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