coding a standard data set, with the aim of meeting the needs of commissioners, public health, and general practitioners. The Read coding classification seemed the logical choice for the standard data set because Read codes are the basis of a standard classification of general practice data. However, the coding structure has several weaknesses that were difficult to resolve, and the standard data set had to be changed to match available codes. This paper may prove helpful to similar project teams attempting to develop and use a standard data set.

Care of schizophrenia in general practice: the general practitioner and the patient

BACKGROUND

The transfer of patients with chronic schizophrenia from large mental hospitals into the community has had an impact on the role of the general practitioner in the effective delivery of primary care services to these patients.

AIM

A study was undertaken to assess the care available in general practice for patients with schizophrenia, the attitudes of general practitioners and patients to the care provided and the factors influencing patients' use of services.

METHOD

Eighty three patients with a diagnosis of schizophrenia and 26 doctors in 13 London practices registered on the VAMP research bank took part in a series of structured and semi-structured interviews. This was followed by a systematic examination of the patients' case notes.

RESULTS

Only 14 patients (17%) had no active symptoms according to the present state examination interview and 52 (63%) were currently taking antipsychotic medication. Fifty three patients were in contact with a psychiatrist. Approximately one quarter of patients were visited by a community psychiatric nurse; in 18 of these 19 cases, the main reason for contact was reported to be for administration of medication by depot injection. In all but one case, patients seeing a community psychiatric nurse were also being seen by a psychiatrist. Sixteen doctors reported having had a consultation in the previous month with a patient's relative, friend or member of hostel staff. There were considerable differences between patients and their doctors in their attitudes to the use of services. Of the 26 general practitioners, 23 were enthusiastic about the possibility of introducing shared care records. Of the 54 patients in contact with a mental health professional, only 18 favoured the use of shared care records. Most of the doctors (19, 73%) reported they would welcome a psychiatric liaison service in their practice; 40% of 53 patients said they would not. Patients receiving antipsychotic drugs and patients registered with inner city practices attended their general practitioners more frequently than those not taking antipsychotic medication and those registered with suburban practices. Use of antipsychotic medication (adjusted odds ratio (OR) 8.2, 95% confidence interval (CI) 2.2 to 30.7, P < 0.01), male sex (OR 5.8, 95% CI 1.5 to 22.1, P < 0.01) and active symptoms on the present state examination (OR 4.1, 95% CI 1.0 to 17.5, P = 0.06) were all predictive of current contact with mental health professionals.

CONCLUSION

Family doctors were closely involved with the care of patients with schizophrenia and their relatives and were eager for increased liaison with secondary care services. Although patients were more resistant than doctors to management innovations this may reflect lack of familiarity with changes in community services. Greater input is needed by mental health professionals, particularly community psychiatric nurses, and some consideration of the burden of care in inner city practices is necessary in health service planning.

The role of general practitioners in diabetic eye care in Lanarkshire

This study reports data from 50 practices (3550 patients) in Lanarkshire taking part in an audit of diabetes care. Data were obtained by review of general practitioner records and the correspondence from consultants and opticians contained in them. The principal study measures examine the process of care. Overall levels of performance were low: only 35.5% of patients had visual acuity and 54.5% fundoscopy recorded in the previous year. Significantly better results were observed for both examinations in those few practices which performed these examinations in more than 10% of their patients (51.4% vs 32.0% (mean difference 19.4, 95% CI 16.1-23.7) for visual acuity and 65.7% vs 53.3% (mean difference 12.4, 95% CI 3.0-21.8) for fundoscopy. Less than half of diabetic patients in Lanarkshire currently receive adequate screening for the ocular complications of diabetes. Most practices rely on hospital diabetic and ophthalmology services. Where practices undertake ocular examination of patients, this is currently in addition to those services provided elsewhere.

Accuracy of diagnosis of psychosis on general practice computer system

OBJECTIVES

To determine the accuracy of diagnoses of schizophrenia and non-affective psychosis entered by general practitioners on a computer system. To compare recording of clinical events on computer with written records.

DESIGN

Examination of case notes of all patients with a computer diagnosis of psychosis. Search of 8000 randomly selected patient records to identify patients with psychosis not recorded on computer and comparison of 141 computer and written entries for prescribing and consultation in each practice.

SETTING

13 London practices on the VAMP research bank.

MAIN OUTCOME MEASURES

Accuracy of record of psychosis compared with ICD 9, American Psychiatric Association diagnostic manual, and syndrome checklist criteria.

RESULTS

Computer search revealed 102 patients with schizophrenia, 78 with other psychoses, and 71 with non-affective psychosis who had adequate case notes. The sensitivity and positive predictive value of the computer diagnosis of schizophrenia were 88% (95% confidence interval 62% to 98%) and 71% (48% to 88%). For all non-organic psychoses sensitivity was 91% (74% to 97%) and positive predictive value was 91% (74% to 98%). On average 95% of all known prescriptions and 74% of all consultations were recorded on computer compared with 42% and 75% in written records.

CONCLUSIONS

Recording of psychotic illness on the VAMP computer is accurate and complete. Prescribing was more fully recorded on the computer than on the written records. Computer databases of well motivated general practitioners could be used for research.