Download SCIMP Conference Nov 2006

CODING/ OSCAR
PROJECT Workshop
SCIMP Conference
November 2007
Karen Lefevre & Hazel Dodds
Introduction
• Read codes
• Issues in practices
• OSCAR Project
• The National Picture/ Snomed
Background/ history of Read
codes
• Devised by Dr James Read as a means of coding
patients history, problems, care and treatment
• Purchased by UK Government in 1990 for use in NHS
• Is used in all General Practice systems
• There are now >80 000 read codes available
Benefits of coding
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Recording data consistently
Retrieving data more easily
Analysing data more thoroughly
Also, competent computer systems can search for
anything that has been typed – except for
–
Typing mistakes
– Different words for the same thing
– Human foibles
Read code structure
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Hierarchical/ tree-like structure with 5 levels
Alphanumeric coding – from 1-5 characters
The more letters/ numbers – the more detailed the code
‘….z’ indicates the lowest level of coding
• Example
• Asthma NOS = H33zz
• Each code has preferred wording (some with synonym
choice)
• Example
• P Diagphragmatic hernia
• S Hiatus hernia
J34..
J34..
• The first digit indicates which chapter the code is from
• Example – all codes commencing A…. = Infection
Read code thesaurus
0….
1….
2….
3….
4….
5….
6….
7….
8….
9….
A….
B….
C….
D….
E….
Occupations
History/ Symptoms
Examinations/ Signs
Diagnostic Procedures
Laboratory Procedures
Radiology/ Physics in Medicine
Preventive Procedures
Operations, Procedures, Sites
Other therapeutic procedures
Administration
Infections/ Parasitic diseases
Neoplasms
Endoc/ Nut/ Met/ Immune diseases
Blood/ blood organ disease
Mental disorders
F….
G….
H….
J….
K….
L….
M….
N….
P….
Q….
R….
S….
T….
U….
Z….
Nervous System/ Sensory organ disease
Circulatory system disease
Respiratory System disease
Digestive system disease
Genitourinary system disease
Pregnancy/ Childbirth/ Puerperium
Skin/ Subcutaneous tissue disease
Musculoskeletal/ Connective tissue disease
Congenital Abnormalities
Perinatal Conditions
(D) Symptom, Signs, Ill defined condition
Injury and Poisoning
Causes of Injury/ Poisoning
(X) Ext. cause Morbidity/ Mortality
Unspecified Conditions
Read code structure
Example:
G…. = Circulatory system disease
G3… = Ischaemic Heart Disease
G30.. = Acute myocardial infarction
G301. = Anterior myocardial infarction
G3011 = Acute anteroseptal infarction
Symbols used in Read Thesaurus
[P]
[S]
NOS
NEC
[D]
[SO]
[M]
[X]
[V]
Preferred terminology
Synonym for preferred code
Not otherwise specified
Not elsewhere classified
Diagnosis (symptom as a diagnosis)
Site of (e.g. an operation)
Morphology of neoplasms
Uses ICD 10 coding
Supplementary influencing health
services or contact other than for illness
The Issues in Practice
The Process In General Practice
The
Consultation
Record Keeping
- The Computer
Interpretation
- Notes
Reports
Letters
Labs
Issues in Practices
System requires:
• Good IT
- Hardware/ software
• Good information management
- Reliable data entry – complete & consistent
- Audit/ search tools
- Communication/ feedback/ prompts
Reliable Data Entry
• Who collect the data?
- GPs, nurses, admin staff, data clerks
- Automated (lab results)
• What data is collected?
- Sources – letters/ consultations
• Why is it collected?
- Audit/ clinical support/ clinical communication
• How is it collected?
- Systems within practices
Which would you chose?
Which would you chose?
Coding Systems
Why use a standard Coding Summary (formulary)?
• Within practice
- Simplifies data entry
- Retrieval of information
- Standard search systems (+ payment purposes)
• Outwith Practice
- Transfer of specific information (e.g. referrals, reports, ECS)
- Transfer of electronic notes (GP2GP)
- Aggregation of information – National Disease Prevalence,
Public Health Initiatives
Records Transfer – History/ Future
Record Transfer
GP2GP
?
SCIMP LIST
• First produced in 2001 (pre-contract)
- A recommended list of 800 (with limited 300 list)
- Common conditions for patient summaries
- Not intended to be exhaustive
• Updated list September 2006
- To align with new developments in IT, Contract, NCDDP, other
coding formularies (inc. OSCAR)
- Available for use in formularies/ other developments
- Also separate list for Contract with recommended codes
- Found on SCIMP website - http://www.scimp.scot.nhs.uk/
Contents of a Summary : 1
Work being done through RCGP to define contents of
the GP Summary (specific for the NHS Summary Care
Record)
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Major diagnoses
Conditions that may have a chronic or relapsing course
Conditions for which the patient receives repeat medications
Conditions that are contraindications for types of medication
Major operations
Significant therapies and treatment plans
Significant investigations
Fractures
Other entries as agreed by the GP and patient to include items
that are significant for that patient
Contents of a Summary : 2
Key aspects
• Over time requires ongoing revision and maintenance of
the summary to ensure accuracy, completeness and
appropriateness
- Systems for the initial inclusion of new or incoming
information
- Systems for revising and editing the existing summary in
the light of new circumstances
• Depends on the context of the patient, the author and
the reader
• Patients have a crucial role in deciding what constitutes
a meaningful medical summary for them
Priorities
Sharing
Vision
Limited Individual
0
Full
1
High
Inactive' Clinical History
Local
2
?Medium
Other Clinical Activities
Local
3
?Medium/Low
Sensitive Information
Clinical Summary
Others - Administration, Midwifery, AHP's, HV, DN, PN
GPASS
THE OSCAR PROJECT
Optimal Summarising, Coding &
Accurate Records
Major problems identified in
summarising clinical records
in primary care:
• Inconsistency of diagnostic coding due to wide selection of
codes available in full read code thesaurus
• Difficulties in extracting accurate/ auditing information from
practice systems
• Widely varying completeness across practices
• Practices moving to paperlite/ paperless status
• All members of practice team need to be involved in data entry
• Data entry needs to be consistent and accurate
Reasons for the project
• Standardise summarising/ coding across WL
• CDM in primary care
– Enable practices to identify, track and treat these patients more
effectively
• Good practice to have patient summaries
• Enable collection of data from all practices
• Research tool
– Demonstrate more accurate/ actual morbidity figures in primary
care
– Improved capture of primary care data - influence resource
allocation
Reasons for the project
• Electronic transfer of patient information
– Consistent coding required for cross population between
software packages/ databases, e.g. SCI-DC, ECS etc.
• Electronic transfer of whole patient record, e.g. GP2GP
• Paperlite practices
• GMS contract
– Quality payments - depend on extracting accurate data from
practice systems
– Practice required to have up to date summaries in records
Objectives
• To support all practices to develop and maintain a
standardised summarising/ coding system
– All practices would be supported regardless of system used
– All practices would receive an element of funding
• To produce a comprehensive coding formulary and
protocol
• To regularly update and further develop coding formulary
and protocol
• To train practice personnel in accurate/ appropriate data
entry methods
Progress to date
• Summarised approx. 70% of patient records
• Roll out of the project
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Training workshops across Lothian
Training in individual practices across Lothian
Practices in Tayside and Fife
Forth Valley/ Fife/ Highland Gpass Users Groups
Practices in the Borders
SPS across Scotland uses OSCAR
Training of GMS IT Facilitators National Team completed
• Annual audit review demonstrates a clear improvement
in quality of summarising
The National Picture
The Health Service
- Hospitals
- Primary Care
- Community
- Patients
Record Keeping
Interpretation
- Paper
- Computer
- Web based
Reports
Audits
Research
The (Inter) National Picture Communication
Aided by:
• A common language
• Consistent and uniform use of the language
• IT infrastructure
SNOMED CT– a common language
= Systematised Nomenclature of Medicine –
Clinical Terms
• A comprehensive clinical terminology that is used to
code, retrieve and analyse clinical data (includes
dentistry, vetinary, pharmacy, laboratory etc.)
• Over 350,000 concepts (codes) - Read has approx.
80,000 codes
Examples : Diabetes Resolved - Read
- Snomed
Max. BP treatment - Read
- Snomed
= 212H.
= 315051004
= 8BL0.
= 407567007
• Concepts arranged in 18 hierarchies each with subhierarchies (Read = 1)
Snomed CT
• Currently run by International Health Terminology Standards
Development Organisation (IHTSDO) – based in Denmark
• An international system (approx 35 countries with licences)
• Mapping of Read 2 to Snomed
• Snomed GP systems in early development stage (e.g. INPS
Vision 4, EMIS Web)
• Partially used in localised sites (A&E dept. in London)
• Challenges for software providers/ end users
– Education, support etc.
Standardised and Consistent
use of coding
National Clinical Dataset Development Board
• Development of standardised datasets/ data definitions for
Scotland
• To ensure data has the same meaning at time of entry and
subsequent use
• Will be Snomed CT coded
• Current datasets include Cancer, CHD, Diabetes + others
• Published via NCDDP website:
http://www.clinical datasets.scot.nhs.uk/Links.html
Dr Karen Lefevre
Email: [email protected]
SCIMP website: http://www.scimp.scot.nhs.uk
Hazel Dodds
Office Tel: 01506 771872
Mobile Tel: 07734 540504
Email: [email protected]
OSCAR on the web:
http://intranet.lothian.scot.nhs.uk/nhslothian/healthcare/a_z/o/oscar.aspx
or
www.westlothianchcp.org.uk/chcp/what/community/oscar/