Indexing EBM guidelines with ICPC-2 and linking guidelines

to medical records Ilkka Kunnamo, MD

The Finnish Medical Society Duodecim Finland

ilkka.kunnamo@duodecim.fi

Marc Verbeke, MD University of Gent, Belgium

WONCA Europe Kos 6.9.2005

Problems with accessing guidelines during encounters

• Time needed to explore websites and guidelines

• Different search terms or search systems

• Physicians’ ability in defining the question

• Correct spelling in other language

• No standardized way of assessing keywords

• Patients are watching what the doctor is doing

Aim: creating tools to• Improve the accessibility of selected

guidelines on-line

• Make it work during patient encounters

• Search with a language independent system

• Search with own terminology in own language

• Create short-lists of quality controlled sites

• Find only guidelines linked to your problem

Components of the system• EPR system that makes the link from ICPC

code used by EPR in assessment of the patient’s problem

• 946 topics in “EBM guidelines” indexed by ICPC: to which question is this guideline an answer?

ICPC codes 1-29 and 70-99 at assessment / diagnostic level

ICPC code used at intervention level (process codes *30-*69)

Guidelines accessible by ICPC instead of search terms

Indexing result

Number of guidelines in search result

Number of ICPC-2 codes used as main indexing terms

1 1882 833 404-6 357-10 12More than 10 14

Indexing result

• 372 ICPC codes used as main indexing terms

• 20 guidelines with a process code as main indexing term

• 50% of ICPC codes retrieve only one guideline

• 93% of the ICPC codes retrieve not more than 6 guidelines

Search results with ICPC-2 codes• L77

– Sprain of the ankle– Joint and ligament injuries in children

• P20– Evaluation of a neurological patient– Memory disorders and dementia– Examination of patients with memory disorders and dementia– Treatable causes of dementia and memory disorders– Neuropsychological problems

Search results with ICPC-2 codes• R78

– Acute brochitis– Acute bronchitis (instructions for patients)– Mycoplasma pneumoniae infections– Wheezing in children– Treatment of obstructive bronchitis and acute asthma in children

• S70– Herpes zoster– Herpesvirus skin infections– Fever and rash in a child– Meningitis in children

• *31– Diagnostic tests in dermatology

ICPC is not always specific enough

• ICPC– D99 Other diseases of the digestive system

• ICD-10– K56.6 Bowel obstruction– E73.9 Lactose intolerance– K85 Acute pancreatitis– K90.0 Coeliac disease

ICPC code found by usingDutch thesaurus

Guidelines searchedautomatically using theICPC code as search term

Pilot use by 10 Belgian GPs• Opened articles 1287• Search 168• Browse 85

Comments from test users 4/2005 

• Very useful during doctor-patient encounter• Real improvement and very good tool!• 10-20 % new search needed• Very user-friendly and high speed search: very

quick results and accurate information• Evaluation scores of 8-9/10

Problems with search terms• Atrial fibrilation• Basal cell epithelioma• Erythema infectiosa• Fiever• Fistulisation• Hydradenitis• Intertigo• Neuronitis• Paulbunnel• Prostate malignancy

Comments from test users 8/2005• Very user friendly• Easy and adequate access• Useful information• Daily use• Can be used in cooperation with patient• Better search results compared with using

EBMG by entering search terms• Seldom second search needed• Level (ICPC code) needed during encounter• No better search system known• Good cost/benefit balance

Critical comments• Not always congruent with Belgian or Dutch

Guidelines (e.g. sometimes too much use of antibiotics)

• Too Anglo-Saxon• Sometimes too general guidelines - nothing

more than needed during encounter• No automatic login (first use of the day)• Problem with ICPC rag-bag (D99, T99):

specific diagnostic label links to other guidelines

• Create use of ICPC/ICD link (-99 codes)• Process codes less commonly used

Conclusions

• Indexing guidelines by ICPC codes and linking directly to the EPR– enables quick use during patient

encounters– avoids spelling mistakes when searching– improves search results

Wishful thinking?

• All primary care journals and expert systems indexing with ICPC in addition to keywords

• Guidelines created in ICPC structure

• Uniformity in the use of ICPC codes

• Developing links even more patient-oriented (sex/age/history/risk profile)

Future developments? • Indexing other general or “regional-specific” sites

– Prodigy– Trip Database– Dermis– Clinical Evidence

• Indexing sites in other languages (each in his own country)– e.g. Diagnostisch Kompas– NHG standards

• Imaging and investigation sites as guidelines – (e.g. “consilium radiologicum”)

• Indexing drug information sites with ICPC drug codes or ATC • Generating pick up lists with all the quality controlled sites

giving an answer to the physician’s question