Quality assurance in gastroenterology: the Telegastro project

computer m e t h o d s and programs in biomedicine ELSEVIER

Computer Methods and Programs in Biomedicine 45 (1994) 165 169

Quality assurance in gastroenterology: the Telegastro project F.T de D o m b a l *a, O. Winding b, C. O h m a n n c "Clinical lnJbrmation Science Unit, University q/ Leeds, Leeds, UK hDepartment of Forensic Medicine, University of Copenhagen, Copenhagen, Denmark 'Abteilung fur Allgemeine and Unfallchirurgie, Universitat Dusseldorf, DusseldorTf~ Germany

Abstract The goal of this Telegastro project is to improve standards of care in gastroenterology by establishing and circulating a 'consensus' view of several aspects of 'good practice' in specific areas of gastroenterology. The background for the study is described, followed by the detailed goals of the project and the modus operandi designed to achieve these goals. Finally, the problems of implementing such a package are discussed along with progress in the first 18 months and schedules for future activities. Key words: Quality Assurance; Consensus; Telematics; Gastroenterology

i. Introduction Young doctors in the 1990s emerging from medical school face a major and compelling problem. The training course occupies a finite time. The resources for training also are finite. However, the amount to learn in order to practice medicine effectively has exploded. The total ~knowledge base of medicine' at the present time amounts to between 10 and 15 million 'facts'. A diligent student can learn and retain approximately 10 facts per hour of study. Hence, a major problem exists. The most obvious solution is to appropriately employ information science and technology. Ideally a 'core curriculum' should be available, and a further body of knowledge (an 'access curricu-

* Corresponding author.

lum') should be defined; this much larger body of knowledge could well be held on some kind of automated system, (a 'telematics package') for ready access as and when needed. To achieve such a goal, however, three positive criteria are relevant: • The package presented to young doctors should represent a consensus view of their experienced peers. • The presentation of the package should be 'honest' - - that is to say the package should accurately reflect the collective view of peers, and not attempt to claim or present artificial sets of agreements where none exist. • The package should seek to teach and guide rather than dictate to individual doctors what to do in an individual case. With this in mind collaboration has begun between the Research Committee of the O M G E and

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F.T ~h" Domhal et al./ Comput. Methods Programs Biomed. 45 (1994) 165 169

the AIM Programme of the Directorate General XIII of the Commission of the European Communities. The attractions of such collaboration were immediately obvious to both organisations. The O M G E (World Organisation of Gastroenterology) has access to an unparalleled level of gastroenterological expertise from clinicians in all parts of Europe and the rest of the world. The AIM Programme has links to virtually every major computer manufacturer and software house in Europe. The obvious and logical solution to the problems raised is for these two organisations to collaborate so that a telematics package designed and executed to the highest clinical and technical standards may be created to help young gastroenterologists.

of gastroenterology may be measured in a widely agreed, standardised and reproducible fashion; • to develop using appropriate technology, a multi-media package by which this information can be disseminated; • to distribute and measure the reaction to the multi-media package. However, a further (implicit) objective concerns the bringing together of gastroenterologists and computer scientists, thereby developing a cadre of senior clinicians who are both literate in and knowledgeable about information technology and enriching the AIM Programme as a whole.

3. Project plan 2. Objectives of project The main objectives of the Telegastro project may be stated as follows: • to develop via wide consultation a consensus view through which health care in specific areas

The overall project plan is outlined in Fig. 1. The first year of the project has been devoted to seeking consensus agreement (for specific areas of gastroenterology) concerning such matters as definitions of disease, criteria for diagnosis, criteria for assessing severity and extent of disease, mini-

OVERALL PROJECT PLAN

CLINICAL

YEAR3

YEAR ";

YEAR 1

EVALUATION

SEARCH for

ASPECTS

CONSENSUS i

COMPUTING ASPECTS

I DEFINITION of REQUI3~.~EMENTS and SYSTEMDESIGN

~ PACKAGE FINAL

PRODUCTION/ DISTIL~UTION of PROTOTYPE PACKAGE

DISTRIBUTION

J EVALUATION1

7

Fig. 1. Overall Telegastro Project Plan.

F.T de Dombal et al. / Comput. Methods' Pro,grams Biomed. 45 (1904) 165 169

m u m data-sets, performance measures, indications for high technology and surgery and so on. In the second year, as internationally agreed consensus has developed the elements have been transferred to a multi-media package consisting of computer disks, teaching video tapes, and appropriate documentation. The final year of the project will incorporate evaluation to assess the response to the package and also its effect, under the general direction of a panel of international authorities in the field of quality assurance. 4. The telematics product

The telematics product (Figs. 2 and 3) is designed for wide distribution to those without sophisticated computing equipment, and also for use by those hitherto unfamiliar with computers. It is therefore, deliberately written in simple format (technically, Q BASIC and MS-DOS 3.2 or 3.3), in order to enable usage on relatively simple ( I B M PC compatible) equipment by clinicians previously unfamiliar with computers. After switching on, the user is introduced to the system by a welcome module setting out the background to the project, the aims and modus operandi of the disk, and including briefings for

the potential user on both the O M G E and the EC and A I M Programmes. To enable further use, however, the user needs to pass a security barrier ensuring that before the use of the program the user has read and accepted the terms and conditions for use. For each clinical area, information for decision support is available under a series of headings, including such items as definitions, criteria, minimum data-sets and so on. Several further features of this product deserve mention. First, there is an educational package for each clinical area for self-testing. Next, a 'tag facility' enables each user's pathway through the disk to be traced and recorded for future analysis. Third, a "reaction' module invites the user after each episode of use to give reactions, to the advice and information made available. Finally, provision is made for linkage of this disk to other products or systems to enable collection of data by the user (such as hospital information systems). In many hospitals, no such facility for linkage of systems exists and many users may still wish to file personal data, either to conduct self-audit at a later date or to compare personal experience with other participating users in the project. For this purpose a second disk is made available for data collection King a spread sheet program and operating under DBASE II1.

THE " VIRTUOUS " C I R C L E

Disc 1

Disc 3

.omeO.l Education

167

I =.eme-t 1 I•Nrmation

Disc 2

Fig. 2. "Virtuous' circle showing interlinkage of Telegastro Project lelematics product discs.

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F.T de Dombal et al. / Comput. Methods Programs Biomed. 45 (1994) 165-169

Modus operandi of distribution (3). Distribution ] ~

[ Comfputer I

I

[ IBD ]

Information Disc

Data Collection Disc

I

I * * * * * * * *

r

J

d.ca.on D,sc

Defs of IBD [ Diagnostic Criteria Criteria for extent * Criteria for severity * ]Vfinimum datasets * Defs of terminology * Performance indicators Indications for high tech / surgery

f

I

about EC about OMGE about IBD about Ethics

I * * * * *

I

Enter / store new case Update information View data Analyse data Dump data

Fig. 3. Details of contents of Telegastro product (section dealing with inflammatory bowel disease - - IBD). Other sections for other diseases are similar.

5. Progress to date

6. The search for consensus

As of the mid-term of the project, progress has been highly satisfactory. The project is running on schedule and within budget. A total of 10 scheduled deliverables have been produced on time. As a result, prototypes of the telematics product have been developed and demonstrated (or used in preliminary fashion) in several centres in three different EC countries. Initial response has been highly favourable and more detailed evaluation is about to begin. Every relevant major supranational association (in gastroenterology or in digestive endoscopy) in the world is now associated with the project. The work to date has raised a number of issues. Some are still in the process of clarification (e.g., what is the optimal mode of evaluation, how can maximum impact be assured, can other areas of medicine be treated in the same way?): but one issue which may be unfamiliar to readers of this Journal (though vital to much related work) is the issue of seeking consensus.

This process is vital, and since it must affect other similar projects it is perhaps worthwhile discussing in detail. In some European languages, 'consensus' is translated as a universal viewpoint of those surveyed; this is not so in the English language. Any information technology product which purports to be a 'consensus' statement has, however, a number of characteristics which need to be observed. • It needs to represent the views of a substantial body of authoratitive, experienced clinicians. • It needs to represent the majority view of those who have input. • It needs to be attributable. • It needs to indicate the degree of consensus obtained. • It needs to be based (where relevant) upon data which are capable of reliable and reproducible collection.

F.T de Dombal et al. / Comput. Methods Programs Biom¢,d. 45 (1994) 165 169

G i v e n these attributes, a consensus s t a t e m e n t m a y or m a y n o t be useful. L a c k i n g these a t t r i b u t e s , it is p o t e n t i a l l y n o t only useless b u t d a n g e r o u s . T h e q u e s t i o n arises, therefore, h o w are these a t t r i b u t e s to be o b t a i n e d ? In the view o f the present project t e a m there is really no substitute for seeking the v i e w p o i n t s o f those a p p r o p r i a t e n a t i o n a l b o d i e s a n d associations. (In this respect o f course, the O M G E a n d its Research C o m m i t t e e are p a r t i c u l a r l y well placed.) A s to h o w these v i e w p o i n t s can be obtained, the only feasible solution is via an iterative process o f r e p e a t e d c o n s u l t a t i o n . It is the firm o p i n i o n o f the O M G E a n d Eur o p e a n C o m m u n i t y project t e a m s that p r o v i d i n g this iterative process is closely followed, and p r o v i d i n g the resultant s t a t e m e n t s o p e n l y distinguish between degrees o f a g r e e m e n t ( r a n g i n g f r o m universal a g r e e m e n t to no a g r e e m e n t at all), the consensus s t a t e m e n t s which emerge ( t h o u g h not perfect) represent the best estimates o f senior a n d experienced clinical o p i n i o n which can currently be o b t a i n e d . The process is suggested as a template n o t merely for the areas in the present project b u t also for o t h e r areas in the future.

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Suggestions for further reading This p r e s e n t a t i o n has necessarily s u m m a r i s e d the project a n d some issues (such as the m e t h o d o logical plan) are a d d r e s s e d m o r e fully elsewhere. A d d i t i o n a l b a c k g r o u n d i n f o r m a t i o n m a y be f o u n d in the following references: v. Dallos and F.T. de Dombal, Meeting report. Coming to terms with the information explosion in clinical medicinecan Information Technology help? Theoret Surg. 7 (1992) 51. F.T. de Dombal. O.Winding and C. Ohmann.. Quality Assurance in Gastroenterology: the joint OMGE/EC Study, Gastroenterol. Int. 5 (1992) 262 267. J.G. Williams, F.T. de Dombal, R. KnilI-Jones and M.P. Severs, Collecting, communicating and using information. The educational issues, J. Roy. (57011.Phys. 26 (1992) 385 387. F.T. de Dombal et al. Objective medical decision making: acute abdominal pain. In: Advances in Biomedical Engineering, ed J.E.W. Beneken. V. Thevenin. IOS Press 1993, 65 87. F.T. de Dombal. Mini Symposium: Towards ~bjective medical decisions with the aid of knowledge based systems, Technol. Health Care 1 (1993) 75 76. O. Winding, S.E. Clamp and C. Ohmann, Specific practical considerations: Evaluation and quality, Technol. Health Care 1. (19931 101 105.