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September 2004
“Every primary care provider will use information technology that includes electronic health records with the ability to access and communicate needed clinical information to achieve high quality, safe, and affordable health care.” – Vision Statement, AMIA Primary Care Informatics Working Group.
Introduction: The Primary Care Informatics Working Group (PCIWG) of AMIA has been developing a National Strategic Plan for Primary Care Informatics since November 1999. These efforts have produced a strategy encompassing the efforts of four subcommittees: Infrastructure, Clinical, Education, and Research. Each subcommittee contributes to the overall vision of the Working Group to promote the development and utilization of information technology to improve the quality of ambulatory patient care.
The Strategic Plan was initiated under the direction of Dr. Moon Mullins, who championed the development of a White Paper identifying the critical need for a centralized and coordinated “One Voice” for Primary Care Informatics in America. The White Paper identified important obstacles to the development of primary care informatics in the U.S., including the wide variety of primary care providers (General Internal Medicine, Family Practice, Pediatrics, Emergency Medicine, Nurse Practitioners, et. al.), sectors (civilian and military), payors, and vendors. The PCIWG concluded that without such a “voice” it would be nearly impossible to develop and implement an informatics strategy necessary to provide practitioners, and our patients, with the tools needed to improve the safety and quality of health care. It concluded with the following goals:
Following the development of the White Paper, the PCIWG leadership convened a series of planning meetings with leaders of several primary care societies to build a consortium to become the “One Voice”. Two summit meetings were held, including the American Academy of Family Practice, American Academy of Pediatrics, Ambulatory Pediatrics Association, Society of General Internal Medicine, North American Primary Care Research Group, Agency for Healthcare Research and Quality, American Medical Informatics Association, International Medical Informatics Association, and World Congress of General Practice. The first summit resulted in the development of the Vision Statement, which was subsequently endorsed by every participating organization. The group agreed to move forward as an unfunded, volunteer alliance.
The second Summit was held in Atlanta at the Spring AMIA 2001 meeting, where the group adopted its new name, the National Alliance for Primary Care Informatics (NAPCI) and established two working goals for the AMIA 2001 meeting in November: development of a White Paper on the role of the National Alliance for Primary Care Informatics, and continued exploration of funding sources for a working “secretariat” of NAPCI that could begin the actual work of planning and developing positions with the member organizations as well as with additional members to be defined (e.g. vendors, consumers, payers, government).
In conjunction with the AMIA 2001 Fall Symposium, each of the four subcommittees met to develop goals and objectives for the Working Group in support of the Vision Statement. These goals are incorporated into the PCIWG Strategic Plan presented here.
Infrastructure: The Infrastructure Subcommittee examines the state of informatics within primary care practice across the United States, including issues of funding, consensus building in primary care, and representation of informatics interests in the future directions of the American health care system. A critical function of the Infrastructure Subcommittee is the dissemination of the primary care informatics vision to all relevant interests throughout the health care system- clinicians, academic organizations, policy makers, and informaticians.
The Infrastructure Subcommittee has been the instrumental force in uniting primary care societies into the NAPCI organization. NAPCI is positioned to assume a leadership role in shaping the future of primary care informatics, and to promote a vital connection between the informatics community and the organizations which support primary care practice, training, and research. At the 2001 AMIA Fall Symposium, the Infrastructure Subcommittee reaffirmed its Strategic Plan to the following goals:
1. Publish the PCIWG’s White Paper, “Funding the Infrastructure to Support Primary Care Informatics”. This paper, as produced by Dr. Moon Mullins, makes the compelling argument for the role of informatics and is value to primary care practice.
2. Publish NAPCI’s White Paper, “The Need for Electronic Medical Records in Primary Care.” This paper is the first document developed through NAPCI. It defines the essential nature of the EMR for all future clinical care, research, education, and cost-effective health care.
3. Publish the PCIWG report on Bioterrorism. This report emerged from the PCIWG Special Session on Bioterrorism conducted at the 2001 AMIA Fall Symposium. The Special Session featured presentations from the American Academy of Family Physicians, the Centers for Disease Control, the U.S. Department of Defense, and the British Computer Society. The session reinforced the essential role of multidisciplinary primary and ambulatory care in our nation’s surveillance for chemical and biological attack, and called for the creation of a national infrastructure in information technology and development.
4. Seek funding of a secretariat through foundation grants to begin the work intensive phase of bringing to NAPCI additional primary care societies, vendors, payers, consumers and the government in the development and implementation of the infrastructure needed for an effective National Strategy in Primary Care Informatics.
5. Continue to promote the development of Information Technology and Management Standards at national and global levels.
6. Support PCIWG initiatives in the clinical, educational, and research endeavors in the context of a coordinated strategy to promote the development of informatics capacity throughout primary care practice and training.
Clinical: The Clinical subcommittee of the PCIWG exists to promote the incorporation of informatics applications to improve clinical practice in the ambulatory setting. The strategy of this group is to define the information technology needs of the practicing clinician, and to advocate for the development and implementation of tools for clinical practice. Over the course of the strategic planning period, the group has developed four goals:
1. To examine the practice of primary care in the ambulatory setting, and conduct a global “needs assessment” for information technology applications in clinical practice. The subcommittee seeks to define the “activities of daily living” (ADLs) of the ambulatory clinician. This assessment will provide a practical springboard to the creation of applications to improve practice. The present summary of primary care ADLs which the group has compiled is included in Table 1.
2. To develop and implement point of care technology to meet the information needs of practicing clinicians. The emergence of handheld and wireless computing in primary care has already begun to change ambulatory practice. A wide variety of clinical knowledge bases are available, and electronic prescribing is gaining widespread acceptance. (REFERENCES???) The Clinical subcommittee proposes to serve as an information conduit to assist in the development of point-of-care applications.
The objectives in reviewing point-of-care technology applications are as follows:
(a) To catalog and publish existing resources of clinical information;
(b) To advocate a mechanism to endorse the reliability of clinical information (“seal of approval”) for point-of-care applications; and
(c To examine the existing resources in the context of the primary care ADL’s, with the goal of defining the future information needs of the clinician in ambulatory practice.
3. To evaluate clinical vocabularies, such as SNOMED-CT, and progress toward better clinical coding strategies for ambulatory practice. There has been a long-standing disparity between clinical diagnoses and billing codes, particularly in the ambulatory setting. The presence of a strong primary care voice in the ongoing development and implementation of clinical vocabularies will facilitate improvements in coding and billing, and lay the framework for a standardized vocabulary to support the evolution of an ambulatory electronic medical record.
4. To define and communicate the essential components, features and functions of an electronic medical record in primary care. The electronic medical record (EMR) deployment on the U.S. is substantially behind that of many other countries. Many factors pose as obstacles to EMR utilization, especially in the ambulatory care setting. A number of these obstacles, identified by the clinical subcommittee, are outlined in Table 2. This list is by no means exhaustive.
The Clinical subcommittee proposes to provide a clinical voice to the EMR development process. The greatest stumbling block to the ambulatory EMR is not technological, but organizational. Primary care clinicians need to have a seat at the table in the design and implementation of EMR technology. Through its liaison with primary care organizations within NAPCI, the Clinical subcommittee will develop recommendations for vendors, funding agencies, and clinicians to address the fundamental and practical implementation issues surrounding the ambulatory EMR.
Education: The Education subcommittee of the PCIWG exists to promote the development of informatics skills across the spectrum of primary care. These educational functions directly support the PCIWG Mission Statement, which seeks to meet the needs of both clinicians and educators. Specifically, the subcommittee seeks to address the educational requirements of five groups: undergraduate medical students, primary care residents, practicing physicians, primary care faculty, and primary care informatics specialists. Specific goals of the Education Subcommittee include:
1. To establish a consensus statement on informatics competencies. The task of producing a single, comprehensive set of recommendations for the primary care arena will involve the input of organizations within each of the relevant disciplines. National organizations such as the Association of American Medical Colleges, the Liaison Committee on Medical Education, and the Accreditation Council for Graduate Medical Education have produced recommendations. (REFERENCES) Specialty-specific groups including the American Academy of Family Physicians, Society of Teachers of Family Medicine, American Academy of Pediatrics, have also defined skill sets for their own audiences. The PCIWG has recognized the need for “one voice” in primary care informatics, leading to the creation of NAPCI to bring the various groups together. In a similar vein, the Education Subcommittee recognizes the need for a unified strategy for developing and disseminating informatics competencies throughout primary care. We aspire to work through NAPCI to serve as a clearinghouse in defining informatics competencies, and to develop a body of educational resources to assist the various societies in meeting their training needs.
2. To establish recommendations for curriculum and teaching methods. Once the core competencies for training have been established, the subcommittee will devise curriculum recommendations for each level of training. Many of these recommendations will be derived from existing programs in the United States, the United Kingdom, and Australia. The curriculum will be designed to incorporate informatics training into existing primary care education, including an assessment of the resources needed to implement such training activities.
A critical element in the integration of informatics into clinical teaching and practice will be the effective modeling of these core skills by faculty mentors. Thus, a successful Faculty Development Strategy will be essential to encourage physicians in training to implement technology into their future practices. The final aim is to incorporate information management skills into the daily practice of medicine, rather than to advocate the use of technology for its own sake.
3. To disseminate these recommendations, and facilitate communication among professional and academic organizations across multiple disciplines. Interest in teaching informatics skills in primary care is broad-based, throughout undergraduate medical centers, residency programs, faculty development initiatives, and continuing education programs. Once a set of recommended competencies and teaching methods are developed, the committee envisions its role as a “clearinghouse”, where interested individuals may obtain the necessary resources and support to conduct their own programs rather than “reinventing the wheel”.
This function will be enhanced further as the Working Group develops a network of faculty and clinicians with common interests. We will seek to encourage collaborative relationships and joint projects across institutions and disciplines. The development of NAPCI as a unified voice for informatics will provide opportunities to disseminate our findings. The PCIWG Web site, and printed publications, will provide further opportunities to communicate our recommendations.
4. To evaluate the effectiveness of the informatics curriculum across the variety of primary care academic settings. The long-term vision for the Education subcommittee will involve evaluative studies of the effectiveness of informatics education. Baseline studies of informatics competencies, and comparative studies of curricula between institutions will document its benefits and lead to ongoing curriculum improvements. The multidisciplinary focus of the PCIWG and its clearinghouse functions will lend themselves to collaborative opportunities among multiple institutions.
Research: The Research Subcommittee serves to propose, encourage, support and help with the dissemination of research activities that lead to the discovery of new knowledge that supports the practice of primary care.
A central theme of the strategic plan is to think about research with an eye toward primary care:
1. How do we ensure that the findings of other research projects generalize to the world of primary care?
2. Given the unique aspects of primary care practice, what areas of discovery are needed specifically for this domain, and how do we ensure that these areas are being addressed?
The research strategic plan complements the clinical and educational plans of the Working Group. For example, PCIWG’s involvement in SNOMED CT represents an attempt to enlighten and educate standards-developing bodies about the unique requirements of primary care. Where unanswered questions arise, such as “how robust is SNOMED for representing psychosocial problems?” these questions should be endorsed and supported by the PCIWG’s research agenda and plans. The Research Subcommittee has formulated four major goals:
1. To promote funding for Primary Care Informatics Research. The Research Subcommittee proposes to support research funding by identifying and publishing a list of current resources, and advocating new support from vendors, foundations, academic institutions, and government. Further, the Subcommittee will explore mechanisms to develop a seed funding program for primary care informatics research projects.
2. To define the Primary Care Informatics Research Agenda. A great deal of the primary care research infrastructure is undeveloped. The subcommittee proposes to develop a white paper on the infrastructure necessary to support primary care informatics research.
A second White Paper will be developed to address the research agenda needed to improve primary care through information technology. This paper will be developed using the Friedman 4-level framework: model formulation, system development, system deployment, and evaluation.
In order to follow through with the development of the primary care research agenda, the subcommittee will create partnerships with professional organizations, funding agencies, and vendors. These partnerships will address both the national and global needs and explore opportunities to collaborate on multinational projects through the International Medical Informatics Association (IMIA) and other primary care informatics societies from around the world.
3. To support Informatics Research and provide a primary care perspective. Many of the research activities throughout primary care interface with the informatics commmunity. We will seek to collaborate with the North American Primary Care Research Group (NAPCRG) on their requirements and resources for primary care informatics projects. Opportunities for collaboration with practice-based research networks will also be explored. Practical projects, such as EMR usability studies, are another potential area for collaboration between the primary care clinical and informatics communities.
4. To disseminate results of Primary Care Informatics Research. The PCIWG has already enjoyed a measure of success in establishing a presence at the AMIA Symposium. The subcommittee aspires to increase that presence by encouraging broader representation in panels and presentations. Additional dissemination of primary care informatics research will be pursued through IMIA, through a proposal to establish a Yearbook section for primary care informatics.
An exciting development in primary care informatics is the emergence of the global Journal of Primary Care Informatics. The Research Subcommittee will adopt this international journal as a mechanism to foster communication and enable collaboration in research.
Discussion: The field of primary care informatics is at a crossroads in its development. The U.S. Health care system lags far behind many other nations in its ability to employ information technology in the ambulatory care setting to provide coordinated and cost-effective care to the population. AMIA, and particularly the Primary Care Informatics Working Group, is in a position to have a meaningful influence on the development and implementation of informatics systems to correct this deficiency.
The PCIWG has adapted a coordinated strategy to promote the growth of informatics through developing infrastructure and facilitating clinical applications, education, and research. The key component to this strategy is consensus building with the influential organizations supporting all the primary care disciplines. The creation of NAPCI represents a significant first step in this process. Once the Alliance is established and funded, NAPCI should create the momentum to carry out the goals and objectives presented here.
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