Hart, HE (Bertien)

Höppener, P

Knottnerus, JA

van Schendel, GJ

Wouden, Hans

English

EUR Research Repository

Journal of the American Medical Informatics Association Volume 6 Number 2 Mar / Apr 1999 173Case Report nGeneral Practice RegistrationNetworks in the Netherlands:A Brief ReportHUBERTA E. HART, JOHANNES C. VAN DER WOUDEN, PHD, PAUL PHD,¨HOPPENER,GEERT J. VAN SCHENDEL,† J. KNOTTNERUS, PHD´ANDREA b s t r a c t In the Netherlands, several general practice registrations exist. Groups ofgeneral practitioners register elements of patient care according to agreed-upon criteria, and thesedata are collected in a central database. By means of a questionnaire the authors interviewed themanagers of all nine computerized registration networks extensively about the possibilities andlimitations of their registration. In addition, respondents answered some questions with datafrom the central database of their network. Various items are collected by nearly all theregistration networks, while other items are collected by only one network. Answering questionswith data from the central database turned out to be difficult. Organization and manpower arethe main obstacles.n JAMIA. 1999;6:173–175.In the Netherlands general practitioners hold a keyposition in health care. They are the first health careprofessionals people see when they are ill, and theyact as gatekeepers to secondary care. Most cases thatpresent to a general practice are taken care of by thegeneral practitioner alone.The vast majority of general practitioners in the Neth-erlands register their patient data by computer.1 Theyuse their computer not only to collect and store patientdata but also for practice organization and financialadministration. Several software systems exist side byside, each with its own possibilities and obstacles.In the Netherlands several general practice registra-tion networks have been established in the past 25years. A registration network is a group of generalpractitioners from different practices who collectelements of patient care according to agreed-oncriteria.2 – 4 The collected items are often coded. At reg-Affiliations of the authors: Erasmus University, Rotterdam(HEH, JCW), and University of Limburg, Maastricht (PH, GJS,JAK), The Netherlands.†Deceased.Correspondence and reprints: J. C. van der Wouden, PhD, De-partment of General Practice, Erasmus University Rotterdam,Room Fe317, Postbox 1738, 3000 DR Rotterdam, The Nether-lands; e-mail: ^vanderwouden@hag.fgg.eur.nl&.Received for publication: 6/29/98; accepted for publication:10/28/98.ular intervals these data are collected in a central da-tabase. We made a systematic inventory of these reg-istrations.MethodsBy means of a questionnaire we interviewed the man-agers of all 14 registration networks. Data collectiontook place between summer 1995 and spring 1996 andall the managers participated. The questionnaire ad-dressed objectives, methods, size, and content of theregistrations, availability of morbidity items such assymptoms, diagnoses, side effects of therapy, anditems referring to the management of the generalpractitioners and whether the registrations would en-able further analyses in their databases and could beused as a sampling frame for follow-up studies. Inaddition, we asked the managers to answer some spe-cific research questions with data from their centraldatabase, to determine whether obstacles would arisewhen answering research questions.ResultsEach registration network consists of a group of gen-eral practitioners from different practices. The sizevaries from 3 to 103 practices with 7 to 161 generalpractitioners. These general practitioners collect datadaily from 10,000 to 200,000 patients. Mostly the gen-eral practitioners code the data themselves, using the174 HART ET AL., Dutch Primary Care Registration NetworksTable 1 nNumber of Computerized Networks in the Netherlands Registering Morbidity and Management ItemsCoded Free TextRestricted toSelected DiseasesNotRegisteredSymptoms 1 2 2 4Acute diseases 4 None 4 1Chronic diseases 5 None 4 NoneSide effects 3 None None 6Reasons for encounter 1 2 1 5Physical examination 1 3 1 4Diagnostic tests 2 3 2 2Watchful waiting None 3 None 6Patient education 1 2 1 5Follow-up policy None 3 1 5Referrals 8 None None 1Prescriptions 7 None 1 1International Classification of Primary Care.5 Nine ofthe registrations are computer based; two others arein a phase of transition from paper forms to computerregistration. We consider only the nine computer-based registration networks, working with four dif-ferent commercially available computer programs.They are all connected to a university.It is a challenge for the managers of the networks toget the registering general practitioners on a par. Themanagers of five of these networks made a manualavailable to the participating physicians. Furthermore,all nine managers organize consensus meetings sev-eral times a year in which they discuss and create firmcriteria for labeling the presented morbidity. Thisstandardization is important for minimizing interdoc-tor variation with respect to labeling morbidity andinterventions. The managers are responsible for thefinal quality of the registration and an optimal struc-ture of the database; these are regularly testedthrough cross-checking for impossible codes and com-binations.Five registrations have developed a central databasein which patients are not identifiable, for research pur-poses. Three of them have set up their database pri-marily as a sampling frame, allowing researchers toselect patients with particular health problems forsubsequent recruitment by the patient’s general prac-titioner. Other objectives are education (one network),postmarketing surveillance (one), description and ex-planation of the ‘‘transition’’ from reasons for encoun-ter to diagnosis (one), mapping the management ofthe general practitioner (three), improving such man-agement (one), and policy development (one).The content of the registrations concerns mostly mor-bidity, connected to the management of the generalpractitioner in a specific case. Five registrations collectdata of all morbidity, whereas four restrict themselves,for instance, to morbidity of a few chapters of theICPC-classification or to chronic diseases only. Table 1gives an overview of the different registered morbid-ity items and the management of the general practi-tioner.Answering research questions with data from the cen-tral database turned out to be difficult. The managersanswered fewer questions than they ought to havebeen able to answer on the basis of their registrationdata. Various reasons have been advanced for thesedisappointing results. A few registration networks col-lect items for specific disease groups only; a specificquestion can concern another disease. Organizationand lack of manpower seemed to be the main obsta-cles.ConclusionWhen starting research with an existing database it isimportant from a methodologic viewpoint to be wellinformed about the method of registration of the spe-cific network. Researchers should be quite specific inwhat they want from networks and choose the net-work that best fits their question. For this purpose abrochure has been written.6 On the other hand itwould be advisable for managers of the registrationnetworks to make their networks better accessible forexternal researchers. They should develop and laydown procedures for situations in which outsiders askfor information. Good logistics are important. An ade-quate organization of the privacy of patient data asksfor attention.Journal of the American Medical Informatics Association Volume 6 Number 2 Mar / Apr 1999 175References n1. Van der Lei J, Duisterhout JS, Westerhof HP, et al. The intro-duction of computer-based patient records in The Nether-lands. Ann Intern Med. 1993;119:1036–41.2. Meyboom-de Jong B. Morbidity registration in general prac-tice in the Netherlands. Huisarts Wet. 1993;36(suppl):49–68.3. Metsemakers JF, Höppener P, Knottnerus JA, Kocken RJ, Li-monard CB. Computerized health information in the Neth-erlands: a registration network of family practices. Br J GenPract. 1992;42:102–6.4. Middelkoop BJC, Bohnen AM, Duisterhout JS, Hoes AW,Pleumeekers HJCM, Prins A. Rotterdam general practitionersreport (ROHAPRO): a computerised network of generalpractices in Rotterdam, The Netherlands. J Epidemiol Com-mun Health. 1995;49:231–3.5. Lamberts H, Wood M (eds). International Classification ofPrimary Care. New York: Oxford University Press, 1987.6. Hart HE, van der Wouden JC, Höppener P, van Schendel GJ,Metsemakers JFM, Knottnerus JA. Huisartsgeneeskundigeregistraties in Nederland. Rotterdam/Maastricht: InstituutHuisartsgeneeskunde, 1996.ERRATUMOmission of Abstract from ProceedingsThe following abstract was omitted from the Posters section of the Proceedings of the AMIA Annual Fall Symposium 19981:Developing Virtual Patients:Taking a Lesson from the TamagotchiEugene M. C. Loke, H. N. Quek, and K. C. LunMedical Informatics ProgrammeNational University of SingaporeIn recent years, the Tamagotchi, an electronic virtual pet, has takenthe world by storm. A Japanese invention, the toy requires the elec-tronic pet owner to look after it with tender loving care throughdaily ‘‘feeding,’’ ‘‘playing,’’ and ‘‘toilet training’’ by pushing littlebuttons on a pocket-size screen. Failure to look after the pet resultsin its ‘‘death.’’Since its release, young children and teenagers have become hookedon the toy, to the extent that several studies have found it to haveundesirable sociologic and psychologic effects, particularly onschool children. The children bring their pet to school in order tolook after it when the toy beeps for attention, to the annoyance ofteachers. Worse still, children have been found to grieve and sufferpsychologic distress over the ‘‘loss’’ of their pet.At the NUS Medical Informatics Program, we have found a positiveuse for the Tamagotchi concept in the development of virtual pa-tients. Using VBscript and Active-X, we have constructed an inter-active Web site to train users in the proper care and managementof a virtual patient who is diabetic. The site contains textual as wellas video clips that show various elements of diabetes self-care, in-cluding the proper administration of insulin and the correct use ofa glucometer. If the user dutifully looks after this virtual diabeticpatient, the virtual patient will thrive and the disease will be wellcontrolled. If management of the patient is neglected, the patient’scondition will deteriorate in accelerated time.The user can choose from three levels of ‘‘play.’’ The amount ofallowed deviation from stipulated criteria, such as caloric intake,decreases with increasing level of play (difficulty).To speed up the game, an accelerated 24-hour clock is used, withthe 24 hours played out in 30 to 50 minutes. There are remindersto inject insulin as well as reminders to eat regularly and not toskip meals.User input is through the insulin module and the dietetics module.Clicking on the insulin module administers insulin to the patient,whereas clicking on the dietetics module feeds the patient. The userchooses from two different menus—(a) a mix-and-match menu thatallows him to pick from basic food groups like staples/carbohy-drates such as rice or noodles, proteins, and fibers, or (b) a menuof prepared meals, including various types of fast foods and pop-ular local dishes available from food centers and canteens. As a fooditem is selected, the caloric intake for that particular meal combi-nation is registered on the screen in real time.We consider the use of the Tamagotchi concept a novel way to ed-ucate patients, and the general public, on the importance of medi-cation compliance through a gaming approach. Such virtual pa-tients help promote awareness of the importance of self-care in thetotal management of chronic illnesses.The virtual patients of the Medical Informatics Program can be ac-cessed from the MIP Multilingual health information Web site,Health ONE, at http://www.health1.nus.edu.sg.References1. Tamagotchi Link page. Available at: http://www.urban.or.jp/home/jun/tama/link.html.2. Tamagotchi Graveyards. Available at: http://www.yahoo.com/Recreation/Toys/VirtualPets/Tamagotchi/Graveyards.3. Samp J. Critical thoughts about Tamagotchi. Available at:http://www.sims.berkeley.edu/courses/is296a3/s97/Focus/Identity/Final/index.htm.4. Kay WJ. Pet Loss and Human Bereavement. Ames, Iowa: TheIowa State University Press, 1984.5. Glantz K, et al. Virtual reality for psychotherapy: from the phys-ical to the social environment. Psychotherapy. Fall 1996;33:464 –73.1. Chute CG (ed). A Paradigm Shift in Health Care Information Systems: Clinical Infrastructures for the 21st Century. Proceedings of theAMIA Annual Fall Symposium; Nov 7–11, 1998; Orlando, Fla. Philadelphia, Pa.: Hanley & Belfus, 1998.

General practice registration networks in the Netherlands: a brief report

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General practice registration networks in the Netherlands: a brief report

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