Q: I have a number of patients taking warfarin and therefore unable to take aspirin. My concern is that this might not be picked up in the audit.
Answer: No problem - the Miquest audit counts patients who are not on aspirin, but have been prescribed warfarin in the year running up to the audit, as a contraindication. The practice just needs to us the computer to prescribe warfarin and the audit will pick it up.
Q: I feel the audit process should be able to identify if patients DNA their appointments
Answer: DNA is not part of audit for 2 reasons
1) it is not part of a PCAG audit criterion
2) identifying DNAs as part of the audit would break patient confidentiality
However, we will look into this useful
suggestion as part of the Recall set
Q: Our Doctor is
happy to convert the read codes. How
easy is it to transfer the data from the existing CHD template into the PCAG CHD
template? Would it be better just
to revise the codes and customise the existing template to include IHD, MI and
Angina codes, so we are collecting/recording data necessary to improve patient
care and undertake the MIQUEST audit? Any
advice would be appreciated.
Answer: The issue here is codes not templates. The data in EMIS is actually held 'within' a template at all, so it is meaningless to talk about transferring data from one template to another. The templates are merely a way of displaying the read codes available in a patient's record. The issue is rather will the template they end up using 'display' the codes they have converted. Therefore there are two possible options to this problem:
Option
1. Convert the codes as I suggested and then edit the existing template
to use the agreed codes & add the diagnostic codes. This would have the
advantage of retaining data that the
practice may find useful for codes that are not converted e.g. On warfarin
(LOCALCODEON5), as well as retaining the basic pattern of the template which
they are familiar with.
The disadvantage
would be that it would not integrate with the new diabetes and heart failure
protocols, which have all been designed around a common core of sub-templates
for smoking etc. However, a problem would arise if PCAG decided to revise the
sub-templates, because they could not be automatically updated. Also the
template would not include the diagnostic coding for other aspects of the NSF
e.g. A, PVD etc - although they can load the diagnostic template separately from
the website.
Option
2. Convert the codes, but load the PCAG template/protocol for use in the
practice. It would be possible to modify various parts to suit your
practice. The only disadvantage would be the practice getting use to a new &
probably longer template, although they could use the shorter version as well.
Providing the
coding is right both methods would be compatible with the audit &
housekeeping queries
Q: I
am working
on the Alcohol Consumption codes in my practices, converting them from EGTON418
to the new code 136. However, I was
talking to a colleague about the PRIMIS audit, which looks at the READ codes
1361, 1362 (i.e. it actually looks for a numeric value).
I am
therefore worried that by using 136, we are just putting in an unknown
value for the consumption and so losing data quality.
Answer: PCAG are using the code 136, however when people enter the amount of alcohol consumed per week, a value (the number of units per week) is attached to the 136 code. Hence, there is no loss of data quality and the actual value is what the Miquest queries search for in deciding whether males or females are over the recommended weekly intake (14 units for women and 21 units for men).
The
problem with read codes is that some can have values associated and some can use
specific codes like 1362, to code the amount consumed. The problem with the
1362-like approach, is that the code 1364 '3-6 units a day' does not allow you
to tell if a male is consuming 21 units, an acceptable level, or 42, a health
damaging level. These codes are also a problem if the recommended acceptable
alcohol consumption changes, whereas if we are working with the value there is
no problem. Incidentally the HIP for CHD EMIS protocol uses 136 like PCAG,
with a value attached. The EGTON418 code records intake by attaching a value and
when you make the code conversion that value is transferred to 136 i.e. without
loss of data.
Nationally
people are using values associated with EGTON418 or 136 and have been since EMIS
started. AFAIK, the templates installed with the EMIS system by default, use
values associated with the above codes - so every EMIS practice in the country
will actually be recording alcohol intake in this way. Hence, there
will literally be millions of entries coded this way throughout the country and
no one is going to edit them all to 136 sub codes!!!
PRIMIS
must have considered this, so we must ask whether the colleague has got her
facts right?
Q: I have a
practice where we have transferred to the PCAG template but there is some data
with different codes. I note that the read codes used in template for Angio
should be 554, would this include angios recorded with codes 55 or 55-2?
They have also recorded this info in
synonym code 7939-1. For echo it should be 5853, would this include code 5853-1?
Answer:
Where possible it is a good idea to avoid the synonym codes i.e. codes ending
with '-2' etc ( note: this is unavoidable for diabetes Type1/2). However, we do
think that Miquest queries will pick up synonym codes, for instance 5853-1 will
be picked up but 55 and 79 will not. The 554 codes do not really feature in the
audit anyway - so not a significant problem
Q: A
surgery on EMIS LV writes - most of our patients buy their own aspirin,
so we are using the 'Buying Own' code. However, the CHD Protocol indicates
that Aspirin has not been checked, even though I have recorded it as 'Buying
own'. I am also worried that this
will not be picked up on the Audit, is this so?
Answer:
The own aspirin code has to be added annually at the review for it to be
picked up in the audit, because a patient could stop taking their own aspirin
without telling you. Hence, the presence of a 'buying own aspirin' code that is
over a year old, is not considered a good guide that the patient is still taking
aspirin and so the protocol will ask for the code to be refreshed. If you
go into the 'own aspirin' template section, it will show when this code
was last entered
Q: I was
demonstrating data entry on the "on own aspirin" template in the IHD-PROTOCOL,
when I realised that nothing was being shown on the IHD summary screen and that
it was still prompting me to check whether the patient was taking aspirin
Answer: The
Protocol checks to see whether the code for aspirin prophylaxis has been entered
in the last year or whether the patient has been recorded as having a
contraindication to aspirin. If they've not been prescribed it and the
code is absent, it gives a message to 'Check on own aspirin'. If the code is
present it asks you to 'ensure on own aspirin'. If you've just entered the code
it will therefore still bring up the message 'ensure on own aspirin'. The
problem with programming this is that patients may stop taking OTC aspirin
without telling you and could have done so any time since it was last recorded.
So what cut off do you take because whatever time period you choose there will
always be patients where a problem will arise. We took the decision to have a
one year cut-off, rather than asking if the code has been added in the last day
or 2 days or....
Q:
A Surgery on
EMIS LV system using the CHD protocol writes: I start by going into the CHD
protocol and to see what needs updating, e.g. smoking not recorded.
I then goto the list screen and press "A" for the smoking
template. Once I have added
the information I press either return until the end or F8 to get back to list
again. The screen is now showing
that the smoking information is not missing.
I then press F8 to leave the protocol.
However when I return to the protocol again, the information is not
recorded and it is flagging that Smoking status is needed still.
Answer: This
could happen if you leave another template by pressing F1 at any stage after
entering the smoking data. NEVER EVER EVER PRESS F1 in a protocol -
you'll lose data entered in templates during that execution of the protocol.
Q. GMS2 has resulted in a load of new codes being released for heart failure. How has PCAG handled this?
Answer: The newly released codes for GMS2 and the abandonment of dual coding have necessitated a revision of the suggested coding for the heart failure register.
Previously we were also hamstrung by the lack of specific codes for LVSD and LVDD
The original version was:-
G58 Heart Failure and one or more of G581 Left ventricular failure (usually taken to mean LVSD), G54z5 Valvular Heart disease
or G58z for Other cause, with additional coding as needed for echo results.
After
discussion with Dr Salkin (Heart Failure Lead City East PCT) we have come up
with the following suggested coding for the heart failure register...
G5yy9 Left ventricular systolic dysfunction OR G5yyA Left ventricular diastolic dysfunction
AND / OR
G58z Heart failure NOS for other causes including valvular heart disease and other causes of heart failure
AND / OR
G58 heart failure for cases where the patient has the syndrome but where the clinician is unable to define the cause in more detail but needs to add a code.
(There is a case for not adding heart failure codes until echocardiography gives
the definitive diagnosis; however there will always be situations where
echo is non-diagnostic or is declined / not appropriate)
Any or all of these codes can co-exist in a patient's record (with the exception
of G5yy9 and G5yyA, which, by the definition of LVDD, are mutually exclusive) as
we no longer are dual coding.
(We have dropped G54z5 Valvular Heart disease because without dual coding it cannot be associated by convention with G58 to indicate heart failure due to valve disease. Subsuming it with
'Other' causes does not result in significant loss of discrimination for the purposes of audit)
Housekeeping searches look for the above codes and confirmatory codes such as echocardiography result codes, NYHA codes etc
This new coding is now included in the latest LV templates for heart failure on
the website.
Confirmation by echocardiography can be recorded by use of the echo codes in the template.
This approach is consistent with GMS2 but will also allow effective coding of heart failure that does not fall within Q+O framework.