Download Quality improvement * Quality data leads to quality connections:

Slide 1
Supporting Early Diagnosis in cancer
in primary care
Improving GP Coding&Safety Netting
The key to quality data with quality outcomes in cancer
and beyond.
Dr Afsana Bhuiya
Macmillan GP Improvement Lead
LONDON CANCER
Contact: [email protected]
*London 5 year cancer commissioning strategy
Slide 2
Early Diagnosis
The Problem:
•
Cancers are not being diagnosed early enough in primary care.
•
Emergency presentations of cancer up to ¼ - lung and colorectal most common.
•
It can be difficult to differentiate early symptoms of a cancer – up to 50% of cancer
patients in UK seen in did not have NICE symptom suspicious for cancer (Neal et al
2014 Bjc). Non-specific symptoms rather than RED flags.
•
Significant disease but relatively uncommon.
•
Two week wait referrals have a 10% conversion rate (lower in London) – this is going
down – as more GPs refer since new guidance.
Why does it matter?
•
Better outcomes, survival and patient experience.*
•
NICE guidance June 2015
What are the DRIVERS for early diagnosis in a primary care surgery?
*London 5 year cancer commissioning strategy
AIM:
Patient Factors
General Practice
Increase early
diagnosis in
cancer
Doctor
Slide 3
Community Team
Community
Public Health
Lack Of knowledge
Appointment
system
Consultation :
Time and Priorities
Practice Nurse
Knowledge
Screening
Fear/Denial
Access
GATE KEEPER
function
HCA
Stigma
Awareness
campaigns
Language Barriers
IT systems
Complex patients
Community
Matron
Consultation
behaviour: hidden
agenda
Different GPs/lack
of continuity
Consultation style
– not eliciting the
correct symptoms
District Nurse
Cultural factors
Safety Netting
styles/systems
Information
documented –
CODING
Coding&Safety Netting
KEY AREA IDENTIFIED FOR QUALITY
IMPROVEMENT
Slide 5
Why?
Good standards in Coding and Safety-Netting enhances patient safety by having the most upto-date, relevant and connected information about your patient at your fingertips,
regardless of how long you have known them.
This quality improvement initiative would lead to more meaningful results from risk
assessment tools, like QCancer. Together, these processes will reduce misses, lead to
earlier cancer referrals and early detection, as well as improved screening and care for
patients who have survived cancer.
There are no agreed guidelines/standards for coding or safety netting and there is little
agreement on how to interpret or apply safety netting. No formal training for GPs for
coding/using computer systems.GP VTS trainees do not have standard teaching on this and
it often depends on their individual trainers knowledge.
The aim of project was to develop primary care coding and safety netting standards, to educate
GPs on effective coding and to support them in applying tis change.
The quality of input – determines the quality of the output.
Slide 6
Coding in Primary care
Most patient contact is recorded in a consultation electronically and can be written
coded as it is entered.
The Read Code system was developed in the early 1980s by Dr James Read (who
was a GP in Loughborough) to handle the problems of recording
information in a way that could be retrieved from the computers available
to GPs at the time. In 1989, the importance of the system became clear and
the number of codes rapidly expanded, it was purchased by the NHS Executive
for further development.
Letters, correspondence, investigations and other contacts (appointments, tasks etc)
are integrated in the same interface and can be coded.
Slide 7
What is Safety Netting?
The term ‘safety-netting’ was introduced to general practice by Roger
Neighbour – central to GP consult.
A process where people at low risk, but not no risk, of having cancer are
actively monitored in primary care to see if the risk of cancer changes.
Safety Netting can go wrong! little agreement on how to interpret or apply
safety netting.
Good safety netting is dependent on good continuity of information and
record keeping/coding.
NICE guidance July 2015 and the cancer task report both highlight the need
for rigorous safety netting. And this in turn is dependent on continuity if
records and good record keeping.
Slide 8
GP SURVEY
Slide 9
Slide 10
Where are we now?
What is coding and safety netting like now?
The three major systems are: EMIS WEB, SYSTEM ONE, VISION.
CODING AND SAFETY NETTING practices are immensely variable from
practice to practice and system to system.
CANCER RISK ASSESSMENT TOOLS like QCANCER may help minimise the
risk of not thinking of cancer, BUT these rely on correct information
being CODED! If relevant data isn’t coded then the risk calculator will
not know it exists.
NICE NEW URGENT CANCER GUIDANCE (July 2015) – the referral criteria
has changed and is much based on ‘softer’ symptoms – not just RED
flags (too late). Hence importance of recording these symptoms and
safety netting in a systematic/stringent manner.
Improve the quality
CODING & SAFETY
NETTING
GP – the clinician
Attitude to coding
Practice
Organisational
systems
GP2GP
Competence in coding
The SOFTWARE
chosen to use ie. Emis,
system one, vision
Coding outside QOF
Risk assessment tools
– QCancer – integrate
to systems
Understanding of
SAFETY NETTING
Read code limitations
eg. Cancer stages or
dx
Clinicians IT
competences
Surgery structure eg.
Who codes?
GP type –
Partner/Salary/Locum
DOCMAN –
implications of
intellisense coding
SUMMARISING of
notes for new patients
– rules/guidance
Information
dissemination for
non-partners.
GP
Curriculum/RCGP
CCG
Slide 11
Health professional
Hospital Systems
Coding in curriculum
Support practices with
training
Nurses attitude
Radiology eg. Cxr
missed
Safety Netting in the
curriculum
Ensure information is
available to all
clinicians eg. locums
HCA role
Pathology lab eg.
Abnormal results
Wider community
professionals eg
Comm matron
InHealth or other
subcontracted
companies
Slide 12
The STRATEGY
CODING AND SAFETY NETTING
SET A STANDARD OF GOOD
CODING PRACTICES
Slide 13
•
PROBLEM CODE all consultations – obligatory. Relevant. Symptoms.
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Utilise SYMPTOM CODES more
•
SYMPTOM code within a consultation
•
Ensure problem title codes are subcategorised or linked properly – eg.
CANCER diagnosis remain and ACTIVE problem INDEFINITELY.
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Code FAMILY HISTORY, SMOKING, WEIGHT
•
Safety net codes – fast track cancer refs, follow up, advice issued, checking
contacts details.
•
SCREENING coding – Cervical, Breast, Bowel
•
Use QCANCER risk assessment tool to aid decision making.
•
Living with cancer and beyond – code cancer treatment and side effects.
Slide 14
Case Study – Problem title/coding
• 64 year old lady seen for left shoulder pain for 1/12 – no trauma. Painful to move,
but on o/e – gen bit sore – GH OA?
• Patient recently joined the surgery. No other significant history seen on significant
problem list. Ex-smoker. Due to see nurse next for her ‘new patient screen’
• Sent for XR of shoulder and analgesia given
• Report: Abnormal apical shadow in the left lung!
• GP arranges an urgent recall of the patient to discuss the results.
• The GP reviews the hx – fortunately GP2GP notes have come through:
•
•
•
•
Seen by several different clinicians in the last 12/12. ‘e’ appointments.
Notes were v. difficult to follow as consultations had not been problem coded, many
generic symptoms at different times.
Seen by nurse 6/12 ago and had a cough – with flecks of blood once – haemoptysis
wasn’t coded. CXR was requested but not followed up.
Breast cancer was documented in one consult – the problem list checked – and it has
been coded as ‘minor – past’ problem!
Slide 15
Case Study:
Commenting on screening/recall/docman coding
• A 70 year old man, non frequent attender, completed a bowel screen – which was
ABNORMAL. The result was commented on appropriately in path links by the
clinician. As FOBt was abnormal, he was offered a bowel screening nurse
appointment and advised to have a colonoscopy.
• The GP was notified of a DNA for the colonoscopy – no code was applied through
docman. No action was taken.
• 8 months later – seen locum – non specific tiredness – nil else. Routine blood tests
were requested.
• Lab telephoned through results – VASTLY ABNORMAL – microcytic anaemia, low
ferritin and a raised Hba1c – at 6.30pm. The regular dr arranged an urgent face to
face consult the next day.
• Plan – FAST TRACK LOWER GI CANCER ref made
• Lesson – coding standards for the practice – who and what.
Slide 16
Case Study: Wasting resources/time
• A patient with known myeloma was seen by a locum in clinic for a minor
illness.
• The patient had her recent blood test results as the last recorded
information and all were commented on as – ‘abnormal – speak to dr’
• The locum seeing the results did an FAST TRACK CANCER ref.
• Few weeks later a letter was received from a confused Haematologist
asking why a patient with known Myeloma (stable disease) being
referred.
• Myeloma was NOT coded anywhere. The letters from the haematologist
were not coded.
• Lesson: Problem coding imperative. Appropriate pathology commenting –
‘known myeloma’ or ‘consistent with known disease’. Why did the patient
not know?
Slide 17
QCancer RAT
Video – demo on how to use:
https://www.youtube.com/watch?v=p_elWswIeNo
https://www.emisnug.org.uk/using-cancer-symptom-checker-emis-web
RAT – risk of current cancer undiagnosed cancer. Not cancer dx.
Access – Templates. View Individual risk.
Why - uncertainty
What % is relevant – no clear consensus. 3% threshold.
Evidence: gets the GP thinking more about the diagnosis of cancer – further
evidence needed re changes on early diagnosis rates.
SAFETY NETTING
Slide 18
Slide 19
Stages of Safety Netting
BROADLY DIVIDED INTO:
GP/Patient
System Processes
Practice/Hospital
Slide 20
Stages of Safety Netting
Stages of safety-netting
1.At the first consultation
2.With the same problem
3.Investigations
4.Communications with the hospital
5.Referrals
6.Follow-up of patients
7.Locums and Leave
8.Proactive Safety-Netting
Case Study:
Safety Net, High Risk
Slide 21
45 year old Somalian man seen by your colleague for knee pain. He had requested an XR. You
receive an urgent fax reporting a likely bone sarcoma! The fax was slightly odd as it did not
on heading paper and did not say where it came from. But the radiologist name was at the
bottom.
What do you do now? What could have done in the first consult?
Confirm the result. We rang the patient. Then his wife. Then any other family member at the
address. Not trackable. Estranged from wife. Sent him letter. Spoke to the initial dr –
patient didn’t report he was going on holiday. Sent TASK to myself to track patient.
Two weeks later he has been booked on my list by a different receptionist who wasn’t aware
about how hard we were trying to get hold of him? And then DNAs. This time I refer to
royal national sarcoma clinic 2ww in the hope he may just go there.
What could have been improved?
I put an alert on his notes after that. Sent a TASK to all staff to be aware of him. Sent him
another letter.
What happened: ?
Case Study:
Safety Net, Low risk – but NO risk
Slide 22
You see a 53 yr old Romanian lady who came with her daughter to see you about tiredness. Language barrier. Daughter
translates. Her 3yr old granddaughter is running around the consultation room.
What do you do? What challenges do you identify?
Hx – nil. BP – normal. Plan: ‘tiredness screen’ blds. Adv to call back for results. Concern levels: low.
Next – 2/12 later she returns, on her own. She did not do her blood tests as you had advised. She looks pale, thinner
and c/o of a lump in neck. LB still.
Now? Language line. Appetite loss and weight loss. O/e – pallor and wide spread lymphadenopathy. Impr – Lymphoma.
Actn: fast track cancer referral. Concern relayed re cancer and next steps. Address and number checked. Ref
emailed.
What next?
End of month fast track cancers search reveals no letters from hospital – concern – arrange recall.
She reports she missed the appointment as she had to baby sit the grandchildren when her daughter was was having
housing problems with the council. You reiterate how important this appointment is. Leaflet issued in Romanian.
Two weeks later – she returns with her daughter – she has come to get the biopsy results and they seem very anxious.
You don’t remember receiving anything through docman – you check the notes – NO hospital communication.
What now!
Slide 23
At the first consultation
Give the patient clear oral and written instructions.
Book the follow-up appointment.
Ensure that the patients contact details are correct, and that their mobile number is documented.
Send him/herself a patient TASK to remember to follow-up with the patient.
Ensure that the patient understands how and where to go for investigations, and how to get any results.
Document and code follow-up (9N7).
With the same problem
With the same problem after several consultations the GP should:
Implement investigations for recurring and/or unresolved problems.
Slide 24
During the investigations process the GP should:
Tell the patient to chase results within a reasonable timeframe and told how to do so.
Not rely on patient calling - significant result recall should be in place.
Relay significant results urgently and in person or telephone.
Document their recalls and any failed recalls.
Keep electronic list of worrying results
Ensure pathology comments are suitable, and that reception staff can understand them.
During communication with the hospital, the GP should:
Check their local hospital pathology and radiology policies regarding how urgent results are communicated.
Phone through urgent results (this is ideal but not universal)
Ensure new clinical colleagues have pathology codes set-up so results are not sent elsewhere.
Review near misses/SEA.
Advocate that the hospital communicates new cancer diagnoses in a timely fashion.
Advocate that the hospital sends up-to-date diagnoses and treatment plans in a timely fashion.
Ask the hospital to clarify follow-up plans if there are spurious (sometimes the clinician can be contacted on NHS.net).
Slide 25
During the referral process the GP should:
Communicate to patient what to expect, and give them the cancer referral leaflet.
Recommend using electronic methods to send cancer referrals (many sites now have dedicated email referral).
Keep an electronic list of cancer referrals (this is made easier if referrals are coded).
During follow-up of the patients:
Proactively chase non-attenders by calling or writing to them.
Consider that vulnerable patients will require more flexibility (i.e.: elderly, illicit drug user, and alcohol dependent patients etc.).
Ensure locums use electronic methods of relaying concern (i.e. tasks/alerts for patient with concerns).
Administrative staff should also document their attempts to follow-up with the patient.
Strategies for Locums and when you are on leave:
Give Locums a Locum Pack with information on how to refer and code.
Ensure that the Locum uses the right pathology code so results come back to the regular doctor.
Ensure results and/or letters are buddied up with another colleague if you are away.
Ensure any concerns are relayed to a colleague before taking leave. This should be documented in notes.
Slide 26
Safety Netting Codes:
Slide 27
FULL GUIDANCE AT:
http://www.londoncancer.org/media/126626/15070
8_Guide-to-coding-and-safety-netting_report_DrA-Bhuiya_V3.pdf