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Points, QOF & QMAS. VTS Awayday 10/11/04. Relevant issues:. Screen set up (we use INPS Vision but the principles should apply to any system) Read Codes Guidelines Disease Registers CDM areas Exception reporting Other data to collect Medication reviews Smears
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Points, QOF & QMAS VTS Awayday 10/11/04
Relevant issues: • Screen set up (we use INPS Vision but the principles should apply to any system) • Read Codes • Guidelines • Disease Registers • CDM areas • Exception reporting • Other data to collect • Medication reviews • Smears • Capturing Data/Summarizing • Clinical Audit • QOF and QMAS
Guidelines • Enable essential data to be collected consistently • Make sure correct Read Codes are being used • Have been customised by INPS and NSMC • Care & commitment needed to use correctly
Read Codes - 1 • We have a Read Code formulary for every patient contact – clinical & administrative • We aim to use codes that are straightforward and Contract-compatible • We use Guidelines • We use Keywords = mnemonics • We use Holding Codes when diagnosis not yet established
Read Codes - 2 • Use Read Code at top of hierarchy • Do not use “H/o …” codes • Do not use “PMH of …” • We use Priorities rather than Problems • Crucial to use the Recall facility and use it correctly • Avoid multiple entries of same diagnosis as “new diagnosis actions” would then apply e.g. angina
Disease Registers • Crucial for the new Contract • Need to ensure right patients are in the right register • No need to use the set “registers” in Vision now - Asthma, CHD, DM, HT – because • Virtual registers best i.e. the diagnostic code • Need to clean registers – to correct inaccuracies and to determine prevalence • System needed for capturing new patients/diagnoses
Asthma • Those prescribed asthma related drugs in past 12 months with Read Code H33 • Could use active and inactive register • What we are doing - if no longer suffering or history unclear use “Asthma resolved” - will remove from disease register • Need to validate with those with respiratory drugs but no diagnosis
Cancer • Cancers excluding non-melanotic skin cancers diagnosed after 1/4/03 • Virtual register fine if coding correct • Using appropriate Read Codes in B hierarchy – put Neoplasm as well as diagnosis • Care over event type – has to show as “First ever” • Cancer review is straightforward
COPD • Register made by appropriate Read Code = H32 • Confirmation of diagnosis since April 2003 • More accurate diagnosis of existing patients • Sorting out COPD from asthma • Finding patients – those on anticholinergics, oxygen, frequent oral steroids, asthmatic smokers over 50
CHD • Most points available in this area of the new contract • G3 hierarchy (except CABG) • “Referral to cardiology” will bypass some actions and is a useful code • Validating - • Search Read Codes • Search drugs e.g. nitrates, beta blockers, statins, ACE inhibitors • Lots of cleaning of data has been done
LVF • May be different from patients on CHD register but may need CHD in addition • Read Code = G58 • Validate by looking for patients with LVF, CCF, Heart Failure and Echocardiography • Drug searches • Review those with diagnosis without echocardiogram
Diabetes • Read Code C10 • Double code Type 1 (C10E) and 2 (C10F) • Drug searching on oral medication and blood testing reagents • Contract does not require confirmation of diagnosis • At risk pre-diabetics need to be in system
Epilepsy • Those currently receiving treatment (in last year) age 16 and over • Read Code F25 • Need to validate as there will be some patients taking some anti-epileptic drugs for other reasons
Hypertension • Large numbers and therefore workload • Read Code G2 • Looking for patients – those known & with Read codes for HT, drug searches, those with last BP > 150/90 not on Rx (up to 50% of over 60s)
Hypothyroidism • Those on levothyroxine with recorded diagnosis of hypothyroidism • Read Code C03 & C04 • New contract requires TSH in last 15/12
Stroke & TIA • Read Codes = TIA (G65), Haemorrhagic Stroke (G61), Non Haemorrhagic Stroke (G64), Stroke NOS (G66) • Validation needed because new Contract distinguishes these types of strokes & suggests different actions
Mental Health • Entry onto register is discretionary • Suggestions are those with psychosis e.g. schizophrenia & bipolar disorder, those on a care programme or with complex care packages • Read Code 9H8 = On severe mental illness register • Remember Lithium monitoring
Exception Reporting - 1 • From whole domain or individual indicators • What could be exception coded? • Refusal to attend after 3 invitations • New patients or recently diagnosed • Not clinically appropriate e.g. perhaps age, frailty • Informed dissent • Unable to tolerate Rx • Maximum medication • Another supervening condition
Exception Reporting - 2 • Two levels for each clinical category: • - High level (Read Codes 9h) – applied to all Indicators • within category – need to be noted annually • - Patient unsuitable • - Informed dissent • - Indicator level – applied to individual Indicators only • - Maximum tolerated medication dosage • - Drug allergy / contraindication • - Patient recently registered • - Patient recently diagnosed • - Procedure / treatment declined
Exception Reporting - 3 • Duration of exceptions: • - Expiring exceptions – annual, as above • - Persisting exceptions e.g. drug allergies • - Aspirin etc contraindicated – needs contraindications • or allergies to ALL THREE drug types annually • - ACE / A2 contraindicated – needs contraindications or • allergies to BOTH drug types annually • - Buttons within Guidelines to enter all these
Exception Reporting - 4 • Who should be excepted at the High level –patient unsuitable and informed dissent? • No national or local guidance • Practice needs to take a view about this • May be appropriate to write a practice protocol
Other data to collect • BP every 5 years age 45+ • Smoking status age 15-75
Medication Review • Needs to be recorded in previous 15 months for those on 4 or more repeat medications • All patients on repeat medication – needs to be in SDA in Vision • Additional specific disease area medication reviews - buttons
Smears – what is needed? • Performance – age 25-64 every 3-5yrs • Policies – e.g. one crucial area is in the area of dissent – needs 3 invitations, must sign a disclaimer, must be given the opportunity to dissent again next time round • Audit
Capturing data / Summarizing • Agreement in-house about Codes • Issues around new diagnoses • Protocol for data entry • External sources - hospitals • New patient checks • Community nurses? • Nursing homes? • Housebound?
Remember non-clinical protocols • Points to be earned in the new contract for having practice protocols • Some are clinical and need clinical input e.g. Infection Control, Smear Taking • Some are not primarily clinical e.g. Health and Safety, Complaints Procedure • Potentially a lot of work for the practice manager • Very tricky without some practice management
How can we make all this work? • Involve everyone - who all have to be committed to the process • Agree what is important • Work together on policies • Use different skills within the team • Value what they contribute • ? Financial incentives – e.g. with set-up money
What is QOF? - 1 • Quality Outcomes Framework • The new Contract “scoring” system • Clinical and administrative components • Clinical criteria translate to clickable buttons within Guidelines
What is QOF? - 2 • Points achieved against 146 criteria will affect practice payment in 2005 • QOF points will not simply be paid • “Voluntary” assessment provides validation and opens way for payment • Stated aims of assessment are to be formative, helpful & developmental
How points are assessed - 1 • Clinical Audit will measure points – • correct Read Codes required • Practices will need to report on QOF • monthly • “The bit in the middle” reports the • achievement – this is QMAS
So what is QMAS? • Quality Management and Analysis System • The software that will interrogate • practices’ (compatible) IT systems • Can be run from now, fully live by 3/05 • Once registered, can get current level of points or forecast level for 31/3/05
How points are assessed - 2 • Year-end report used for payment calculation • Prevalence will be taken into account • Between 2 and 18 Quality Indicators for 11 Clinical Categories, 1 Organisational Category, 1 Additional Services category • Validated by QOF assessment visit
How points are assessed – 3 • First Indicator in each clinical category – the diagnostic code - is Virtual Disease Register – no need to use Disease Registers now • Other Indicators are scored against different target populations i.e. Denominators • Denominators and Indicators take Exceptions into account • Exceptions do not affect Virtual Disease Registers
QOF Assessment Visits - 1 • Start in 10/04 – NSMC will be visited in 1/05 • QOF visiting teams consist of 1 PCT manager, 1 clinician (a GP although some nurses have been trained), 1 lay member • Havering PCT planning 2.5 hours – how realistic? 4 may be more likely
QOF Assessment Visits – 2 • Visiting team will have a practice profile, a timetable for the visit and access to current level of QOF points • May have other information e.g. prescribing data • Will look at QOF criteria – not clear at present how many of the 146 but could be all or any • Stated aim is to be light-touch, high trust, • low bureaucracy
QOF Assessment Visits - 3 • Will interview representative team from practice & will discuss aspects other than points e.g. patient experience • Not a full quality review but will seek to validate QOF points • There may be other agendae including a change agenda
(Some of the) Unresolved issues • Information for visits & amount of preparation by practices • Time for visits & disruption to normal activities • Confidentiality of clinical data • Formative vs. summative usage • Possible aims of PCT vs. aims of practices • What happens to all the “other” data? • Preparation & workload of visiting teams • Membership and payment of teams