Towards the semantic annotation and the prevention of the loss of information of second opinion requests from rural Brazilian primary healthcare providers: the Q-codes use case – a work in progress

Objectives. To support documentation, various terminologies have been created to assist in this activity. Only a few terminologies cover the General Practice / Family Medicine (GP/FM) domain (e.g., the International Classification of Primary Care - ICPC). As ICPC fails to capture some non-clinical issues (e.g., organizational and managerial aspects), the Q-Codes taxonomy has been developed to extend ICPC, encompassing those contextual professional issues. The aim of this work is to show the value of Q-Codes in preventing loss of information through the semantic annotation of Second Opinion Requests of rural Brazilian primary healthcare providers. Methods. Question-answer pairs for the years 2010-2012, in the Brazilian-Portuguese language, was obtained from an urban telehealth center. Each selected question was read to determine its semantic meaning, and coded using both the ICPC and Q-Codes classification systems. Based on this meaning, each question was manually assigned between 0 and 5 Q-Codes. Results. The majority of Q-Code assignments were almost equally split between the Patient's Category", QC (42%) and the "Family Doctor's Issue", QD (37%) domains. Domain QT, that is "Knowledge Management", covered 21% of the assignments, while a single assignment was made to the domain QP, “Patient Issue”. Six of the top 10 Q-Codes assigned belong to the cited QC domain, 3 to the QD, and 1 to the QT domain. Discussion. Analysis demonstrates that lost information represents age (QC), health prevention (QD), and medical education (QT). Medical education is one of the reasons that the telehealth system was implement, while age and health prevention are important to providing healthcare in Brazil. Conclusions. Preliminary results show that Q-Codes capture information that otherwise would be lost in the case of using only clinical coding systems such as ICPC.