Title: East of England QOF Development Network
1East of England QOF Development Network
- Thursday 29th May 2008
- Hilton Stansted Airport
2Welcome and Introduction
- Rebecca Thornley
- PCCA, NHS East of England
- NHS Primary Care Contracting
3East of England QOF Development Network
- Thursday 29th May 2008
- Hilton Stansted Airport
4Where are we with QOF?
- Philip Leech
- Medical Advisor
- NHS Primary Care Contracting
5Progress on QOF health, illness and planning
prevention in primary medical care
Philip Leech
5
6So much going on.
- Pharmacy WP
- (Primary and Community Care strategy)
- NIT report
- BME report
- Big Darzi
7Dickson on Darzi.
- The review is expected to produce the right
answer for the. - reconfiguration of services
- quality and safety of care,
- constitutional and accountability arrangements
for NHS services, - right combination of incentives,
- future of health care leadership,
- right pathways of care, and
- future shape of GP and community services.
7
8So much going on.
- Pharmacy WP
- (Primary and Community Care strategy)
- NIT report
- BME report
- Access strategy
- Big Darzi
- Cardiovascular screening
- Refresh of Health Inequalities
- Accreditation and Registration
- And..and..and.
9Despite policy commitments to focus on health and
well-being, the nationally negotiated contractual
arrangements for primary medical care contain few
incentives for health promotion or illness
prevention
9
10The incentives in the Quality and Outcomes
Framework for evidence based quality care are
predominantly focused on diagnosis, management
and secondary prevention of long term conditions.
10
11What do we want to achieve and where do we want
to achieve it?
11
12Both quality of care and staff satisfaction have
improved since the introduction of the QOF. But
there are issues we need to address to ensure QOF
continues to improve quality of care for patients
12
13So what are the issues we need to address to
ensure QOF continues to improve quality of care
for patients ?
13
14Is there an opportunity for a coherent approach
to interventions for a number of the major
disease areas?
Key challenges
Key questions at this stage (avoid thinking in
terms of QOF or DESs!)
14
15Population Health Measures
Partnership Vision and Strategy Leadership and
Engagement
Frontline Health Services
Community Engagement
16Achieving Percentage Change in in Population
Health
- Programme characteristics will include being -
- Evidence based concentrate on interventions
where research findings and professional
consensus are strongest - Outcomes orientated with measurements
locally relevant and locally owned - Systematically applied not depending on
exceptional circumstances and exceptional
champions - Scaled up appropriately industrial scale
processes require different thinking to small
bench experiments - Appropriately resourced refocus on core
budgets and services rather than short bursts of
project funding - Persistent continue for the long haul,
capitalising on, but not dependant on fads,
fashion and policy priorities
17Where should we be looking?
18individual risk management
Indicators for
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24How to add value to QOF CHD (with thanks to NST)
- Calculate an expected prevalence of CVD by
practice, and compare with actual numbers on
registers. Work on verification with practices
showing discrepancy. Address gaps by - improving patient capture from records
- improving practice of screening high risk
patients - recruit community staff to case finding
- Have strict criteria for exceptions and
exclusions from registers for QOF purposes. - Audit records of excepted and excluded patients
excluded. - Ensure excepted patients have a care plan -
they are likely to be high risk, and should be
targeted. - Establish from QOF scores which practices are not
claiming full points for CHD5/Stroke 5 ( of CVD
patients with BP recorded) and/or CHD7/Stroke 7
( CHD patients with cholesterol level recorded). - Review their register and its management systems.
- Do they have sufficient staff time for the annual
review of patients? - Where maximum points are claimed, audit a sample
of notes.
25How to add value, continued.
- 6. Establish from QOF scores practices with scope
to improve overall effectiveness of clinical
practice, i.e. those not obtaining maximum points
for CHD6/Stroke 6 ( CVD patients where last BP lt
150/90) and CHD8/Stroke 8 ( CVD patients where
cholesterol lt 5 mmol/l). - Work to ensure these practices a) clinically
follow NSF/NICE guidance, and b) have strategies
to improve patient adherence to therapy. - 7. Audit practices claiming maximum points for
CHD6/Stroke 6 and CHD8/Stroke 8 to verify
outcomes. - Examine output from the computer search
generating the data. - Inspect a sample of records where target outcome
is claimed. - 8. Consider a Local Enhanced Service (LES) /
bonus payment for CHD6/Stroke 6 and CHD8/Stroke 8
outcomes between 70 90 . Reflect this also in
PMS and APMS contract specifications. - 9. Promote systems of medicines management and
patient adherence to therapy based on active
assessment and appropriate support based on
cultural and language requirements. - Ensure referral of newly diagnosed angina for
exercise testing and specialist assessment. - Follow up to ensure attendance and implementation
of ensuing care plan.
26Code of Confidentiality
- Where practices are unable to anonymise
records, those who act on behalf of PCTs are
entitled to access non-anonymised records either
for NHS management purposes (if they are
themselves under a duty of confidentiality) or to
check a persons legal entitlement to payment. It
is not necessary for practices or PCTs to inform
individual patients that individual records will
be accessed for such purposes, nor to seek the
consent of individual patients to obtain access
to individual records in such circumstances.
Nor, in the view of the Department, would such
access constitute a breach of the data Protection
Act."
27Three hurdles.
- Software has been procured for the purpose
- Informed patient consent
- If 1 or 2 not possible then anonymise records
- ONLY if 1, 2, and 3 cannot be achieved
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29East of England QOF Development Network
- Thursday 29th May 2008
- Hilton Stansted Airport
30Refreshments are being served in the foyer area
- Please be ready to start the next session at 11.10
31Using QMAS Apollo
- Paul Carnduff
- Insight Solutions
32Apollo QMAS Exceptions
- Paul Carnduff
- Insight Solutions
33Who are Insight Solutions?
- Independent Primary Care IT Training Consultancy
- Unique in that we can provide clinical system
training across all main systems - Flexible approach to the restrictions you face
with training - Budgets
- Time
- Staff availability
34Who are Insight Solutions?
- Experts in Primary Care QoF, IMT DES, Enhanced
Services other NHS initiatives - Accredited training provider for
- Welsh Assembly Government
- Many 3rd party software providers
- Ensure that you get the best possible investment
out of your training
35Ethical Disclaimer
- Most of the information provided in this
presentation is fact, however, is open to
interpretation opinion - It is a practice decision as to whether you
choose to implement any of the changes
36Agenda
- Apollo toolkit
- QMAS
- Exception coding
- Triangulating with other sources
- Suggestions
37Apollo Assessor Toolkit
- Commissioned by DH
- Criteria set by DH
- Initial problems
- Downloading
- Working on some systems
- Conflict with other software
- No change to functionality but problems sorted
38Apollo Assessor Toolkit
- Confidentiality a big issue
- Data must be anonymous
- Each patient given a unique identifier
- No free text requirement of commissioning
- Not perfect but another tool to use
- Excel spreadsheets
39Apollo Assessor Toolkit
- Not to be confused with other Apollo software
- No dial in from Apollo
- Practice can be in control of data extract
- Wizard scheduled to run once a week but this can
be altered - Emailed to PCT as often as needed
40Apollo Assessor Toolkit
- Compatible with all major computer system
- On going project
- If assessment imminent and download not complete
Apollo will assist need to notify them - Requires downloading and installation at other
practices prior to visit. - Worth checking with the practice as to the status
of the software.
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46What is the purpose of toolkit?
- Pre assessment information being available for
the assessors better informed assessors - On going information about practices achievements
emailed to PCT in order keep track of points and
perform spot checks - Practices not supplying data high priority
for post evaluation check
47What reports are generated?
- Blood Pressure
- All Disease registers that require blood pressure
recording - For each patient the actual BP Readings and dates
of recordings - Patient Exceptions
- All disease areas where exception codes have been
used, the actual code and date of recording
48What reports are generated?
- Random Selection of Patient Records
- List of 20 randomly selected patients
- All QoF related entries for previous 2 years
- Patient specific Reports
- Can only be run manually
- Typically carried out on day of assessment by QoF
Assessor - Assessor can reproduce all the automatic reports
on day of assessment
49Manipulation of Data
- Uses Excel
- Need to have an understanding of Excel and how to
apply filters - Reports to prompt searching questions for the
assessor to ask on the day of visit
50Apollo Support
- Apollo happy to help with problems
- support_at_apollo-medical.com
- Apollo able to tell which practices have
attempted download - Instructions for running the wizardhttp//www.apo
llo-medical.com/qof/documents/QOF20AVRG20Wizard
20Instructions.pdf - Screenshots and general guidancehttp//www.apollo
-medical.com/qof/
51Exception Coding
- Must not use exception codes to replace good data
quality - There may not be an excepting code for every
scenario - The 10 at the top of the threshold is there to
mop up such issues - Used to show a practice has offered good care
but unable to meet the criteria
52Exception Reporting
- Can either
- Remove patient from the whole register
- Group Exceptions
- Or
- Remove patient from individual indicators within
a disease register - Single Indicator Exceptions
53Prevalence
- Disease prevalence figures not effected by
exception codes - Disease registers counted excluding exceptions
- i.e. 72 Stroke Patients 2 with exception high
level codes 70 patients to record data but
prevalence is still 72
54QMAS and Exceptions
- Breakdown of Exception Codes
- Gives an opportunity to compare
- Also shows exclusions as an exception
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56Group Exceptions - Unsuitable
- Not acceptable to use a group exception code to
meet the need of a single indicator - E.g. Diabetic patient with lower limb amputation
not able to record accurate BMI, but no
exception code for Diabetic DM2 - Patient too Frail
- No benefit to patient
- Terminally ill
- When a patients is added to palliative care
register practice may consider adding group
exception code for other registers
57Group Exceptions - Dissent
- Where informed dissent is added should be 3
invites coded into patient record - Ignored by patient
- At least a month apart and all coded
- 1st, 2nd, 3rd, Telephone or Verbal
- Free Text to support
- Expires Annually
- Not acceptable to add at as bulk entries each
patient to be assessed on own merit - Not acceptable to add at beginning of year and
if patient attends record entries
58Single Indicator Exceptions
- Patient happy to be monitored however for
- various reasons cannot/will not comply to all
- indicators within a register.
- Allergies to drugs
- Patient refuses procedure
- Procedure not available
- Too numerous to list here but see separate sheet
of acceptable exception codes - Some expire each year others are permanent e.g.
Allergies
59Maximum Tolerated Doses
- For reasons out of the doctors Control the
targets set within the register cannot be met and
there is no benefit to increase mediation - E.g Blood Pressure is 200/ 90 and Dr does not
wish to add any more medication to the regime or
increase dosage levels for valid reasons - Patients medication is being monitored by
hospital and not the surgery.
Expires annually- good practice to have free text
justification If added by non clinician
reference to the clinician who authorised
60Expiring / Permanent
- Expiring
- Patient unsuitable
- Informed Dissent
- Contraindicated / Not indicated
- Declined / Refused
- Not tolerated
- Maximal tolerated doses
- Lithium stopped
- Permanent
- Allergies
- PH/HO of allergy
- Adverse reactions / PH or HO of Adv reaction
- Removed from MH Register
- Condition resolved
- Hysterectomy codes for smears where cervix is
removed - Exercise Test declined
- Angiogram declined
- Echo declined
61Condition Resolved
- These codes are permanent and should be used
where appropriate - Not an exception code
- Ideal for patients coded with Asthma who have now
progressed to COPD - Practice using 4 byte codes did not have a
specific code for gestational diabetes and
therefore might have added diabetes resolved once
pregnancy over. Not necessary in 5 byte as the
code for Gestational Diabetes is L1808, L1809
and does not interfere with contract doing
62Multiple exception codes
- CHD
- CHD9 Anti-platelet must have exception for all
three - CHD11 Aces and A11s must have both
- Stroke
- Stroke9 Anti-platelet must have exception for all
four - Exception code after every new stroke
- AF
- AF3 Anti-platelet must have exception for all
four - HF
- HF3 Aces and A11s must have both
- CKD
- CKD4 Aces and A11s must have both
63Management of Exceptions
- Ideally practices should have protocols in place
for - searching for patients who were exception coded
last - year. It should be
- Clear that the patients have been reviewed and
not just - exception coded this year because they were
last year. - Free text should be explanatory and indicate who
authorised the code if it was not added by
clinician - Free text should never contradict any coding in
patient record - Patients should always be encouraged to attend
for screening and every effort should be made to
gain commitment from patients
64Identifying Codes used
- Apollo Software Exception report gives full
details dates, codes etc. for group exceptions - Free text is not be attached to report
65Summary
- Exception codes must not be used as an
alternative to practices tidying up their data - Evidence to support the code e.g. free text,
Invite codes etc. - Management process in place
- Practice to understand the rules
66Overview of Clinical Systems
- EMIS LV
- EMIS GV
- EMIS PCS
- iSOFT Premiere
- iSOFT Synergy
- iSOFT Ganymede
- Vision
Population Manager
Contract QE (From Supplier) Or full version
(Purchased)
Clincial Audit
67Contract
- QMAS Edition
- Limited functionality but adequate to do the job
- Provided through iSOFT
- Supported by iSOFT
- Uses 31st March or today as Reference date
- Full Version purchased by practice
- Supported by Informatica
- Much more functionality
- Both Versions full accredited for QMAS
68Vision Clinical Audit
- Integrated into Vision
- Lists patients with data
- Lists patient without data
- Achievement of
- Many Searches other than Contract
- No calculation of points so far
- Reference Date
- Pop up reminders in Patient Records
69EMIS Population Manager
- Integrated into EMIS LV GV PCS
- Lists of Patient with data
- Lists of Patient without data
- Achievement of
- Achievement of Points
- No automatic pop ups but can ask for missing data
within the patient record - Reference Date today can give false impression
- Able to see which read codes it searches on
- Does include some EMIS /Egton codes that are not
true read codes.
70Other Support software
- MSDi
- QMS
- Apollo SQL
- Chart (PRIMIS)
- Not accredited with QMAS
71Suggestions
- Prevalence
- Is practice aware of local/national average?
- How do they compare?
- Exception Coding
- Free text qualifiers
- Updated
- Using codes to remove incorrect diagnosis
- Summarising
- Up to date
- Correctly Coded
- Comprehensive
- Policy
72Suggestions
- Medication Management
- Full review completed
- Have old medications been removed
- If disease related MR coded have all meds been
checked? - Who is carrying out the review if coded by
admin why?
- medication linked to indication
- Does practice know how to look for 4 or more if
not how can they be sure they have achieved this? - EMIS Routinely asks if Dr wants to add code when
in prescribing mode easy to say yes
73Suggestions
- Look for clustering of BP reading just under
150/90 or 145/85 for diabetes - If numbers look quite high is appropriate
number of them on hypertensive medication - How well is data distributed throughout the year
if all readings are with the last few months of
the year what benefit to patients - No of patient diagnosed with hypertension but no
medication being issued - Apollo software helps with this
74East of England QOF Development Network
- Thursday 29th May 2008
- Hilton Stansted Airport
75Panel Discussion and QA
- Thursday 29th May 2008
- Hilton Stansted Airport
76Lunch is being served in the Restaurant
- Please be ready to start the next session at 13.30
77Round Table Discussions
- Hot Topics
- QMAS and Apollo
- Exception Reporting
- Action Planning/Further support requirements
78East of England QOF Development Network
- Thursday 29th May 2008
- Hilton Stansted Airport
79Next Steps
80Thank you for attending
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