Health and health care information networks with GPs in Belgium

A SWOT analysis

Viviane Van Casteren

Epidemiology Unit

Covered topics (1)Covered topics (1)

What is a SWOT analysisWhy networks with GPsSentinel general practitioners (SGPs)

DefinitionObjectivesGeneral principlesCriteria for recorded health problemsRegistered themesDenominatorExamplesSWOT analysis

Covered topics (2)Covered topics (2)

Quality improvement by registration of consultation data in general practice

Quality AssuranceMethods for assessment of quality of careObjectives of this networkQuality cyclePartners in the networkProjects carried outExamplesSWOT analysis

Covered topics (3)Covered topics (3)

Computerized network for health andhealth care information from generalpractice

Advantages of EMRProjectsPartnersEncountered problemsSWOT analysis

Acknowledgements

SWOT analysisSWOT analysis

Internal strengths Internal weaknesses

External opportunities External threats

Excellent fast and simple way for analysinga programme, a department, etc…

Building on strengths Minimizing weaknessesSeizing opportunities Counteracting threats

Why networks with GPs ?Why networks with GPs ?

GP has key role in health care system

HIS 2001 indicates that

94% of general population has regular GP80% of general population at least1 encounter/yearmean number of encounters/person/year =6.5no important barriers for use of GP care

Sentinel general practitioners (Sentinel general practitioners (SGPsSGPs))

DefinitionsSurveillance : ongoing systematic collection, analysis and interpretation of public health data for use in planning, implementation and evaluation of public health programmes (CDC)

Sentinel sites : group of hospitals, labs, GPs providing timely information on a wide range of health problems

do not cover entire populationbut sufficient information for PH decisions and study of long term trends

SGPsSGPs objectivesobjectives

Evaluation of public health problems and their importance within the population in general, and study of the most important epidemiological characteristics.

Continuous observation of certain health problems over time, such as measles, mumps, requests for HIV tests, in order to study the impact of prevention and vaccination campaigns.

Study of the management and follow-up of health problems by the general practitioners.

SGPsSGPs general principlesgeneral principles (1)(1)

Participation by general practitioners is voluntary.

The participants (158 practices or 175 GPs in 2001) are representative for the profile of physicians in Belgium, i.e. according to age, sex and homogeneous geographical distribution.

SGPsSGPs general principlesgeneral principles (2)(2)

Registration is continuous and from weekly forms. Each registration programme lasts one year, about eight different themes are included. Next to age and sex of the patient, other parameters, varying according to the theme, are recorded.

Anonymity of the patient is always preserved.

Retro-information is regularly distributed to participants, concerned authorities, the medical press, scientific associations and interested individuals.

SGPsSGPs recorded health problemsrecorded health problems (1)(1)

Recorded data concern problems for which the GP is by preference consulted or plays a central role in the management (in order to increase sensitivity).

The problem has to be one for which clear and standardised definition is possible (in order to increase specificityor positive predictive value).

SGPsSGPs recorded health problemsrecorded health problems (2)(2)

It must concern an important health problem not subject to surveillance of another system, unless the network of sentinel general practitioners provides complementary information to this end.

The frequency of the problem should, on the one hand allow statistical analysis, but on the other hand not represent too heavy a burden on the participating physicians.

SGPsSGPs registered themes registered themes –– infectious themesinfectious themes

79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03

Acute conjunctivitisAcute diarrhoea

Acute gastro-enteritis 02

Condyloma acuminatumGonorrhoea

Herpes genitalisLyme 03

Male uretritis 88

MeaslesMeningitis

Mononucleosis infectiosa 84

MumpsOtitis media 86

PneumoniaSyphilis

VaccinationsVirale hepatitis

Urinary infections Zona 84

82-83

79-80

91-92

79-80

79-80

Infectious diseasesRegistration period

86-87

79-80

82-83

82-87 91-00

82-83

79-80 82-00

00-01

86-87

91-92

93-94

93-03

79-80 82-83

79-80

SGPsSGPs registered themes registered themes –– non infectious themesnon infectious themes

79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03

Acute allergic manifestationAcute myocardial infarction

Asthma (incidence)Asthma (prevalence) 01

Asthma in children 84

CancerCerebrovascular accident 84

Chest pain 03

Chronic bronchitis Diabetes (incid.+preval.) 01

Diabetes type II (incid.)Emergencies in elderly 87

Gastro-duodenal ulcer 84

Prev. cancer examinationThyroidal diseases

Varicocele 94

85-86

85-87

96-97

98-9988-89

85-86

85-03

90-03

Non infectious diseasesRegistration period

85-86

97-98

02-03

SGPsSGPs registered themes registered themes –– behaviour related themesbehaviour related themes

79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03

Accidents : all kinds 02

Alcoholism related problems 84 93

Drugs related problems 84

HIV testHome accidents 84

Home accidents 96

Home accidents in elderly 95

Interrupted pregnancyMorning after pill

Rest home 94 03

Sport accidentsSuicide (attempt)

Violence 02-03

90-95 00-01

88-00

82-83

93-95

82-83

Behaviour related problems

82-83

93-95

Registration period

85-86

SGPsSGPs denominator estimationdenominator estimation

P = sentinel populationPi = estimated population of a districtCSGPi = total annual number of contacts with SGPs in the

districtCGPi/Ni = mean annual number of contacts with GP per inha-

bitant in the same district

Estimated population coverage 2001 :Flanders: 1.6%Wallonia: 1.2%Brussels: 0.9%

∑ ∑= =

==43

1

43

1 /i i

CNiC

PiPGPi

SGPi

SGPs SGPs example measles (1)example measles (1)

Clinical case definition (CDC) :

Generalized rash lasting >= 3 daysTemperature >= 38.3 CCough or coryza or conjunctivitis

SGPsSGPs example measlesexample measles (2)(2)

Measles incidence in Flemish and WalloonRegion (1982-1998)

Period Inc 100 000 inh. 95% C.I. Inc 100 000 inh. 95% C.I.1982-1983 714 654-775 1281 1147-14191984-1986 367 332-399 519 465-5681987-1990 79 65-87 252 217-2771991-1993 76 64-85 102 79-1251994-1996 87 76-97 134 112-1531997-1998 23 17-31 40 27-57

Flemish Region Walloon Region

SGPsSGPs example measlesexample measles (3)(3)Age distribution of measles cases in Flemish

and Walloon Region in various registration periods

< 1 jaar 1-4 jaar 5-9 jaar 10-14 jaar 15-19 jaar > 19 jaarIHE/GJ

SEM12_1M2

N=5411982-1983

N=345

N=2101991-1993

N=116

N=2631994-1996

N=153

N=431997-98

N=30

%

VLAANDEREN

0

10

20

30

40

50

WALLONIE

0

10

20

30

40

50

%

SGPsSGPs example Diabetesexample Diabetes

Age standardised prevalence rates of DMper 1000 persons >= 45 years, in 2000

Country°/°° C.I. °/°° C.I.

Belgium 76.3 72.9-79.6 74.9 71.8-77.9CroatiaEngland 50.3 48.3-52.2 37.8 36.2-39.4France 63.4 58.2-68.5 45.8 44.8-49.9Netherlands 60.8 57.5-64.1 63.1 60.0-66.3Portugal 47.9 44.8-50.9 54.1 51.2-57.0Spain 50.4 48.6-52.2 56.3 54.5-58.1Slovenia 39.1 38.4-39.8 36.7 36.1-37.3

Male Females

SGPsSGPs SWOT analysisSWOT analysis

Internal strengths Internal weaknessesHighly motivated GPS DenominatorHigh acceptability RepresentativenessFlexible network Sensitivity-specificitySimplicity of recording Large confidence intervalsMonitoring over long or repeated periods Continuous effort requested from GPsDetailed information

External opportunities External threatsGlobal medical record Budgetary restraintsElectronic medical record No accreditation for GPsDevelopment of "patientele" by the Inter- Competition with other networks

mutualistic Agency (IMA)International collaborative studiesCollaboration with other networks in

Belgium

Federalisation

Quality improvement by registration of con-sultation data in general practice

Quality assuranceQuality assurance

Continuous Prevention of mistakesFocusses on process and outcome of carePractice orientedConsiders organisation, available faci-lities, skills

Methods for assessment of quality of careMethods for assessment of quality of care (1)(1)

Competence methods Performance methodsWritten exams Self registration in practiceInterviews Clinical notesWritten cases (vignette) PrescriptionsOral exams (without pat.) Referral lettersSurveys Data from pharmacies

Data from insurance agenciesTelephone-traffic registrationCritical incident reviewData from hospitals (e.g. labs)Practice activity analysisTrained practice surveyors

Objectives of the projectObjectives of the project

Development of instruments to measure elements of care in general practice by means of self registration

Comparison of these elements with national and international guidelines and recom-mendations

To generate interest among general prac-titioners about quality of care for the selected topics

Methods of the projectMethods of the project

Choice of topics

Choice of quality indicators and criteria

Development of registration forms

Practical organisation of a network of general practitioners

Data collection and analysis

Feed-back

Quality cycleQuality cycle

QualityCyclus

Analysis and selectionof quality problems

Setting priorities

Evaluation of results

Implementationof interventions Selection of

interventions

Development of guidelines Selection of

indicators and criteria

Data collection

Data analysis and feedback

Identification of barriers to improve

Partners in the projectsPartners in the projects

Scientific associations of general practi-tioners (SSMG and WVVH)

Scientific Institute of Public Health

Accreditation steering group of the NSIII

FPS Health, Food Chain Security and Environment

SESA (UCL) - Kindly Marked up Electronic Health Record (KMEHR) – working group

Softwareproducers

Projects carried outProjects carried out

Management of acute sore throat (321 GPs) and diabetes type II (287 GPs), 1 February till 31 May 1999

Pharmacological treatment of elderly patients with osteoarthritis (387 GPs), 5 February till 11 March 2001

Management of hypertension and diabetes type II (299 GPs), 15 April till 16 June 2002

Quality improvement projects, Quality improvement projects, management of acute sore throatmanagement of acute sore throat (2)(2)

Distribution of % of episodes for which AB were prescribed among GPs (individual feed-back)

Line = individual result code 7008 (= 40 %)% calculated on 53 episodes of acute sore throat

Num

ber

of G

Ps

% episodes for which AB was given

0 10 20 30 40 50 60 70 80 90 1000

50

100

150

200

Quality improvement projects, Quality improvement projects, management of acute sore throatmanagement of acute sore throat (3)(3)

14,8%

14,3%

21,7%

32,3%

52,5%

56,0%

Other reason

Risk patient

Demand of the patient

Prevention rheumatic fever/AGN

Prevention local complications

Shortening duration of illness

Determinants of use of AB (multilevel analysis)

Quality improvement projects, Quality improvement projects, management of acute sore throatmanagement of acute sore throat (4)(4)

C.I. C.I.

Male 1.15 1.06-1.25≤ 45 years 1.23 1.06-1.43

Walloon region 1.90 1.64-2.21 Home visit 1.43 1.32-1.54

Solo practice 1.37 1.15-1.63

GP determinants Patient determinants

Quality improvement projectsQuality improvement projectsA SWOT analysis

Internal strengths Internal weaknessesHighly motivated GPs Selection biasClimate of mutual confidence Method limited to elements of care which Network spread over the countryDetailed global and individual feed-back on

can be recorded

performance indicatorsCross-sectional studies, impossible to

study evolution of care for a specific We can link health problems with medical patient

services Only about 400 GPs are involved, whatInformation on determinants of about all the others ?

e.g. prescriptions of drugs No good denominatorInformation on over the counter products

counter products and over non reimbursed drugs

External opportunities External threatsNew themes to study emerge as new Year to year funding

guidelines are being developed or as new Climate of competition with other networkscampaigns of Health Authorities are being (e.g. Institut de Récolte de Données launched Médicales), often with far more budgetary

Collaboration with the Information Cell on meansAccreditation from the National Sickness and Invalidity Insurance Institute

Computerized network for health and health care information from general practice

Present situation in BelgiumPresent situation in Belgium

More and more GPs have EMR

Wide variety of software packages

Labeling procedure for software packages in 2002

17 packages received label in 2002

Computerized network: PartnersComputerized network: Partners

Federal Public Service Health, Food Chain Security and EnvironmentNSIII

Scientific Institute of Public Health (IPH)

Scientific associations (SSMG and WVVH)

SESA (UCL) - Kindly Marked up Electronic Health Record (KMEHR) - working group

Software producers

Our networkOur network

Semi-anonymousSemi-automaticMixed (paper and electronic)Encryption using PGP technique and sending through classical e-mail orThrough MedibridgeKMHER-One XML exchange formatICPC codes for diagnosis, ATC or CNK codes for drugsGPs recruited on voluntary basis

Data collection (1999Data collection (1999--2002) (1)2002) (1)

Phase 1

On cardio-vascular risk factors

3 software packages

2 months recording

Data collection (1999Data collection (1999--2002) (2)2002) (2)

Phase 2

Quality of care assessment regarding treatment of osteoarthritis

Enlargement of network

Mixed network (paper and electronic)

5 software packages

5 weeks recording

Data collection (1999Data collection (1999--2002) (3)2002) (3)

Phase 3

Quality of care assessment regarding management of high blood pressure and diabetes type 2

Mixed network (paper and electronic)

8 software packages

2 months recording

Our findingsOur findings (1)(1)

Encountered problems

drop out of participants

missing data

Our findingsOur findings (2)(2)Participation rate and number of registered

patients

Phase Method Registered Paticipating Paticip. Registered GPs GPs rate patientsNb Nb % Nb

1 EMR (3 softs) 63 39 62 3 559

2 Paper 274 233 85 21 892

EMR (5 softs) 241 152 63 9 384

3 Paper 236 193 82 12 194

EMR (8 softs) 188 115 61 6 850

Our findings (3)Our findings (3)

Encountered problems

Drop out of participants

Problems with :

üinstallation of extraction module (36.7%)üuse of extraction module (36.7%)üsending of files (23.3%)üencryption of files (13.3%)

Our findings (4)Our findings (4)

Encountered problems

Problems with extraction module

Sometimes use of extraction module required upgrade of the EMR software

Not always possibility to complete or correct data in extraction module

Updating of EMR after correction of module not always possible

Our findings (5)Our findings (5)

Encountered problems

Missing data

data not present in EMR

data not captured by module

differences in results regarding indicators for quality of care (paper < -- > EMR)

Our findings (6)Our findings (6)üProcess indicators for quality of care for

diabetes type 2 patients. % missing information

Process indicatorPaper EMR

(N=2 730) (N=1 174)

Last weight check 30.3 25.0

Last foot inspection 51.8 92.7

Last fastening glycaemia check 11.8 55.0

Last BP check 14.9 8.5

Last creatinaemia check 14.9 53.6

Last referral to ophtalmologist 58.1 85.8

Last microalbuminuria check 51.3 89.2

Last check Hba1c 16.4 57.3

% no information

Computerized networkComputerized network ::A SWOT analysisA SWOT analysis

Internal strengths Internal weaknessesIn theory : Drop out of participants

Recording over long periods Missing dataData collection from many GPs Problems with extraction moduleNo data entry at the co-ordinating centre Being dependant on goodwill of software Data collection about many patients and developers

on different kinds of parameters No use of POMRStrength of our network : Different formats for labresults

Model of collaboration and transmission of data accepted by the partners

KMHER- XML exchange format is suitable

External opportunities External threatsMore and more GPs becoming computerized Few budgetary means available to develop Progress in the labelling procedure a computerized networkDecreasing number of softwares Climate of competition with other computerized

networks (Intego, Institut de Récolte de Données Médicales)

Network spread over the countryVarious softwares are involved

Less reliable data on home visits

AcknowledgementsAcknowledgements

Bastiaens HildeBossuyt NathalieDevroey DirkJeanfils GuyJonckheer PascaleLaffineur Anne-Lise

Lafontaine Marie-FranceOrban ThomasPirson YolandePuddu Marina Vandenberghe HansVan der Heyden Johan

And especially all the participating GPs!!