Two Cheers for Ecology

Kerr L. White

doi:10.1370/afm.50

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A Fourth Cheer for Ecology
Esko A. Kalimo

Published on: 15 August 2003
Correction of Copy Editing Error
Kurt C. Stange

Published on: 06 August 2003
Correction of copy editing error
Kurt C. Stange

Published on: 02 August 2003
Cheers for Kerr White, tears for US family practice
Henk Lamberts

Published on: 31 July 2003

Published on: (15 August 2003)
Page navigation anchor for A Fourth Cheer for Ecology
A Fourth Cheer for Ecology
Esko A. Kalimo, Professor
Other Contributors:
The Author brings up a number of critical points in the improvement of health information systems. As a starter he offers the following recipe “the overall health information system urgently requires a 21st century conceptual vision, framework, or schema”. This basic stand cannot be stated more clearly. The health information systems are too often derived in terms of the health care systems that are used to provide at...
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The Author brings up a number of critical points in the improvement of health information systems. As a starter he offers the following recipe “the overall health information system urgently requires a 21st century conceptual vision, framework, or schema”. This basic stand cannot be stated more clearly. The health information systems are too often derived in terms of the health care systems that are used to provide at least a part of the data. Yet, a thorough systemic understanding of the interplay of the essential elements in the social functioning of the health care systems is then an indispensable prerequisite.
From the European point of view the use of the word “ecology” in the context of the article requires a brief comment. As the Author points out, Webster’s dictionary defines ecology as “ the totality or pattern of relations between organisms and their environment”. From the point of view of American usage, the choice of the term “ecology” is correct, even more so, as it emphasizes a strong focus on the entirety of relations within a system. On the other hand, the British Oxford dictionary defines ecology as “the branch of biology concerned with the relations of organisms to one another and to their physical surroundings”. The European usage of this term involves a natural science orientation. It may be questioned, whether the biological paradigm may be hidden even in the American usage of the term “ecology”. If this is so, it may have slowed down the development of health information systems, as health care actually is a social phenomenon - with biological and other natural science elements.
The selection of the science paradigm has often crucial repercussions. In the natural sciences, also usually in medicine, new findings nullify totally the earlier ones, and the life span of the findings is often short. In the behavioural or political sciences based studies on health care related issues new findings do not typically nullify the earlier findings; these only become old fashioned and are forgotten. In this perspective, the Author refers to some conceptual models, methodological solutions and empirical findings that were published about thirty years ago. It seems that these scientific contributions - that may be quite relevant to the further development of health information systems - are examples of such interdisciplinary studies that have been considered old fashioned and become forgotten, perhaps unnecessarily.
The Author stresses the usefulness of WHO introduced international classifications in the development of health information systems. It is worthwhile to also refer here to the WHO International Classification of Functioning, Disability and Health to classify the functioning, health and disability of people across the world. This ICF is another tool to help develop health information systems in an internationally coordinated manner, since it has been accepted by 191 countries as the international standard to describe and measure health and disability.
The views claimed by the article are also most welcome with a view to European discussions on the improvement of health information, when the concern relates to the care of the health of individuals and the associated health policy arrangements - and not only to the diagnosis and cure of a disease.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (6 August 2003)
Page navigation anchor for Correction of Copy Editing Error
Correction of Copy Editing Error
Kurt C. Stange, Editor
In the penultimate paragraph of Dr. White's editorial, the citations for the last sentence, "Unmet need was a more important determinant of hospital use than the availability of beds.” should be references 16 and 17 (not 17 and 18). We apologize for our error and will publish a full erratum in the next issue of Annals.
Competing interests: None declared

Competing Interests: None declared.
Published on: (2 August 2003)
Page navigation anchor for Correction of copy editing error
Correction of copy editing error
Kurt C. Stange, Editor
The previous commentator, Henk Lamberts, has identified an error in the editorial by Dr. White. This error was introduced during the copy editing process. The editorial currently states that "The International Classification of Primary Care, available for 2 years, is used widely in Europe but much less so in the United States." It should state "The International Classification of Primary Care, available for nearly 25...
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The previous commentator, Henk Lamberts, has identified an error in the editorial by Dr. White. This error was introduced during the copy editing process. The editorial currently states that "The International Classification of Primary Care, available for 2 years, is used widely in Europe but much less so in the United States." It should state "The International Classification of Primary Care, available for nearly 25 years, is used widely in Europe but much less so in the United States." We regret the error, and appreciate Dr. Lamberts' vigilance. Kurt Stange, Editor
Competing interests: None declared
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Competing Interests: None declared.
Published on: (31 July 2003)
Page navigation anchor for Cheers for Kerr White, tears for US family practice
Cheers for Kerr White, tears for US family practice
Henk Lamberts, Professor of General/Family Practice
White is absolutely right: there is very little to be cheerful about if one wants to understand how individuals in the US perceive health problems, how these are interpreted by family doctors, and what happens over time during episodes of care that have been correctly labeled and classified. The famous publication of the comparative WHO study by Kohn and White (1976) still outshines any ecology of health care study in th...
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White is absolutely right: there is very little to be cheerful about if one wants to understand how individuals in the US perceive health problems, how these are interpreted by family doctors, and what happens over time during episodes of care that have been correctly labeled and classified. The famous publication of the comparative WHO study by Kohn and White (1976) still outshines any ecology of health care study in the US till now.1 Although MEPS is important for the US, both its small size and its inherent coding problems make it close to impossible to effectively take the patient’s problem as the starting point, and to develop an episode of illness and an episode of care model. White rightly castigates the Health Secretary for choosing Snomed-CT as the standard vocabulary for the US, because it can greatly harm the family practice perspective in health information systems that will be introduced on a large scale in the near future. As easily as the wrong classification has been consistently chosen in the US, now an architecture for an electronic health record (EHR) can be put in place that completely disregards the central role of primary care. In the next few months, two decisions will be crucial for the development of the US EHR: will the EHR focus on episodes of care of individuals, and will it allow the use of ICPC through a reliable mapping of the diagnostic concepts in Snomed-CT to ICD-10?2 If nothing is done by the family practice community, it is quite likely that a logically structured primary care oriented documentation starting with the patient’s complaints and concerns, giving precedence to the patient’s problem over the interventions that occur will be out of reach. If the practical utility of the expected avalanche of provider and intervention data collected with Snomed-CT is similar to that of the Read code data from the UK, the curtain will fall for family practice research with routine EHR data.3 The possibility to retrieve information from real life family practice that can support the role of family practice depicted in the 1996 IOM Report on the future of primary care in the US will then dissipate. Kerr White, Maurice Wood and I go back for over 25 years in our joint unwillingness to take no for an answer when family practice research needs support.2,4 I find it increasingly puzzling that US family practice still takes blow after blow practically lying down.
References 1. Kohn R, White KL. Health Care: An International Study. Oxford, England: Oxford University Press, 1976. 2. Lamberts H, Wood M. ICPC International Classification of primary Care. With a Historical preface by K.L.White. Oxford, England: Oxford University Press, 1987. 3. Brown PJB, Warmington V, Laurence M, Prevost AT. Randomised crossover trial comparing the performance of Clinical Terms 3 and Read Codes 5 byte set coding schemes in general practice. BMJ 2003; 326:1127-30. 4. Lamberts H, Wood M. The birth of the International Classification of Primary Care (ICPC). Serendipity at the border of Lac Léman. Fam Pract 2002;19:433-5.
Competing interests: None declared
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Competing Interests: None declared.