PRIMIS Partnerships For Progress March 2004

Clinical Coding for the New GMS Contract

Dr Pete Horsfield and Dr Colin Price

PRIMIS Partnerships For Progress March 2004

Background and chronology

• June 2003: New GMS contract agreed and published

• July 2003: 1st version of data specification issued– Tabular format– Missing codes identified

• October 2003: Special release of Read codes– Exception reporting– ‘Missing’ allergies, contraindications etc– Review codes

• November 2003: 2nd version data specification– Tabular format– Additional detailed business rules– Sign-off by 4-country body

PRIMIS Partnerships For Progress March 2004

Background and chronology (2)

• January 2004: Routine biannual release of Read codes

• January 2004: 3rd version data specification and business rules compiled– Awaiting sign-off by 4-country body

• July 2004: Read code release and 4th version

• 2004 – 2006 Biannual versions tied to Read code release cycle– Minor revisions and corrections only

• 2006: Major review of QOF

PRIMIS Partnerships For Progress March 2004

Interfaces and QA

• DoH / NPfIT working groups• NHSIA conformance testing team• 4-Country body• Suppliers• BMA / GPC• Original (clinical) authors of indicators• RCGP• User groups

PRIMIS Partnerships For Progress March 2004

Exception reporting

• Exception from entire domains

• Exception from single indicators

PRIMIS Partnerships For Progress March 2004

Exception from entire domains

• The 9h… series of codes– 9h01. Excepted from CHD quality indicators: Patient unsuitable

– 9h02. Excepted from CHD quality indicators: Informed dissent

– Required annually (15 monthly)

• Newly diagnosed / newly registered

• Ignored if an individual indicator is achieved

• Subject to scrutiny at review visits

PRIMIS Partnerships For Progress March 2004

Exception from single indicators

• Allergies / Adverse drug reactions– Lifelong

• Contraindications, refusals, intolerances– Required annually (15 monthly)

• Ignored if an individual indicator is achieved

• Subject to scrutiny at review visits

PRIMIS Partnerships For Progress March 2004

Mental Illness Register

• The only register not based on diagnosis codes– Unable to compile a ‘cluster’– ‘……severe long-term mental health problems who require and

have agreed to regular follow-up’

• Addition to register– 9H6 - On national service framework mental health register– 9H8 - On severe mental illness register– Prescribed lithium in last 6/12

• Removal from register– 9H7 - Removed from severe mental illness register

PRIMIS Partnerships For Progress March 2004

Questions

SNOMED – The RealitySNOMED – The Reality

Dr Colin PriceDr Colin Price

PRIMIS CONFERENCE2nd March 2004

Systematized Nomenclature of Human and Veterinary Medicine

OutlineOutline

Some history Where are we now? What happens next? Questions.

Where have we come from?

How did we get here?

Since 1992, the NHS has had a Since 1992, the NHS has had a strategic commitment to using a strategic commitment to using a singlesingle comprehensive terminology to support comprehensive terminology to support

patient care.patient care.

Standardarchitecture

Input

Output

Standards for clinical descriptions

Standard queries & messages

AgreedDatasets

Confidentialitystandards

Input

Output

Standards for clinical descriptions

Standard queries & messages

Standardarchitecture

AgreedDatasets

Confidentialitystandards

Clinical Terms V3 developmentClinical Terms V3 development

April 1992

April 1996

April 1993

April 1994

Term collection – 55 SWGsRead V3 file structure

Start-up

April 1995

Release 1 April 1994

Medical

April 1997

1995 Nursing

Allied Health

Withybush NAO etc

Jan 1997 IMIA WG 6

Florida

Clinical “enthusiasm”

SNOMED CT developmentSNOMED CT development

April 1999

April 2003

April 2000

April 2001

Agreement signed with College of American

Pathologists

Read/SNOMED merger SNOMED CT design

Formative Evaluation.Start-up

April 2002

Release 1 January

2002

Alphatest

April 2004

ImplementationFoundation.

Evaluation & Testing

Core Refinement.

DraftStandardClinical engagement

What lessons did we learn from Read 3?What lessons did we learn from Read 3?

User requirements need to be clearly understood

The product needs to be fit-for-purpose Clinical users need to buy into it Evaluation and testing needs to be

focussed Implementation needs to be planned The “soft” change management challenges

need to be addressed.

Where are we now?

600 x 800 = 480 000 pixels

SNOMED CT 420,000

READ 2

4 BYTE

ICD10

OPCS4

Distinguishes concepts from terms Semantic definition of concepts

Tonsillitis: Finding site = tonsil structure Associated morphology = inflammation

Uses description logic Formal basis for definitions

Auto-classification Maintains hierarchical relationships between

codes Based on semantic definitions.

Technical AspectsTechnical Aspects

ConceptsConceptIDCTV3IDSNOMEDIDFullySpecifiedNameStatus

RelationshipsRelationshipIDConcept ID1RelationshipTypeConceptID2Characteristic TypeRefinability

DescriptionsConceptIDDescriptionIDTermDescriptionTypeDescriptionStatusLanguageCodeInitialCapitalStatus

SNOMEDSNOMED®® Clinical Terms Core Clinical Terms Core StructureStructure

© 2000 College of American Pathologists

SNOMED CT Identifier SNOMED CT Identifier (SCTID)(SCTID)

ConceptId, DescriptionId, RelationshipId Numeric (not alphanumeric) E.g. “CT of spine” concept identifiers

SNOMED RT P5-08042 Read V3 X70nv SNOMED CT 241577003.

SCTID

Item ID digits

4 2 9 4 9 6 7 2 0 5

Partition-digit

Check-digit

Other tablesOther tables

Cross references ICD10, OPCS4, ICD9, CPT4

Change management To track changes between 6-monthly re-issues

Subsets E.g. primary care, ophthalmology

Extensions E.g. NHS administration terms

Keywords E.g. renal ~ kidney ~ nephric.

Kaiser-Permanente Cerner

Hospital EMR

Ardais Tissue banking project

TheraDoc Decision support in antibiotic prescribing

Cedars-Sinai Medical Center Computerised physician order entry

Hope Hospital, Salford.

Who is using SNOMED CT?Who is using SNOMED CT?

ImplementationWhat happens next?

What might go wrong?

What is SNOMED Clinical Terms?What is SNOMED Clinical Terms?

SNOMED CT is a terminological resource that can be implemented in software

applications to represent clinically relevant information reliably and reproducibly.

What is SNOMED Clinical Terms?What is SNOMED Clinical Terms?

SNOMED CT is a terminological resource that can be implemented in software

applications to represent clinically relevant information reliably and reproducibly.

Functional requirementsFunctional requirements

Documentation in electronic records Decision support Clinical audit Reporting Summaries Administrative & management

information Epidemiology Billing & reimbursement Resource management.

Direct

Indirect

Typology of terminologiesTypology of terminologies

SNOMED CT

OPCS 4

ICD 10

Read 4 byte

ICPC

Focussed

Comprehensive

Content

Direct care

Indirect care

Function

CTV3

LOINC Datasets

Brown field = General Practice• IT maturity Use Read Codes at point of care Generalist, summary records

Green field = Most others IT immaturity Little use of terminology Specialist, detailed records.

Two constituenciesTwo constituencies

Will a clinical terminology add value by meeting requirements and delivering benefits?

Primary care Others ?

Is SNOMED CT a suitable terminology to deploy?• More comprehensive content than Read• Flexible structure• Growing support internationally (e.g. USA).

Two questionsTwo questions

Live testing in “green field” settings Agreed with the NHS Information Standards

Boards To confirm benefits in a wider range of

clinical uses Working with NPfIT around NCRS

Primary Care Migration Project Exploring the “brown field” legacy problem GP systems and their data.

Evaluation & Testing Evaluation & Testing programmeprogramme

Implem

entations

Time

Implementation failure patternsImplementation failure patterns

Replication failure

Sustainability failure

Adapted from Heeks et al 1999

History Many years NHS terminology development A lot of lessons learned

Where are we now? SNOMED CT is available

What happens next? We need to get on and use it Refining as necessary through evaluation

and testing Building on our experience to ensure that

implementation delivers real benefits.

SummarySummary

SNOMED – The RealitySNOMED – The Reality

Dr Colin PriceDr Colin Price

PRIMIS CONFERENCE2nd March 2004