PRIMIS in Action: The Cleveland Experience

2. PRIMIS in Action:The Cleveland Experience Dr David Simpson (PhD) IT Co-ordinator, Cleveland MAAG email DavidSimpsonMAAG@email.tees-ha.northy.nhs.uk CMAAG website http://www.pcrdc.co.uk/orgs/maag 3rd April 2001 Birmingham

3. Background of Work • Large amounts of data • Practice Audit, HNA, Commissioning, Research • Information for Health commitment to change • Information requirements enlarged • Clinical governance / evaluation and monitoring • Paper-based systems lacking / variable quality • Electronic data extraction faster / more efficient • Teesside Primary Care IT Data Quality / Electronic CHD NSF projects

4. Primary Care IT Data Quality • The simplified overall aims are: • to provide accurate, comprehensive computer-based data so that services can be reliably informed and standards of patient care can be shown to have improved • to improve data collection processes within general practice so that data is more accessible by computer, it is collected in a standardised way, and can be extracted and analysed across the region easily

5. How are we doing it? • Awareness raising • Training and education • Support • Guidance • Material • Workshops / presentations • Publications and … PRIMIS / MIQUEST and …

6. National Service Frameworkfor Coronary Heart Disease • What are we doing? • supporting the development and implementation of electronic CHD data registers within primary care

7. National Service Frameworkfor Coronary Heart Disease Support

8. National Service Frameworkfor Coronary Heart Disease • Milestones • 2001: Registers • 2003: Auditable results • Support personnel • Short term objectives • Long term objectives

9. Electronic CHD data registers • Why? • Not mandatory, however, the NSF does state: • “To avoid unnecessary work, the information should be recorded in a way that allows practices or PCG/Ts to aggregate and analyse the data so that it can readily be used to support clinical audit. This will be achieved most easily by recording the data electronically.”

10. Why go down the IT route? • Computers and teenagers • often not very bright • need constant feeding and attention • must ask in just the right way or sulk • few people have the time to understand them fully • random unpredictable mood swings

12. So why bother? • because computers are good at doing what WE do poorly: • remembering • finding things quickly • repeating actions • handling large volumes of information • being legible • not getting tired, bored or stressed

13. Proactive management Comprehensive treatment Monitoring IT andChronic Disease Management Know the patientsTreat them well Data registers Decision support Morbidity information Call/recall Medication management

14. The Process Four key stages • Assess and identify • Audit and clarify • Procedures and protocols • Development and implementation

15. CHD NSF Read Codes Read 4 Ver 1 5 Ver 2 Ischaemic Heart Disease G4 G3 Acute Myocardial Infarction G41 G30 Angina Pectoris G44 G33 Heart Failure G6A G58 Cerebrovascular Disease G7 G6 Precerebral Arterial Occlusion G72 G63 Cerebral Arterial Occlusion G73 G64 Transient Ischaemic Attack (TIA) or Transient Cerebral Ischaemia G74 G65 Stroke/CVA undefined or unspecified G75 G66 Other Cerebrovascular Disease G76 G67 Atherosclerosis G81 G70 Intermittent Claudication/ G85/ G73z0 Peripheral Vascular Disease G86 G73z Coronary artery operations (e.g. CABG) 773 792

16. CHD NSF Minimum Data Set CHD review 6621 CHD clinic attendance 662N Cardiology OPD 9N1P On Aspirin 8B63 Patient buys own Aspirin (OTC) (8B3T)** Aspirin contra-indicated 8I24 Systolic / Diastolic blood pressure 246 Height (metres) 229 Weight (kg) 22A BMI (Kg/m2) 22K Cholesterol (mmol/L) 44P HDL cholesterol (mmol/L) 44P5 Alcohol status 136 Smoking status 137 Exercise status 138 ** Read 5 only

17. Prevalence of Appropriate Electronic Recording of CHD Diagnoses (35-74) Teesside 10.00 9.00 8.00 7.00 6.00 Percent 5.00 4.00 3.00 2.00 1.00 0.00 North Tees PCG Langbaurgh PCG Hartlepool PCG Middlesbrough & Eston PCG Teesside Average (Pre IT Project) Average so far... Projected Average (Post IT Project) Data thus far

18. Overall data thus far Appropriately coded so far … 18,775 Mean prevalence (pre-project) 6.85 Population 269,733 (35-74) Patients with a relevant CHD NSF Read code already recorded on the Clinical Computer System

19. Overall data thus far Population 269,733 (35-74) Appropriately coded so far … 18,775 Mean prevalence (pre-project) 6.85 Inappropriately coded so far … 1,624 0.6 Definite so far … 702 Primarily patients recorded on the Clinical Computer System with a ‘History of ‘ Read code Patients inappropriately coded on the Clinical Computer System with confirmed CHD

20. Overall data thus far Population 269,733 (35-74) Appropriately coded so far … 18,775 Mean prevalence (pre-project) 6.85 Inappropriately coded so far … 1,624 0.6 Definite so far … 702 Patients with confirmed CHD following audit Potentials so far … 13,831 5.13 Definite so far … 1,563 Inconclusive so far … 155 Definite so far … 28 Patients that need a clinical assessment of notes Patients without a CHD NSF diagnostic code on the Clinical Computer System but with appropriate medication

21. Overall data thus far Population 269,733 (35-74) Appropriately coded so far … 18,775 Mean prevalence (pre-project) 6.85 Inappropriately coded so far … 1,624 0.6 Definite so far … 702 Potentials so far … 13,831 5.13 Definite so far … 1,563 Inconclusive so far … 155 Definite so far … 28 Average so far … 7.67 Additional 2,283 Additional patients that will be correctly coded on the Clinical Computer Systems

22. Overall data thus far Projected additional patients to be correctly coded on the Clinical Computer Systems Population 269,733 (35-74) Appropriately coded so far … 18,775 Mean prevalence (pre-project) 6.85 Inappropriately coded so far … 1,624 0.6 Definite so far … 702 Potentials so far … 13,831 5.13 Definite so far … 1,563 Inconclusive so far … 155 Definite so far … 28 Average so far … 7.67 Additional 2,283 Projected mean prevalence 7.93 Projected additional 2,928

23. Review Facilitate Develop Better management of a chronic disease Potential for improved care Ease of data access More efficient audit system Transferable skills Meet clinical governance agenda Future NSFs Support EHR Opportunities created

24. The PRIMIS Connection • Useful informative material • Training • Enthusiasm, advice and support • Communication infrastructure • MIQUEST • Implementation problems • Standardised queries and feedback • Rush / CAS • Wonderful people

25. . Where do we go from here? • Change culture in primary care • Address the massive training, education and development issues • Acquire adequate resources to support the ongoing need • Continue to provide support • Sell benefits of IT • Change management skills • Realise potential of primary care

26. PRIMIS – The Challenge Dr John Nicholas GP & North Tees PCT IT lead Primary Care IT Advisor to Tees HA email John.Nicholas@gp-a81002.northy.nhs.uk

27. CHDGP vs PRIMIS • CHDGP able to focus on localities & practices interested in improving data quality and data comparison • PRIMIS to take message to all localities and all practices regardless of current interest

28. Information for Health • Highlighted the problem of health information systems designed primarily to produce statistics, and proposed: • “information forms a natural by-product of the clinical systems required to support the day-to-day care of patients”

29. Potential problems of MDS approach • “Pseudo-data”, e.g. advice re smoking • Corruption of patient record • Alienation and demotivation of professionals • Workload implications • Lack of evidence of benefit of recording

30. High quality clinical record • Primary purpose to support the day-to-day care of patients • Secondary purpose to support audit, clinical governance, epidemiology, service planning • PS. Evidence of benefit of recording, please!

31. PRIMIS in Action:The Cleveland Experience Dr David Simpson (PhD) Dr John Nicholas Cleveland MAAG 3rd April 2001 Birmingham