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Local READ Code Formularies and Templates EMIS NUG conference 6 th September 2001

Local READ Code Formularies and Templates EMIS NUG conference 6 th September 2001. Dr Amrit Takhar General Practitioner Wansford , Peterborough www.wansford.co.uk. How many READ codes?. READ version 2 (5 byte) =107,000. Outline of todays session:. Why coding is important?

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Local READ Code Formularies and Templates EMIS NUG conference 6 th September 2001

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  1. Local READ Code Formularies and TemplatesEMIS NUG conference 6th September 2001 Dr Amrit Takhar General Practitioner Wansford , Peterborough www.wansford.co.uk

  2. How many READ codes? READ version 2 (5 byte) =107,000

  3. Outline of todays session: • Why coding is important? • READ codes – facts and tips • READ code formularies • Development • Implementation • Maintenance • EMIS templates • Future developments

  4. Why use READ codes? • Data quality – • improving standards of care • income generation (IOS claims) • Clinical Governance • Audit and Research • Decision support systems • Communication between systems

  5. Why use READ codes? • Link to Templates, Protocols & Prodigy • Link to previous consultations using same code • Activate drug warnings, interactions, contraindications • Referral letters with coded details automatically added • Helps ensure claim for items of service

  6. What are the Read Codes? The Read Codes are a comprehensive list of terms intended for use by all healthcare professionals to describe the care and treatment of their patients. They enable the capture and retrieval of patient-centred information in natural clinical language within computer systems.

  7. Anatomy of a READ code G304.

  8. READ code facts • Developed by Dr James Read, GP, Loughborough 1982 • Purchased 1990 by NHS and mandatory for GP accredited systems but not in hospitals • Merger with Snomed system scheduled to form worldwide coding system

  9. Anatomy of a READ code 5 characters G…. Chapter heading ( circulatory diseases) G3… Ischaemic heart disease G30.. Acute Myocardial infarction G303. Acute inferoposterior infarction

  10. My choices of codes will then be as follows Circulatory System Disease (G.....) Hypertensive Disease(G2) Benign Essential Hypertension (G201) Secondary Hypertension(G24) Acute MI (G30) Angina Pectoris (G33) Ischaemic Heart Disease(G3) TIA (G65) Cerebrovascular Disease(G6) Stroke and CVA unspecified (G66) Subarachnoid Haem. (G60) Level One Codes Level Two Codes Level Three Codes

  11. READ code chapters • Symptoms Chapter 1 • Examination Chapter 2 • Investigations Chapters 3-8 • Administrative Chapter 9 • Diagnoses Chapters A-S • Medication Chapters a to s

  12. Chapter Contents A Infectious/parasitic diseases B Neoplasms C Endocrine/metabolic D Blood diseases E Mental disorders F Nervous system/senses G Circulatory system H Respiratory system J Digestive system K Genito-urinary system L Pregnancy/childbirth/puerperium M Skin/subcutaneous tissue N Musculoskeletal P Congenital anomalies Q Perinatal conditions R Ill-defined conditions/working diagnoses S Injury/poisoning T Causes of injury/poisoning

  13. What do all the abbreviations in the Read Codes mean? • EC Elsewhere classified • FH Family history • H/O History of • NEC Not elsewhere classified • NOS Not otherwise specified • O/E On examination • OS Other specified

  14. Chapter headings 0 Occupations 1 History/symptoms 2 Examination/signs 3 Diagnostic procedures 4 Laboratory procedures 5 Radiology/medical physics 6 Preventative procedures 7 Operations and procedures 8 Other therapeutic procedures 9 Administration

  15. What does it mean when a term starts [V], [X] etc? • These markers are used to indicate the sort of ICD/OPCS cross-mapping which is attached to the Read Code. • [M] Morphology of neoplasms (ICD) • [SO] Site of (OPCS) • [V] Supplementary factors influencing health status or contact with health services other than for illness (ICD) • [X] Terms which have been added to the Read Codes in order to ensure that every ICD-10 code is cross-mapped to from a Read Code.

  16. Pitfalls • Context vs. coding:- Angina ? = have they got angina. Angina [G33] ? [Free text] = this patient has angina

  17. Finding the right code

  18. Formulary benefits • Avoidance of unsuitable codes • Data searching and audit much simpler • Simplify picking options when selecting a code • Sets scene for data transfer between practices • Raises awareness of coding

  19. Formulary – how to • Written version on paper, on website, in excel • Create your own hierarchy in EMIS • Templates • Synonym access (@ Wish list: Import/export a Code formulary option

  20. Formulary by Synonym access @OM Acute Right Otitis Media, Acute Left Otitis Media, Acute Bilateral Otitis Media etc @URTI has various pharyngitis/tonsillitis @Heart @Mental

  21. Formulary – choosing your codes • Look at the existing formularies • Liverpool • SCIMP (Scotland) • Sunderland (modified SCIMP list) • York – DR Mike Jones • Get local agreement – PCT IT strategy • Build on recent initiatives eg READ codes in CHD NSF

  22. READ code prioritiser (GPASS)

  23. READ code browsers http://www.cams.co.uk/browsers.htm Suite of browsers, including: • Tree Browser • Read Code Comparison Tool • Read Codes GP4-byte, Version 2 and Version 3 • Read Code Subset Wizard • Beginner's User Manual

  24. Implementation options • READ code formulary • Paper versions, alphabetic, and by speciality • Top 100 , laminated for desktop use • Training in READ code structure, terming, hierarchical searching • Encouraging hospital use – autoread coding xml • Minimum data sets

  25. EMIS templates • Data entry forms invaluable for • Saving time • Standardising data recording • Clinical prompts • Can be shared between practices

  26. EMIS templates • Disease management • Health promotion • Maximise IOS income • Consultation records • Links possible to READ codes and protocols

  27. Template options • Code entry dependent on age and sex • Add or insert entries • Add diagnosis as problem title • Insert an existing template • Simple eg Cervical smear. Imms • Complex eg component of NSF protocols

  28. Template sharing • Can be exported from EMIS (CO) to floppy disk • Can be printed or stored as text file • Library of templates of NUG website • Main pitfall is to ensure compatible version of READ ( 4 byte or 5 byte)

  29. Sharing templates CO, TT, A (export to floppy) B (import from floppy) • Ensure the floppy goes in the server A drive • Make sure you know the read code for the title of each template.

  30. READ version 3 • 270,000 codes • The new file structure which forms Version 3 uses the actual Read Code simply as a label for the term. • Hierarchy position thru relational tables. • Infinite number of levels of detail and allows codes and their terms to be moved to form a hierarchical structure which reflects current clinical thinking. • Each term can have qualifiers

  31. READ version 3 • Qualifiers allow addition of detail to "core terms". For example; Inguinal herniorrhaphy using sutures may be qualified by;Priority -ScheduledRevision status -Repair of recurrence • Terms are also available for providing the context of a core term, i.e. the goal of treatment, expected finding or actual finding and certainty

  32. The Future of coding • Changing to SNOMED CT • Improved formulary creation and sharing • Code transfer between hospitals and GPs ( starting in pathology EDI)

  33. Todays session: • Why coding is important? • READ codes – facts and tips • READ code formularies • Development • Implementation • Maintenance • EMIS templates • Future developments

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