B10:    Standardisation, structure and exchange of information in primary care: the aim of clinical coding

Marc Jamoulle MD. General Practitioner "Collectif de Santé de Gilly-Haies", Researcher in Primary Health Care, Member and co-founder of "Médecine de Famille et Soins Primaires (ESP/ULB)" (Belgium), Nick Booth MD. Centre Director: Sowerby Centre for Health Informatics, University of Newcastle upon Tyne (UK), Robert Bernstein, Associate Professor, Department of Family Medicine, University of Ottawa, Head: Medical Informatics Research Group, Co-Chairman and founding member of the Institute for Primary Care Informatics (Canada)

Target level: INTERMEDIATES

Electronic patient record (EPR) based health information system in clinical care needs standardization and classification of gathered data in order to be able to manage clinical care and quality assurance process at the point of care. Moreover the data should have a timeline related structure and be exchangeable between the various provider and fields of health care delivery

As the main work field of the authors of this tutorial is General Practice/Family Medicine, they would address the information process in this discipline. As family doctors care for more than 92% of the patient's health problems, medical informatics in GP/FM is clearly central to the general Health Information System

The tutorial will address the following EPR related concepts:

• terminologies

• classification processes (including ICD-10, ICPC-2)

• encounter and episode structure

• aggregation

• continuous morbidity registration systems

The participants would be able to understand the main concepts and share experiences in the fields of terminologies, classifications (ICPC/ICD/Read/SNOMED-CT), coding, transcoding, automatic transcoding, standardization, structure and exchange of clinical health data as well morbidity and co morbidity.

The tutorial would address the way the clinical data could be gathered through Continuous Morbidity Registration System (mainly in Europe) with feedback to the dispensator, including the problem of the data quality and the various ethical issues concerned by such operational projects.