Twenty years of ICPC-2 PLUS the past, present and future of clinical terminologies in Australian general practice Helena Britt Graeme Miller Julie Gordon Who we are Helena Britt - Director,, University of Sydney - Member, Wonca International Classification Committee (WICC) Julie Gordon - Classifications Manager,, University of Sydney - Member, Wonca International Classification Committee (WICC) & International General/Family Practice Special Interest Group of IHTSDO (SNOMED CT) Graeme Miller - Medical Director,, University of Sydney - Member, Wonca International Classification Committee (WICC) & International General/Family Practice Special Interest Group of IHTSDO (SNOMED CT) 1
Overview of this workshop The first ICPC-2 PLUS release occurred in August 1995 Twenty years on, we will: - outline the history of classifications and terminologies in general practice - discuss the current role(s) of clinical terminologies in Australia - workshop the difficulties you have with clinical terminologies and identify possible solutions - consider the future of clinical terminologies in Australian general practice, including SNOMED CT What is ICPC-2 PLUS? ICPC-2 is the International Classification of Primary Care - Version 2 PLUS is an Australian interface terminology developed from terms used in general practice and community health centres. Each PLUS term is classified to ICPC-2 An interface terminology: terms used in day-to-day practice (the terms you like to use in your clinical notes) and patient lay terms A classification is a system that categorises or groups terms in a stndardised way; used for analysing and reporting Some history.. 2
History of classifications Year 1950s & 1960s Milestone International agreement that the International Classification of Diseases (ICD) was unsuitable for use in general practice-did not cover range of clinical practice 1972 At the inaugural meeting of the World Organisation of Family Doctors (Wonca), the first Wonca Committee formed -- the Wonca (International) Classification Committee 1975 Release of the International Classification of Health Problems in Primary Care (ICHPPC) 1979 Inclusion and exclusion criteria added, Version 2 released (ICHPPC-2) 1983 WHO working party to develop a reason for encounter classification for primary care rejected by WHO because the proposed structure did not align with ICD structure picked up by the Wonca Classification Committee. 1986 The International Classification of Process in Primary Care (IC-Process-PC) released 1987 Release of the International Classification of Primary Care (ICPC) 1998 Release of the second version of ICPC (called ICPC-2) with inclusion & exclusion criteria ICPC-2 built on lessons learned in earlier attempts Chapters Components A B D F H K L N P R S T U W X Y Z 1. Symptoms, complaints 2. Diagnostic, screening, prevention 3. Treatment, procedures, medication 4. Test results 5. Administrative 6. Other 7. Diagnoses, disease A General and unspecified L Musculoskeletal U Urinary B Blood & blood-forming organs N Neurological W Pregnancy, family planning D Digestive P Psychological X Female genital F Eye R Respiratory Y Male genital H Ear S Skin Z Social K Circulatory T Endocrine, nutritional & metabolic Symptoms & complaints: came from the RFE classification Diagnoses, disease: adapted from the ICHPPC-2 classification The processes of care: a compressed version of IC-Process-PC 3
History of terminologies Year Milestone 1980s & 1990s Development of the Read codes (UK) (by a GP James Read) 1991-94 Aus-Read trial (to assess the Read codes for use in Australia) 1995 Release of ICPC PLUS 1998 On release of the second version of ICPC (ICPC-2), ICPC PLUS was updated and re-named ICPC-2 PLUS The Aus-Read Trial READ codes had developed in 80 s & 90 s in UK a terminology first based on ICD and OPCS-4, and built-up by GPs adding new terms. In Aus, when GPs were introducing EHRs, the need for coding & classifying clinical information was recognised. Commonwealth Dep t Health funded us to trial READ codes in Australia GP focus groups & trials in GP EHRs showed that: - Medical terminology differed--meaning of some terms differed in Aus and UK e.g. asthma was seen as a sub-group of COPD. - No changes could be made, no adaptation to Aus spelling or language allowed. Read codes were rejected as a solution for Australia 4
Developing ICPC-2 PLUS No READ codes--- but GP software developers needed a coding system, main aim being to allow linkage of diagnostic and clinical guidelines to a specific problem label or group of labels. In 1990-91 we conducted The Australian morbidity and treatment survey, the first nationally representative study of GP clinical activity and had built a list of terms that GPs wrote in their encounter records for the study, classifying each term to ICPC. This ensured reliable secondary classification of these terms to ICPC, by trained nurses. We used this list of terms and: - applied standard structured to terms so they would present in a good alphabetical order, - created logical key word links to each term to make them easier to find, - classified each term to the correct place in ICPC-2 - provided it to the software houses. ICPC PLUS an Australian interface terminology released 1995. What is ICPC-2 PLUS? An interface terminology allows clinicians to enter terms into an electronic health record that are close to their natural clinical language All terms are classified (or grouped) according to the International Classification of Primary Care, Version 2 (ICPC-2) Owned and maintained by the University of Sydney s Family Medicine Research Centre Used primarily in: - General practice electronic health records (in 8 EHRs, by ~3,000 FTE GPs in ~550 practices) - Research projects (e.g. BEACH) - Community health, prisons, Aboriginal Medical Services 10 5
ICPC-2 PLUS development Updated quarterly - January, April, July, October Developed using: - >2 million encounter records (recorded in free text and converted to ICPC-2 PLUS) - Suggestions from end users Per cent 18 16 14 12 10 8 6 4 2 0 Annual growth of ICPC-2 PLUS Keywords Terms Year 11 How ICPC-2 PLUS works getting the data in PROCESS User enters the first few letters of a KEYWORD Links to a picklist of logically associated TERMS User selects most appropriate TERM EXAMPLE LEG Adjusting;brace;leg Advice/education;legal Cellulitis;leg Disease;Legg-Calve-Perthes Ulcer;leg etc Ulcer;leg TERM is saved into record 12 6
Data analysis Inclusion of the ICPC-2 code in each PLUS term allows data coded in the PLUS terminology to be extracted using ICPC-2 Example: retrieving all patients with insulin dependent diabetes T89 Diabetes, insulin dependent Diabetes; Type 1 (T89002) Diabetes; juvenile onset (T89003) Coma; diabetic (T89005) Hyperglycaemia (diabetes) (T89006) Diabetes; insulin dependent (T89001) Groupers Allow clinical concepts classified to different parts of the ICPC-2 classification to be analysed together Example: retrieving all patients with any type of diabetes Diabetes (all) Diabetes; insulin dependent (T89) Diabetes; non-insulin dependent (T90) Gestational diabetes (W85) 7
General practice Level of computerisation - 97.6% of GPs used a computer in their clinical practice - 69.9% state they used paperless medical records(2013-14) - About 10 GP EHRs in use across Australia Classifications - ICPC-2 (Australian standard) Terminologies used - ICPC-2 PLUS/MD termset/pyefinch - BUT not all mapped to each other, nor to ICPC-2 Who codes? - GPs (+ other clinical staff) at the point of care 15 Hospitals & emergency departments Level of computerisation - Variable - Hospital to hospital - Department to department Classification/terminology used - ICD-10-AM - Some EDs use SNOMED CT (-AU) (? the ED RefSet) - IHPA developing an emergency department principal diagnosis short list (based on ICD-10-AM) Who codes? - Personnel at the point of care (very rare, mainly emergency departments) - Retrospective coding by trained secondary clinical coders 16 8
Medical specialists Level of computerisation - 2011 survey (commissioned by Australian Government DoH) - 42% of specialists use an electronic or computer-readable health record - Of these, only 37% are entirely computerised (so only 15% of total) - About 11 EHRs listed Classifications/terminologies used - No information provided, but probably ICD-10-AM Who codes? - Clinicians at the point of care 17 Allied health physiotherapists Level of computerisation - 2009 survey (Australian Physiotherapists Association) - 32% of respondents used an electronic clinical record (ECR) - Of these, 18% used these ECRs exclusively (so <6% of total) - About 8 electronic record systems listed Classification/terminology used - No information provided No information available about other allied health providers 18 9
The need for standardised clinical terminologies has never been greater Electronic communication (e.g. referrals) Integrated care projects Patient recall Shared health records Practice quality improvement programs 19 ICPC-2 PLUS Workshop questions What deficiencies currently exist in the way you enter diagnostic data into your EHR? - How could diagnostic data entry be improved? What difficulties do you encounter in extracting data from your EHR? What difficulties do you encounter in using data in your EHR for patient recall and communication with other health professionals? 10
Outcomes from 2009 GP workshop Overall messages from the workshop with GPs: It needs to be easy and fast to find terms within a clinical terminology Efficient and user-friendly interfaces (i.e. searching mechanisms) to access clinical terminologies are needed Clinical terminologies need to be complete (i.e. contain all terms used in general practice) 21 Problems identified in 2009 by the GPs with their existing systems included: Lack of integration of coded information into the record in some software programs (for example, populating related fields or referral letters) Users of some software programs stated there were issues with the picklists in their software. Problems related to the lack of efficiency of picklists, the length of the picklists and deficiencies in terms available in the picklists Reluctance by some GPs to enter a coded diagnosis into the record until that diagnosis is definite. GPs stated a need to be able to enter a differential (or query) diagnosis. 22 11
Benefits of coded data (2009) Linkages to decision support tools For patient recall, although the ability to reliably extract data from their records was not seen as a benefit of coding systems by some GPs, indicating that additional work may be needed to integrate coding systems into EHR reporting mechanisms. 23 What do we need for the future? Complementary and integrated use of appropriate terminology with appropriate clinical classifications Implementation models which work in the clinical care workplace Adaptation to local language and clinical vocabulary Recognize the importance of public health data for population health promotion Integrated data for patient care across all health sectors 12
Role of SNOMED CT SNOMED CT is a reference terminology a standardised set of concepts which can be reliably interpreted by a wide range of health professionals - Potentially can be used to underpin the information needs within healthcare - Foundation layer in development of ICD-11 - Mapped to ICPC-2 and ICD-10 Terms used when discussing SNOMED CT - Reference set (or RefSet): a subset of SNOMED CT usually designed for a specific application or use case - IHTSDO - the International Health Terminology Standards Development Organisation (IHTSDO) owns SNOMED CT 25 Why do we need RefSets of SNOMED CT? SNOMED CT is a huge terminology containing many terms that would be rarely, if ever, be used in any individual clinical discipline Its size makes mapping and searching very difficult A subset (RefSet) will make implementation in EHRs much simpler 26 13
Why do we need a map to classifications? SNOMED CT is a reference terminology suitable for patient care and transfer of information between clinicians. It is not suitable for research or statistical analysis of health system performance Therefore SNOMED CT needs to be mapped to classifications such as ICPC-2 and ICD 10 to allow the extraction of meaningful grouped information 27 Work program: The GP/FP RefSet and map to ICPC-2 - undertaken by the University of Sydney s Family Medicine Research Centre under contract to the IHTSDO - Overseen by a Project Group comprising GPs from 5 countries As part of the work program, two products were created: a reference set (RefSet) of SNOMED CT concepts containing commonly used general/family practice content to describe patient health issues (reasons for encounter and problems managed) (the GP/FP RefSet) a map from the content of the GP/FP RefSet to ICPC-2. 28 14
Current status All concepts have been mapped to: - ICPC-2 - ICD-10 The candidate baseline release (suitable for clinical use) is due for release by the IHTSDO at the end of September 2015 In the upcoming candidate baseline release: - 4,346 concepts Suitability of the GP/FP RefSet for Australian implementation Need for an Australian extension to adapt the RefSet for Australian usage - Medical conditions more prevalent in Australia - Problems that only occur in Australia - Australian administrative concepts Linkages from the termsets/terminologies used in general practice to the GP/FP RefSet - Requires mapping from the termsets to SNOMED CT 30 15
Clinical implementation: Using an interface terminology in general practice Local interface vocabulary in the host system, extended as necessary Map to a reference terminology concept selected by clinician Reference terminology concept mapped (classified) to classifications such as ICPC-2/ICD10 SNOMED CT Reference concept GP Interface term: MIGRAINE Aural headache (38823002) Menstrual migraine (23186000) Migraine (37796009) Migraine with aura (4473006) Migraine without aura (56097005) ICPC-2 class N89 Migraine 31 Future international work on GP terminology and classification Wonca International Classification Committee - Development of ICPC-3 to expand and update the classification - Mappings from SNOMED CT and ICD-11 - Collaboration with WHO on primary care version (view) of ICD 11 IHTSDO GP/FP Special Interest Group - Enhance the usability of SNOMED CT for General/Family Practice - Review new content of SNOMED CT for suitability for general practice - Extend mapping of SNOMED CT to ICPC-2 and ICPC-3 ANY VOLUNTEERS?? 32 16