Education and debate

ABC of Medical Computing: USING COMPUTERS IN CLINICAL AUDIT

View larger version (65K): [in this window] [in a new window]   Clinical audit is generally described as a cycle composed of several stages, the traditional audit cycle. Put simply, it is a way of improving current performance by deciding on the ideal (setting standards), looking at the real situation (measuring current performance), and finding ways of moving from the real to the ideal (implementing change). The cycle is closed by reassessing performance after an interval to assess the effectiveness of the change.

All clinicians should be measuring their performance against a locally defined standard. In addition, as awareness of the usefulness of audit increases other issues about guidelines are being raised. There is a growing move towards evidence based medicine and a feeling that best practice can be agreed nationally (or internationally) and local standards developed from guidelines. It is therefore becoming increasingly important to collect clinical information in a way that allows it to be pooled for both local and national analysis. Computers are ideally suited to this role.

 Clinical audit

 The systematic critical analysis of the quality
 of care, including the procedures used for
 diagnosis and treatment, the use of resources,
 and the resulting outcome and quality of life
 for the patient.

Computers and audit

For many people audit has become synonymous with computers. This idea was reinforced when a large proportion of the money ringfenced for audit was spent on computer systems, with varying degrees of success.

Audit is about asking questions concerning clinical practice and necessitates analysis of clinical data. For a few cases, or small data sets, this can be achieved with paper based systems, and many successful audits have not used computers at all. However, if you have a large data set or large numbers of cases paper based systems become difficult to use. Computers are excellent tools for storing and handling large amounts of data, and they can sort through, retrieve, and analyse data in a fraction of the time it takes to do it on paper.

 Advantages and disadvantages of using a computer
 for audit

 Advantages                              Disadvantages
 Handle large amount of data             Difficult to use
 Rapid retrieval of data                 Require extensive training
 Rapid analysis of data                  Regarded as "black holes" where
                                           data disappear
 Automated quality control as data       Data extracted only as good as that
   are entered                             put in (garbage in, garbage out)
 Automatic production of reports         Data must be accurate, reliable,
                                           valid, complete, and timely
 Legible records                         Planning required before
                                           implementing

 Records can be accessed by more
   than one person at a time
 Data for epidemiology readily
   available

Computerised audit systems

Every audit project will be different, depending on the setting, the data to be collected, the people collecting the data, the timescale, the analysis required, and the involvement of information technologists. However, computer systems used in audit projects can be loosely categorised into three classes--routine systems, specialised systems, and ad hoc locally produced systems.

 Examples of routine
 computerised systems

 General practice systems
 Nursing systems
 Case mix systems
 Departmental systems
 Clinical information systems (CIS)
 Patient administration systems (PAS)
 Resource management systems (RM)
 Hospital information support systems (HISS)

Routine systems

Many different and incompatible computer systems have been developed for use in the NHS. These often require a sophisticated and expensive information technology infrastructure and were usually designed for administration rather than audit. They have been introduced with varying degrees of involvement of clinical staff, with the result that many clinicians do not use them. These systems can, however, be a rich source of data for audit, although it may first be necessary to link up with information stored in separate administrative or departmental databases. This potential has not been exploited in the past, although information technologists running these systems are often able to help extract useful information.

View larger version (72K): [in this window] [in a new window]   General practice systems offer sophisticated audit facilities.

Specialised audit systems

These commercial systems are designed specially for audit and run on individual computers or small departmental networks. Some are able to extract information such as name, address, date of birth, general practitioner, and basic clinical data from existing routine systems. This saves time and reduces the risk of error in transcription. However, the systems can be inflexible and difficult or expensive to change, especially if outside help is required to produce reports for new audits.

View larger version (68K): [in this window] [in a new window]   A bronchoscopy database.

The software is often accompanied by hardware devices such as bar code and optical mark readers. These can be used to collect large amounts of data rapidly and accurately, and they save much time. Bar codes, similar to those used in supermarkets, are assigned to each patient, event, or procedure, and a bar code reader is used to enter data into the system without the need for any typing. Optical mark readers are used in conjunction with specially devised forms, which are marked by the person seeing the patient. Information on the forms is then automatically scanned into the system.

View larger version (94K): [in this window] [in a new window]   Bar code reader.

Locally produced systems

With a little technical knowledge you can set up databases or spreadsheets for use in small scale local audit projects. Such systems have the advantage of being very flexible and can be modified as the needs of the audit change. It can, however, be very time consuming to design and create such a system and it will always lack the advantage of feedback from a wide user base. The lack of a sophisticated interface sometimes makes them difficult for members of staff to use. Furthermore, it is difficult to connect them directly to other routine systems, and transferring data manually can lead to inaccuracies.

View larger version (87K): [in this window] [in a new window]   A locally produced database.

The need for coding systems

Clinicians sometimes use the same word or phrase (such as chest infection or dyspepsia) to describe a variety of conditions or several different terms for the same condition (for example heart attack and myocardial infarction). The term used largely depends on personal preference. If these ambiguous terms are used in computer systems, confusion can arise when data are retrieved for audit or research. For this reason several coding systems have been developed to remove the ambiguity. Systems that use a coding system have the added advantage that the data they contain can be pooled for multicentre, national, or international audit and research.

View larger version (101K): [in this window] [in a new window]   Hospital based audit system using OPCS and ICD codes.

Read codes

The most commonly used clinical coding systems are the International Classification of Diseases (ICD), which is used by many hospitals to claim payment from purchasing authorities, and Office of Population Censuses and Surveys (OPCS), which is used for statistical returns to the government and by the insurance industry. Neither of these systems offers enough codes to enable the creation of comprehensive clinical records. Read codes were therefore developed to enable electronic patient records to hold a huge range of clinical concepts in a concise, compact and unambiguous form. Although initially developed for use in general practice, they have been adopted by the Department of Health for use in the whole of the NHS.

View larger version (14K): [in this window] [in a new window]   Mapping codes between Read and ICD 10.

Read code hierarchy

The Read code system is organised using a hierarchy of clinical terms which offers great advantages in clinical audit or research. For example, searches for the broad terms "respiratory disorder" or "infective disorder" will both find a patient with pulmonary tuberculosis. The core terms are updated quarterly to keep pace with changing clinical practice and drug terms are updated monthly. A recent update has added qualifying terms which can be recorded alongside the core term to add extra detail, such as left or right side.

View larger version (59K): [in this window] [in a new window]   Typical Read code browser.

You do not need to learn or use Read codes as computer systems using them are designed to allow the relevant term to be entered as text. The software will automatically look up the term in a thesaurus, identify the relevant core term, and record the appropriate code along with any qualifiers. You never see the code itself.

The future

Since about 90% of general practices in Britain are already computerised and the Department of Health has insisted that all general practice computer systems use Read codes, detailed information about consultations, diseases, treatments, and outcomes relating to 50 million patients is already potentially available in a comparable electronic format. When the remaining practices are computerised, Read codes have been adopted by hospital based systems, and the NHS-wide network has been completed, there will be an unparalleled opportunity to undertake comprehensive, national audits and epidemiological research.

View larger version (80K): [in this window] [in a new window]   Adding a new problem to a general practice computer system.

Sue Kinn is a research fellow, Scottish Clinical Audit Resource Centre, Glasgow University; Nicholas Lee is consultant ophthalmologist, Western Eye and Hillingdon Hospitals (nicklee@online.nildam.co.uk); and Andrew Millman is occupational physician, Gloucestershire Royal Hospital (af89@dial.pipex.com).

The ABC of Medical Computing is edited by Nicholas Lee and Andrew Millman.

The ABC of Medical Computing is available on the Internet (home page http://www.cityscape.co.uk/users/ dl88/abcmc/abcmc.htm).

 Some clinical audit systems

 Company                        System                                  Description                                     Phone No
 AAH Meditel                    System 5                                General practice routine system with
                                                                          audit capabilities                            01527 579414
 CHC                            InfoStat--Clinical audit/research       Multispecialty, administration and
                                                                          audit                                         0131 458 3444
 Clinical Computing UK          Proton, Abies CIS                       Multispecialty clinical information
                                                                          systems with audit capabilities               0181 742 7400
 Compucorp                      Maisy                                   Windows-based multispecialty,
                                                                          administration and audit                      0181 907 0198
 Egton Medical Information      EMIS                                    General practice routine system with
   Systems                                                                audit capabilities                            0113 258 2454
 First Data Health Systems      First decision                          Hospital-wide system with inbuilt audit
   (UK)                                                                   capabilities                                  0173 479 6679
 Healthcare Computer            Auditman                                Departmental and hospital-wide
   Systems                                                                systems with audit modules available          0173 355 8919
 ICS Medical                    Clinics                                 Clinical information system with audit
                                                                          capabilities                                  0161 480 7768
 Landacorp UK                   Prizm and Quartz                        Windows based management and clinical
                                                                          systems with audit facilities                 0181 650 2722
 Medical Systems                Micromed                                Clinical information and audit system           0149 486 6031
 Metasa                         Metabase                                Clinical data management and audit
                                                                          system                                        0193 277 9977
 Siemens Nixdorf                CaMIS clinical support system           Used in conjunction with case mix system
   Information Systems                                                    and departmental systems for audit            0134 486 2222
 VAMP Health                    VAMP                                    General practice routine system with
                                                                          audit capabilities                            0171 498 1330

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