8/10/2015
Twenty years of ICPC-2 PLUS
the past, present and future of clinical terminologies
in Australian general practice
Helena Britt | Graeme Miller | Julie Gordon
Family Medicine Research Centre
Family Medicine Research Centre
Who we are
› Helena Britt
- Director, Family Medicine Research Centre, University of Sydney
- Member, Wonca International Classification Committee (WICC)
› Julie Gordon
- Classifications Manager, Family Medicine Research Centre, University of Sydney
- Member, Wonca International Classification Committee (WICC) & International
General/Family Practice Special Interest Group of IHTSDO (SNOMED CT)
› Graeme Miller
- Medical Director, Family Medicine Research Centre, University of Sydney
- Member, Wonca International Classification Committee (WICC) & International
General/Family Practice Special Interest Group of IHTSDO (SNOMED CT)
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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
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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……..
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History of classifications
Year
Milestone
1950s & 1960s
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
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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
B
D
F
H
K
General and unspecified
Blood & blood-forming
organs
Digestive
Eye
Ear
Circulatory
L
N
Musculoskeletal
Neurological
U
W
P
R
S
T
Psychological
X
Respiratory
Y
Skin
Z
Endocrine, nutritional & metabolic
Urinary
Pregnancy, family planning
Female genital
Male genital
Social
• 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
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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
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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
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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………….
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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
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ICPC-2 PLUS development
Annual growth of ICPC-2 PLUS
18
› Updated quarterly
16
- January, April, July, October
14
- >2 million encounter records
(recorded in free text and converted
to ICPC-2 PLUS)
- Suggestions from end users
Per cent
12
› Developed using:
10
8
Keywords
6
Terms
4
2
0
Year
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How ICPC-2 PLUS works – getting the data in
PROCESS
EXAMPLE
LEG
User enters the first few
letters of a KEYWORD
Links to a picklist of
logically associated TERMS
User selects most
appropriate TERM
Adjusting;brace;leg
Advice/education;legal
Cellulitis;leg
Disease;Legg-Calve-Perthes
Ulcer;leg
etc
Ulcer;leg
TERM is saved into record
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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)
Hyperglycaemia (diabetes)
(T89006)
Coma; diabetic
(T89005)
Diabetes; insulin dependent
(T89001)
Diabetes; juvenile onset
(T89003)
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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)
Gestational diabetes
(W85)
Diabetes; insulin dependent
(T89)
Diabetes; non-insulin dependent
(T90)
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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
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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
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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
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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
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The need for standardised clinical terminologies has
never been greater
Electronic
communication
(e.g. referrals)
Integrated care
projects
Shared health
records
Patient recall
Practice quality
improvement
programs
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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?
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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)
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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.
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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.
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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
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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
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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
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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
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The GP/FP RefSet and map to ICPC-2
› Work program:
- 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.
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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
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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
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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’
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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 ??
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