Customerising (CHD) Templates

These notes are an attempt to tackle some of the questions that have been raised about the design of the CHD templates & protocols. Some practices may wish to modify them to suit their working practice (Although the author cannot take on responsibility for sorting problems created by practices if this is done erroneously). This document should help practices to do so without compromising the results of Miquest audit of their data. The reasons for the design are largely pragmatic or limited by code availability. The document describes the logic of the protocols so that the reader may more easily interpret their output. No doubt you will spot one or two minor inconsistencies which have crept in. There is no reason why templates should not be customised to suit individual practices’ working patterns. Practices doing so should ensure they are thoroughly familiar with the EMIS template editing software. PCAG cannot undertake to offer training and support in this area. Practices should liase with their EMIS trainers. Customising protocols is not recommended as it involves a higher level of complexity.

Sub-Templates

The basic design was to build up the CHD template from sub-templates dealing with discrete areas of CHD secondary prevention. This facilitated protocol and template construction as well as providing sub-templates that can be mixed & matched to build other templates e.g. diabetes, asthma to ensure coding consistency across different diseases and across the county.

I don’t like all the Notes for free text in the templates! These are there where an entry might need further comment for future reference. If you want to remove them you can edit the relevant subtemplate by editing the prompt rules for that prompt without affecting the audit.

Acute myocardial infarction                                  G30

This is a diagnostic coding sub-template that uses the dual coding technique for coding the conditions laid out in the CHD NSF. It was decided to place all these in one template rather than several because it will make registering patients easier and more likely to occur accurately if all the codes can be found in one place. The presence of all codes in one template helps remind the user to code all the diagnoses in the significant number of patients who have multiple arterial pathology. It gives in one place a useful summary of a patients full status vis a vis cardiovascular disease. The disadvantage is that the template is longer. Providing the codes used are the same there is no reason why practices shouldn't create other templates dealing with one disease area each.

The protocols call this sub-template if the user indicates they want to update vascular diagnoses or if the protocol fails to find that the patient is correctly coded for vascular disease.

O/E - blood pressure reading                                 246

The entries for Ave Home SBP & DBP are superfluous to CHD audit. They are there simply because this sub-template is also used in a hypertension template in the source practice. These two prompts can be safely deleted from the sub-template if practices wish, as can the ones dealing with pulse. In designing templates it is important that they meet clinical as well as audit needs. The reason that pulse is present in the template is that many clinicians will want to record this information even though it is not part of the audit. It also means that this sub-template can be used as part of a template for general cardiovascular examination.

Why is there a code for no gallop rhythm but not a code for gallop rhythm. Bizarrely (or perhaps not so for those familiar with the rather ad hoc way in which some of the read code hierarchy has developed) the code for gallop rhythm is not a child of pulse and so does not appear. If desperate you could edit the prompt as a defined picking list to include it.

The IHD protocol prompts for BP checks once the last BP record is over 9 months old. This helps ensure that BP is recorded at least annually.

Serum cholesterol                                             44P

This contains codes for triglycerides and HDL as well as a field that calculates the TC:HDL ratio. This renders the template useful for CHD primary prevention in calculating CHD risk and for diabetes. Only the cholesterol code is actually used in the CHD audit. Practices may wish to add LDL codes etc. It was felt that adding other lipid codes would make the sub-template too long without adding greatly to its usefulness. In setting up GP Path links it is important for practices to link the incoming cholesterol data to 44P, so that this data will automatically appear in the template. The local lab and read codes do not distinguish between fasting and random cholesterols and so it is best to stick with 44P. (Although the Emis code EGTON456 for fasting cholesterol is recognised by the Miquest audit there have been problems in data extraction in practices that use it - I suggest it is best avoided)

The IHD protocol assesses cholesterol for the 0-75 age group prompting once the last cholesterol level is over 1 year old.

Aspirin prophylaxis (Over the Counter)                               EGTONAS1

This is for recording the fact that patients are buying their own aspirin. Although only 1 code is used by the template the Miquest set recognises the following codes as indicating 'On own aspirin' 8B3B, 8B63, EGTONAS1.

In the IHD protocol the 'check on own aspirin' message for those without a CI and not being prescribed aspirin comes up regardless of whether or when the code for on own aspirin was last entered. This is to cover the possibility of patients stopping their aspirin without telling the clinician. It will also come up if a patient has not been issued a prescription for aspirin recently, prompting discussion of the issue.

Hypertensive Disease NOS                                    G2z

This template is there for hypertension coding. There are 3 general categories as per BHS guidelines – established hypertension, BP under assessment and borderline BP under annual review. For established hypertension there is the option of further defining the type of hypertension by using the subcodes, some of which are slightly odd read codes from the hierarchy. In practice you’ll mostly use essential, systolic and secondary hypertension codes. HBP in this template is an abbreviation for High Blood Pressure.

Diabetic monitoring                                            66A

This sub-template provides a simple diagnostic coding for diabetes using a dual coding system C10 for diabetes and C108-2 and C109-2 for type I or type II. This template will be used in any forthcoming diabetes template.

Glucose tolerance test                                        44V

The complexity of this template, including many different measurements of glucose reflects the general uncertainty about using the GTT in screening CHD patients, which many clinicians feel is unrealistic. The other possible candidates for screening were therefore included. The Miquest set reports the different tests used for information. If agreement can be secured on what is required then this unsatisfactory template could be simplified. There is also an issue with path links in that the lab dose not distinguish between fasting & random glucose and so these need to be coded by the practices.

Some people don’t like the picking list for GTT as it appears to include irrelevant stuff. This prompt simply takes all the child sub-codes. If required it can be re-written using a defined pick list.

Body Mass Index                                              22K

Hopefully self explanatory! The BMI is automatically calculated when weight data is entered if there is already height data present. NB the Miquest set looks for BMI, not weight - so it is important to ensure the BMI field is also completed when weight data is added. Weights and heights can be entered in Imperial measures and EMIS will automatically convert to metric. Eg enter 10 stone 12lb as 10S12 and 5' 6" as 5F6 . Why Waist circumference? This was included in anticpation of the need to reuse this subtemplate in a CHD risk assessment template. There is evidence to suggest that this might be a better CHD risk indicator than BMI alone.

The IHD protocol prompts for BMI checks once the last record is over 1 year old. It prompts for advice if the data is in date and no advice has been recorded in the last year.

Urine test for glucose                                        466

See GTT

U-S heart scan                                                       5853

This template is for recording the results of investigations for assessing left ventricular systolic function. The result of the test and the nature of the test should be dated the date of the test. Aspects of the test result other than LV function can be added as free text. At present the duration for which a normal scan can be said to be valid is unclear. The Miquest set looks for the latest LV function code, taking that as indicating current LV function for the purposes of audit of ACE prescribing. The code for LV dysfunction also is one of the dual codes for heart failure.

Adverse Drug Reaction (ADR) / Contraindication (CI) Templates

The following sub-templates deal with patients who have contraindications or adverse reactions to drugs used in CHD secondary prevention. If there is a specific reason why a patient cannot take one of the drugs this should be recorded here. This will then be picked up by the Miquest set. The problem here is that EMIS effectively has two parallel systems for recording drug ADRs and CIs - its own system based on its coding system for drugs and the Read Code system. This is further complicated by the fact that it is not possible to enter EMIS ADR codes into templates, only into its drug allergies module. Additionally (at the time of writing), the prescribing module does not recognise Read Coded ADRs and so will not provide warnings on Read coded data. The system here uses Read Codes as this is used by other systems and will probably eventually be the favoured approach. Protocols, however, can recognise (some!) EMIS ADR codes and so this has been incorporated into the protocols as far as possible. The Miquest set also recognises both systems and so will count patients whichever system is used. Practices need to decide which approach they want to take; either will give adequate audit results. The Miquest set only counts ADRs or CIs on patients who are not taking the drug as it assumes that if a patient is not on a drug and there is an ADR/CI code present, that that is the reason. This is to cope with the fact that some patients do take drugs that would appear to be contraindicated (e.g. aspirin and warfarin) for good clinical reasons.

AR - other antihypertensives (ACE)                          TJC7

AR - betablockers                                            TJC6

Aspirin prophylaxis discussed                                 EGTONAS2

AR - antilipaemic drugs                                               TJC2

Exercise grading                                                       138

This sub-template originally contained many exercise codes but this was found to be too complicated and confusing and in danger of worsening the already low level of recording of exercise. A simple scale of exercise level codes was therefore chosen, which is more likely to be used. Those GPs wanting to record more detail can either add in free text or add other codes to the template. However, the Miquest set only looks for the codes currently in the template.

The IHD protocol prompts for exercise checks once the last record is over 1 year old. It prompts for advice if the data is in date and no advice has been recorded in the last year.

Tobacco consumption                                          137

This should be self-explanatory. Free text can be added to detail any advice given. There is no current read or EMIS code for referral to smoking cessation clinic and so a chronic disease smoking code is being used by convention to avoid the use of local codes. Free text entry should make it clear what referral is being made. A change will need to be made to the template when one becomes available

The IHD protocol prompts for a smoking record annually in those previously recorded as smokers or those with no record. It prompts for data every 4 years in those whose last smoking record indicated they were a non-smoker. This saves time and irritation by stopping the clinician recurrently asking the non-smokers about their non-habit.

Alcohol                                                                                                136

This template was not in the original system as the audit did not cover alcohol. It has been inserted by popular request. Because of this the original instructions omitted it from the list of templates and so it may not have been added to the hierarchy. This should be done in exactly the same way the other templates were. Failing to do so will not affect it however, it simply means that this template will not be directly accessible through the hierarchy. The template uses EMIS codes for alcohol intake (EGTON418) as in the past the Read Codes did not seem to work well with the EMIS Miquest interpreter. This may need to be changed to Read Codes in the future. The alcohol advice code used is a read code.

This does not appear on the IHD protocol front sheet for lack of space but is offered as a data input option.

Ischaemic heart disease                                              G3

This template is simply a concatenation of the above sub-templates, putting the most frequently used ones near the top for easy access. This template and IHD protocol can be used for other atherosclerotic disease as the data requirements in the CHD NSF for IHD, Peripheral vascular Disease and ischaemic stroke are the same.