by Stephen Kay, Ph.D.
Introduction
This paper reports on a method for facilitating progress and
achieving consensus in the contentious area of clinical
terminology. The process was facilitated by management
consultants, but the model of consensus that took form during the
meeting emerged from the participation of the individuals
present. The outcome could not have been predicted at the outset,
but the process succeeded in achieving an unlikely result: an
agreed, shared vision on terminology for primary care.
A successful meeting, "Moving Toward International Standards in
Primary Care Informatics: Clinical Vocabulary," was held on
November 1 and 2, 1995, in New Orleans, after the American
Medical Informatics Association (AMIA) Fall Symposium. The
meeting focused on the value of clinical vocabularies,
specifically from the viewpoint of primary care, as practiced
throughout the world. Issues of clinical terminology and four
specific concept representation systems were considered over a
2-day period.
The group met under the auspices of the AMIA Family
Practice/Primary Care Working Group and Working Group V of the
International Medical Informatics Association (IMIA). It
comprised 79 participants from 9 nations around the world. This
paper gives an early impression of what happened during that
meeting. It is an informal commentary meant to complement the
more formal proceedings.
In particular, this paper introduces what the author has called
"The Mississippi Model of Consensus."
Agenda, Participants, Structure, and
Process
The meeting took place from 3:30 p.m. until late on the first day
and from 7:30 a.m. to midday on the second day. The first day was
focused on dissemination and education, and the second day, on
consolidation and agreement. Both days were integral to the
process of achieving consensus.
The early part of the agenda on the first day gave an opportunity
for a number of presentations. The first was a general
introduction, which prepared the way for 12 15-minute intensive
presentations on specific concept representation systems. The 12
presentations were arranged in sets comprising 3 parts: an
overview, critique, and application. The systems reviewed were
the International Classification of Primary Care (ICPC), Read
Codes, Systematized Nomenclature of Human and Veterinary Medicine
(SNOMED), and Unified Medical Language System (UMLS). The choice
of systems was not exhaustive. Other approaches, most notably
GALEN (Generalised Architecture for Languages, Encyclopaedias and
Nomenclatures in Medicine), were omitted because of meeting time
constraints.
The attendees were expected to participate actively throughout
the two days. It is useful to characterize these participants as
four distinct parties: the presenters, the audience, the
consensus panel, and the coordinators. The presenters, who
assumed the role of "system champions," naturally formed the
first party. The second party comprised the main audience. On the
first day, their role was essentially a passive one of listening
and learning more about each system. At the end of each
presentation set, members of the audience were encouraged to
question the presenters, express their opinions, and clarify what
they had heard. In this respect, their role was identical to that
of the third party, the consensus panel, except that the panel's
primary task was to summarize both the output of the
presentations and the resulting discussion of each system. The
coordinators, who made up the fourth party, were charged with
making the process of the meeting productive. The fourth party
comprised the chairs of the meeting; those presenting an
international survey of clinical vocabulary usage in primary
care; and the two facilitators.
The facilitators retained their role throughout the proceedings.
All the other participants of the meeting forsook their first
role to be organized into seven groups on the second day. Small
groups considered the summary paper from the consensus panel
produced at the close of the first day.
One useful innovation of the meeting was the employment
throughout the proceedings of a stenographer, who recorded
verbatim the spoken content of the meeting. The text was made
available immediately as a modifiable ASCII file. Not only did
this permit a faithful record of the event for the production of
the proceedings, but it also permitted the consensus panel to
accomplish its business before the start of the second day.
Consensus Panel
The five members of the consensus panel were preselected. The
principal selection criterion was a reputation for impartiality
rather than domain expertise; they, too, were expected to learn
from the proceedings. The main meeting finished at 9:30 p.m. on
the first day, and the panel continued its work until after
midnight.
The facilitators, after initial discussions with the panel,
decided on a trial format for producing the report. This was
adapted again once the presentations were completed and became
the final template for the panel's report. The purpose of the
report was to gather and structure the material from the sessions
on the first day. Its completion signified the finish of the
business of the first day.
During that first day, each panel member was given a specific
task: four had the responsibility of focusing on a particular
system, and the fifth member was primarily concerned with the
wider context. After the other participants retired, the panel
met to produce its initial summary report, which was to be an
interim document to be used as input for the second day.
The report had as its central components a "framing issue," in
which the raison d'etre for the meeting was expressed; a
"vision," which looked at the long-term goal of the meeting; a
list identifying the "critical elements" of a controlled
vocabulary, as it emerged during the first day of the meeting;
and a resume of the strengths and weaknesses of each of the four
systems presented. Deliberately, no value judgments were made as
to the best system, but UMLS was singled out as being distinct
from the other three.
Consensus Development
The formal proceedings of the second day began at 7:30 a.m. After
a brief introduction of the interim document, seven discussion
groups of approximately equal numbers were formed to discuss and
modify it. Each group had a chairperson and a rapporteur. At
midmorning, the entire meeting reconvened to discuss each group's
changes to the summary document. The facilitators asked each
group in turn for its response and modified the document online
to reflect the input. The facilitators then asked the audience to
consider the amended text and affirm whether the consensus of the
meeting regarding the modified component was high, medium, or
low.
The purpose of this paper is not to consider the entire
proceedings but rather to focus on the statement of vision.
Development of the vision statement illustrates the process in
action and the character of the meeting. In describing this
process, the author considers a model of consensus that seemed to
emerge from the meeting.
Mississippi Model of Consensus
During the meeting, a participant expressed his frustration at
being given a "hose pipe" when all he actually required for his
clinical practice was a "water fountain." The author subsequently
developed this water metaphor in the meeting. It is expanded here
to incorporate both the micro and macro processes of accepting a
common clinical controlled vocabulary. Hence, the Mississippi
Model is one that maps the natural development of a river by
maturity stages to the development of consensus during the
meeting and beyond.
The meeting started with distinct and separate streams. Remote
from each other, these rushing streams at least seemed to have a
common direction—down. At this early stage, however, there
was
no evidence of convergence or consensus. Rather, there was
considerable distance between the streams. A barrier was created
by the champions, who were perceived as being competitive and out
to convince the audience of the virtues of their preferred
system. There was a common belief among the audience that the
sole object of the exercise was to declare and recommend an
outright winner. The futility of this course became clear, and
sadly, there seemed little hope of any profitable outcome from
the meeting.
As the meeting continued, however, the discussion of the distinct
streams came together by effectively focusing beyond them, on the
clinical requirements of the audience. To allude to "water
fountains" and "hoses" was at least to acknowledge the valuable
existence of the streams, that drought conditions had passed, and
that mechanisms for controlling and directing the flow were now
appropriate so as to prevent drowning and/or wastage. This
"mature stage" of development came about only because the
audience
had, in general, been given sufficient insight from the
presentations to be able to debate the subject of controlled
vocabularies in a reasonable manner. Admittedly, the course of
the discussion meandered, and the streams were still identifiable
as separate entities. However, at least one could now imagine
them as being tributaries of the same broad river, rising from
different sources certainly, but eventually contributing to a
main stream flowing in the same general direction.
The next stage of development involved reaching consensus on the
framing issue and vision. The framing issue was broadened to
recognize that primary care is not an isolated island,
independent of what else might happen to the patient. Not
surprisingly, given the subject of the meeting, there was a high
level of consensus concerning the framing statement. The
progression of the following vision statement is more
interesting, as it made the participants question the assumptions
that had been implicit in the framing issue.
The initial vision statement read:
"Our vision is for
primary health care providers to
easily
and
accurately record all patient information in such a manner that
the information collected will be comparable to information
collected elsewhere in the world."
The clinicians present at the meeting were focused on what could
be achieved in their daily practice and for the patient before
them. The framing issue had two parts that were not obviously
correlated: how was the development of international consensus
likely to benefit the local situation? The initial vision
statement centered on the effective recording, understanding, and
sharing of information, and ultimately, the benefit to be gained
from comparing clinical data across "fading boundaries (1). "The
advantages to be gained were seen as involving long-term research
and epidemiology, the benefit of which would only eventually
cascade back to practice. However, primary health care providers
are pragmatic, preferring immediate gains to future promises.
This is not to say they are not academic or interested in
research; they are. They felt the vision as expressed was
necessary but not sufficient for their specific purposes. Their
fading boundaries are different. At a routine level, such
boundaries typically exist between different types of clinicians
involved in primary health care, and they require a direct focus
on the subject of care at a point in time. The clinicians also
believed that their current practice should be used to shape the
form and content of the vocabularies; they did not want to
passively accept what they are given.
The revised vision statement read:
"Our vision is for
primary health care providers to record data
about patients easily and accurately at the point of care in such
a manner that clinically relevant information is available for
the primary purpose of supporting the care of individual
patients. Additionally, this information should be comparable
with information collected elsewhere in the world."
The changes to the vision statement also represent the tension
between the service-oriented and research-oriented aspects of
primary care. The revised statement reflects the need for both.
As the collaboration process continues, the revised statement may
undergo further changes before being published. It may, for
instance, be changed to reflect some of the following common
beliefs that were voiced: that the vocabulary for primary care is
the core from which others then specialize; that patient focus is
essential; and that health and morbidity are preferable to
mortality as starting points for describing our common condition.
Discussion
The "old age" stage of consensus development was not reached in
the meeting, as lack of time precluded the process for completing
the full program. Perhaps this is symbolic. It would be wrong to
believe or assume that we had finally "arrived." It would also be
wrong to claim too much from a relatively small meeting of
collected enthusiasts.
The sea awaits the outcome. In this analogy, the sea is the whole
terminological domain and debate, which is, of course, much
deeper, wider, and bigger than the Mississippi. Without doubt,
navigation will remain an issue for many years. There is still a
considerable distance to travel to the sea, and the precise route
has yet to be determined. It is clear from the meeting, however,
that one of the world's biggest rivers is ultimately heading for
the sea, and that the sea would be well advised to make itself
ready to accommodate the volume and disturbance inevitable from
such a significant and broad outlet.
Reference
- Hammond WE, Bakker AR, Ball MJ,
editors.
Information systems with
fading boundaries. Proceedings of the International Medical
Informatics Association Conference, Working Group 10 Conference;
1994 Aug 27-30; Durham, NC. International Journal of Biomedical
Computing, Elsevier Science; 1994.
Acknowledgments: To all at the meeting, particularly Moon
Mullins
and Bob Price for initiating events; Nancy Lorenzi and Bob Riley
for facilitating the process so effectively; and colleagues on
the consensus panel—Bob Elson, Philip Hagen, Mike Hagen, and
Michael Kidd.
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