The Capture of Morbidity Information in General Practice

Douglas FlemingDirector, RCGP, Birmingham Research UnitNottingham: July 20, 2005

Content of Presentation

History of morbidity surveys Purpose of morbidity surveys THE POTENTIAL OF ROUTINE

ELECTRONIC MEDICAL RECORDS FOR EPIDEMIOLOGY IN PRIMARY CARE

The Weekly Returns Service SELECTED RESULTS FROM

MORBIDITY SURVEYS

History of morbidity surveys

Deaths by cause 1851 William Farr: the establishment of the ICD-now version 10

1946 the London Sickness Survey 1956 The first national practice based

morbidity survey 1971/72 and on to 1976; 1981/82;

1991/92- the 2nd 3rd and 4th surveys Regular General Household surveys

since 1972

Purpose of morbidity surveys

To describe disease prevalence To examine social and regional

inequalities To monitor changes in prevalence

and to seek for evidence of trend To study co-morbidity To examine GP workload To provide information for health

service planning

Electronic Medical RecordsElectronic Medical Records

Have arrived Let us ensure we use them to

maximum advantage Remember we will arrive at a time

when the record is uniform across primary and secondary care.

Common classification systems and standardises recording protocols are needed

What is the practice EMR used for?What is the practice EMR used for?

Patient Registration Patient Consultation Record Complete Prescribing Record Limited Prescribing Record (e.g.

repeat prescriptions) Research Facilitator – completion of

templates Accessing System for patient lists Quality Assurance Epidemiology

EMR for epidemiologyEMR for epidemiology

If you focus on EMR for epidemiology you can achieve all the other functions.

Conversely if your primary focus is on any other purpose you may exclude the possibility of use for epidemiological research.

The EMR is a filing cabinet containing The EMR is a filing cabinet containing medical informationmedical information

Everything put in it can be retrieved

But if we want to retrieve information readily we must put in in an orderly fashion.

Example patient recordExample patient record

Abdominal Pain for 3 days, radiation to RIF, Vomiting 24 hours, pain increasing. No diarrhoea and no urinary symptoms.

O/E tender RIF, no guarding, t.38.0o C

Urine no protein, no sugar, no blood. Rectal examination not done. Patient

told he may have appendicitis and hospital admission (QE) arranged.

Structure record for filing and decide Structure record for filing and decide what you wish to analysewhat you wish to analyse

Subjective Abdo pain, vomiting

Objective Tender RIF t 38.0oC

Assessment Appendicitis

Plan Admit hospital

In structuring for filing, for analytical purposes, you will l lose the free text describing the negative information egative information and qualifying details and qualifying details

S No urinary symptoms, no diarrhoea.

O Rectal examination not done, Urine no sugar.

A May have appendicitis.

P QE hospital

All boxes need to be filled in a All boxes need to be filled in a structured patient electronic recordstructured patient electronic record

Essential for an accurate patient record. Free text is important. Negative and

qualifying details need to be stored but not in a way that confuses analysis

Sometimes you can bring data together from different consultations in order to fill every box

Many episodes of illness involve only one consultation, therefore complete the assessment box at each consultation.

The meaning of Asthma: an orderly record: The meaning of Asthma: an orderly record: information in the right placeinformation in the right place

Recent hospital admission for asthma Had asthma as a child. Never had asthma. Reversibility test for asthma Worried about son with serious asthma. Father died of asthma. Occupational asthma. Asthma attack. Asthma review.

Who does the filing?Who does the filing?

The Classification System, but you must use it properly

The Read ThesaurusThe Read Thesaurus

Is a medical terminology containing many more codes than ICD. By using Read codes, you can process the

information and analyse by ICD (or ICPC) but you are able to retain a higher level of detail in your patient centred record.

There are separate codes for patient complaints (presenting symptoms) and symptom diagnoses.

Consultation/episode typeConsultation/episode type

Used to distinguish incidence from ongoing illness, but not needed for prevalence. The fact of consultation for the specified condition determines prevalence.

A repeat prescription (without consultation) is sometimes an indicator of prevalence (eg. Hay fever, glaucoma)

Intelligent interrogation of database needed

Episode typing in use:Episode typing in use: the example of otitis media the example of otitis media

Feb 1 Record= Otitis Media F Feb 4 Record= Otitis Media O Oct 10 Record= Otitis Media N Oct 12 Record= Otitis Media O Oct19 Record= Otitis Media O

1 person = annual prevalence 2 episodes and when they occurred =

incidence 5 consultations = workload

The importance of episode typeThe importance of episode type

Much epidemiological research is concerned with the timing of events. For this type of research it is important to identify when new episodes of illness occur. For example we may be interested in the factors which precipitate asthma attacks and we need to know when patients consult with new episodes as opposed to consulting simply to renew medication or as part of routine management. The simplest episode typing must distinguish new episodes from ongoing consultations.

RCGP Weekly Returns Service

Weekly Returns Service (WRS) established in 1964

Fully computerised data entry and automated data extraction since 1994

Record all new episodes (and consultations) of illness (per 100,000 population)

Report on a twice weekly basis (daily possible)

Monitor at national, regional and practice level

Age and gender specific data Now also provide annual prevalence data

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Incidence of influenza-like illness: Virus Incidence of influenza-like illness: Virus isolations in sentinel networks 1996/97isolations in sentinel networks 1996/97

England/Wales The Netherlands

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FluAFluBIncidenceBaselineConfidence interval

From Fleming DM. Zambon M, Bartelds AIM, de Jong JC. The duration and magnitude of influenza epidemics:European Journal of Epidemiology 15: 467-473 1999

Episodes, Admissions and Deaths For Respiratory disease (Age 75+)Episodes, Admissions and Deaths For Respiratory disease (Age 75+)

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Figure 5: Figure 5: Average excess admissions and excess bed days by age group, 1989/90 Average excess admissions and excess bed days by age group, 1989/90 to 2000/01to 2000/01

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Acute bronchitis: weekly incidence in 0-4 and 65+age groups by winter weeks in alternateyears 1995-2002

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Weekly incidence of acute bronchitis contrasted withRSV reports from the Health Protection Agency:winter weeks from selected years1996/97 - 1999/00

Mean weekly incidence of acute respiratory Mean weekly incidence of acute respiratory infections vs antibiotic prescriptionsinfections vs antibiotic prescriptions

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INFECTIONS OF SKIN & SUBCUTANEOUS TISSUE Mean weekly incidence rate by Gender

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Prostate and Breast CancerProstate and Breast CancerPrevalence per 10,000 Prevalence per 10,000 by age and genderby age and gender

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WRS; Influenza vaccination uptake 2003 WRS; Influenza vaccination uptake 2003 compared with 2002compared with 2002

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0-44 (2002) 45-64 (2002) 65-74 (2002) 75+ (2002)0-44 (2003) 45-64 (2003) 65-74 (2003) 75+ (2003)

SummarySummary

Computer storage of medical records is replacing paper records.

The computer is a filing cabinet, but you need a good filing system.

Disciplined data capture is at the heart of a good record whether for routine patient management of for epidemiological research.

The classification system does the filing. Select it carefully according to your purpose and collaborators. Be wary of mapping programmes across classifications.

SOAP is a good structure on which to base your recording but if you want to concentrate your analysis on one or two of these boxes you must make appropriate entries in every box at every consultation including home visits.

Episode typing is needed to study seasonality for contemporary surveillance.