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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 • • • • 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 • • • • 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) • • • • • • • • • 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 - 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/