Health Information Management: Integrating Information Technology ...

28 STARTING POINTS
organizations established a special taskforce on automation in general
practice. This taskforce was to lead the automation of the GPs practices.
The GP organizations explicitly aimed at developing an information system
that would benefit the entire profession, and that would develop into a
comprehensive General Practitioner Information System (GPIS) (including
financial administration, but also a fully fledged EPR).
Initially, however, the efforts of the automation taskforce were primarily
geared towards the automation of financial transactions, because in this
area the practical gains seemed most obvious. Bills ‘which otherwise had
to be produced at night and over the weekend’ no longer had to be
handwritten, but would be produced by the computer more or less
automatically. This would save much time and free general physicians from
doing boring clerical work (Esch, LHV, personal communication).
From the beginning, however, the so-called ‘medical module’ of GPIS
was also an important focus of attention for the professional organizations.
User groups were established to ensure the continuity of both the software
and the contacts with the software producer, while the automation
taskforce took the initiative to write a Reference Model in which the basic
requirements of a GPIS were formulated. The addresses where bills were
to be sent to had to be unambiguously clear, it had to be possible to include
the patient’s medical history, and it had to be possible to mark individual
records with the electronic equivalent of the ‘coloured tabs’ they had used
for their paper records. Following Lawrence Weed, the patient record was
to be problem oriented. This meant that all data, action plans and progress
notes were to be organized around the problem(s) of the patient rather than
kept in mere chronological order (or, as in hospitals, by organizational
function).
On the basis of the first and later developed Reference Models, the
existing software packages were tested and certified. The GP association
commissioned a report on the projected quality improvements GPIS would
have for its members and the health insurance companies. After its
assessment of the report, the Dutch government decided to provide a
subsidy to general physicians who purchased a certified GPIS as of 1 July
1991.
Part and parcel of the problem oriented record was the SOAP structure
(Subjective, Objective, Assessment, Plan), according to which the GP
should categorize his entries. In addition, entries like ‘diagnosis’ and
‘medication’ could all be coded. This structure was meant to discipline a GP
to treat each problem or symptom according to the same procedure and
register data accordingly; structured data were required for research
purposes, but also to afford basic functionalities such as allergy warnings
and so forth.
In practice, however, much of the record consists of free text entries.
There are great variations between practices as to what extent they