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) Screen set up (we use INPS Vision but the principles should apply to any system) Read Codes Read Codes Guidelines Guidelines Disease Registers Disease Registers CDM areas CDM areas Exception reporting Exception reporting Other data to collect Other data to collect Medication reviews Medication reviews Smears Smears Capturing Data/Summarizing Capturing Data/Summarizing Clinical Audit Clinical Audit QOF and QMAS QOF and QMAS

Screen showing NSMC view -

Guidelines Enable essential data to be collected consistently Enable essential data to be collected consistently Make sure correct Read Codes are being used Make sure correct Read Codes are being used Have been customised by INPS and NSMC Have been customised by INPS and NSMC Care & commitment needed to use correctly Care & commitment needed to use correctly

Read Codes - 1 We have a Read Code formulary for every patient contact – clinical & administrative We have a Read Code formulary for every patient contact – clinical & administrative We aim to use codes that are straightforward and Contract-compatible We aim to use codes that are straightforward and Contract-compatible We use Guidelines We use Guidelines We use Keywords = mnemonics We use Keywords = mnemonics We use Holding Codes when diagnosis not yet established We use Holding Codes when diagnosis not yet established

Read Codes - 2 Use Read Code at top of hierarchy Use Read Code at top of hierarchy Do not use “H/o …” codes Do not use “H/o …” codes Do not use “PMH of …” Do not use “PMH of …” We use Priorities rather than Problems We use Priorities rather than Problems Crucial to use the Recall facility and use it correctly 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 Avoid multiple entries of same diagnosis as “new diagnosis actions” would then apply e.g. angina

Disease Registers Crucial for the new Contract Crucial for the new Contract Need to ensure right patients are in the right register 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 No need to use the set “registers” in Vision now - Asthma, CHD, DM, HT – because Virtual registers best i.e. the diagnostic code Virtual registers best i.e. the diagnostic code Need to clean registers – to correct inaccuracies and to determine prevalence Need to clean registers – to correct inaccuracies and to determine prevalence System needed for capturing new patients/diagnoses System needed for capturing new patients/diagnoses

Asthma Those prescribed asthma related drugs in past 12 months with Read Code H33 Those prescribed asthma related drugs in past 12 months with Read Code H33 Could use active and inactive register 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 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 Need to validate with those with respiratory drugs but no diagnosis

Cancer Cancers excluding non-melanotic skin cancers diagnosed after 1/4/03 Cancers excluding non-melanotic skin cancers diagnosed after 1/4/03 Virtual register fine if coding correct Virtual register fine if coding correct Using appropriate Read Codes in B hierarchy – put Neoplasm as well as diagnosis Using appropriate Read Codes in B hierarchy – put Neoplasm as well as diagnosis Care over event type – has to show as “First ever” Care over event type – has to show as “First ever” Cancer review is straightforward Cancer review is straightforward

COPD Register made by appropriate Read Code = H32 Register made by appropriate Read Code = H32 Confirmation of diagnosis since April 2003 Confirmation of diagnosis since April 2003 More accurate diagnosis of existing patients More accurate diagnosis of existing patients Sorting out COPD from asthma Sorting out COPD from asthma Finding patients – those on anticholinergics, oxygen, frequent oral steroids, asthmatic smokers over 50 Finding patients – those on anticholinergics, oxygen, frequent oral steroids, asthmatic smokers over 50

CHD Most points available in this area of the new contract Most points available in this area of the new contract G3 hierarchy (except CABG) G3 hierarchy (except CABG) “Referral to cardiology” will bypass some actions and is a useful code “Referral to cardiology” will bypass some actions and is a useful code Validating - Validating - Search Read Codes Search Read Codes Search drugs e.g. nitrates, beta blockers, statins, ACE inhibitors Search drugs e.g. nitrates, beta blockers, statins, ACE inhibitors Lots of cleaning of data has been done Lots of cleaning of data has been done

LVF May be different from patients on CHD May be different from patients on CHD register but may need CHD in addition register but may need CHD in addition Read Code = G58 Read Code = G58 Validate by looking for patients with LVF, Validate by looking for patients with LVF, CCF, Heart Failure and Echocardiography CCF, Heart Failure and Echocardiography Drug searches Drug searches Review those with diagnosis without Review those with diagnosis without echocardiogram echocardiogram

Diabetes Read Code C10 Read Code C10 Double code Type 1 (C10E) and 2 (C10F) Double code Type 1 (C10E) and 2 (C10F) Drug searching on oral medication and blood testing reagents Drug searching on oral medication and blood testing reagents Contract does not require confirmation of diagnosis Contract does not require confirmation of diagnosis At risk pre-diabetics need to be in system At risk pre-diabetics need to be in system

Epilepsy Those currently receiving treatment (in last year) age 16 and over Those currently receiving treatment (in last year) age 16 and over Read Code F25 Read Code F25 Need to validate as there will be some patients taking some anti- epileptic drugs for other reasons Need to validate as there will be some patients taking some anti- epileptic drugs for other reasons

Hypertension Large numbers and therefore workload Large numbers and therefore workload Read Code G2 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) 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 Those on levothyroxine with recorded diagnosis of hypothyroidism Read Code C03 & C04 Read Code C03 & C04 New contract requires TSH in last 15/12 New contract requires TSH in last 15/12

Stroke & TIA Read Codes = TIA (G65), Haemorrhagic Stroke (G61), Non Haemorrhagic Stroke (G64), Stroke NOS (G66) 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 Validation needed because new Contract distinguishes these types of strokes & suggests different actions

Mental Health Entry onto register is discretionary 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 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 Read Code 9H8 = On severe mental illness register Remember Lithium monitoring Remember Lithium monitoring

Exception Reporting - 1 From whole domain or individual indicators From whole domain or individual indicators What could be exception coded? What could be exception coded? Refusal to attend after 3 invitations Refusal to attend after 3 invitations New patients or recently diagnosed New patients or recently diagnosed Not clinically appropriate e.g. perhaps age, frailty Not clinically appropriate e.g. perhaps age, frailty Informed dissent Informed dissent Unable to tolerate Rx Unable to tolerate Rx Maximum medication Maximum medication Another supervening condition Another supervening condition

Exception Reporting - 2 Two levels for each clinical category: Two levels for each clinical category: - High level (Read Codes 9h) – applied to all Indicators within category – need to be noted annually within category – need to be noted annually - Patient unsuitable - Informed dissent - Informed dissent - Indicator level – applied to individual Indicators only - Maximum tolerated medication dosage - Maximum tolerated medication dosage - Drug allergy / contraindication - Patient recently registered - Patient recently diagnosed - Procedure / treatment declined

Exception Reporting - 3 Duration of exceptions: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 or allergies to ALL THREE drug types annually - ACE / A2 contraindicated – needs contraindications or allergies to BOTH drug types annually 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?Who should be excepted at the High level – patient unsuitable and informed dissent? No national or local guidanceNo national or local guidance Practice needs to take a view about thisPractice needs to take a view about this May be appropriate to write a practice protocolMay be appropriate to write a practice protocol

Other data to collect BP every 5 years age 45+ BP every 5 years age 45+ Smoking status age Smoking status age 15-75

Medication Review Needs to be recorded in previous 15 months for those on 4 or more repeat medications 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 All patients on repeat medication – needs to be in SDA in Vision Additional specific disease area medication reviews - buttons Additional specific disease area medication reviews - buttons

Smears – what is needed? Performance – age every 3-5yrs Performance – age 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 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 Audit

Capturing data / Summarizing Agreement in-house about Codes Agreement in-house about Codes Issues around new diagnoses Issues around new diagnoses Protocol for data entry Protocol for data entry External sources - hospitals External sources - hospitals New patient checks New patient checks Community nurses? Community nurses? Nursing homes? Nursing homes? Housebound? Housebound?

Remember non-clinical protocols Points to be earned in the new contract for having practice 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 clinical and need clinical input e.g. Infection Control, Smear Taking Some are not primarily clinical e.g. Health and Safety, Complaints Procedure Some are not primarily clinical e.g. Health and Safety, Complaints Procedure Potentially a lot of work for the practice manager Potentially a lot of work for the practice manager Very tricky without some practice management Very tricky without some practice management

How can we make all this work? Involve everyone - who all have to be committed to the process Involve everyone - who all have to be committed to the process Agree what is important Agree what is important Work together on policies Work together on policies Use different skills within the team Use different skills within the team Value what they contribute Value what they contribute ? Financial incentives – e.g. with set- up money ? Financial incentives – e.g. with set- up money

Some of the North Street team

What is QOF? - 1 Quality Outcomes FrameworkQuality Outcomes Framework The new Contract “scoring” systemThe new Contract “scoring” system Clinical and administrative componentsClinical and administrative components Clinical criteria translate to clickable buttons within GuidelinesClinical criteria translate to clickable buttons within Guidelines

What is QOF? - 2 Points achieved against 146 criteria will affect practice payment in 2005Points achieved against 146 criteria will affect practice payment in 2005 QOF points will not simply be paidQOF points will not simply be paid “Voluntary” assessment provides validation and opens way for payment“Voluntary” assessment provides validation and opens way for payment Stated aims of assessment are to be formative, helpful & developmentalStated aims of assessment are to be formative, helpful & developmental

How points are assessed - 1 Clinical Audit will measure points – Clinical Audit will measure points – correct Read Codes required correct Read Codes required Practices will need to report on QOF Practices will need to report on QOF monthly monthly “The bit in the middle” reports the “The bit in the middle” reports the achievement – this is QMAS achievement – this is QMAS

So what is QMAS? Quality Management and Analysis SystemQuality Management and Analysis System The software that will interrogateThe software that will interrogate practices’ (compatible) IT systems practices’ (compatible) IT systems Can be run from now, fully live by 3/05Can be run from now, fully live by 3/05 Once registered, can get current level of points or forecast level for 31/3/05Once 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 calculationYear-end report used for payment calculation Prevalence will be taken into accountPrevalence will be taken into account Between 2 and 18 Quality Indicators for 11 Clinical Categories, 1 Organisational Category, 1 Additional Services categoryBetween 2 and 18 Quality Indicators for 11 Clinical Categories, 1 Organisational Category, 1 Additional Services category Validated by QOF assessment visitValidated 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 nowFirst 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. DenominatorsOther Indicators are scored against different target populations i.e. Denominators Denominators and Indicators take Exceptions into accountDenominators and Indicators take Exceptions into account Exceptions do not affect Virtual Disease RegistersExceptions do not affect Virtual Disease Registers

QOF Assessment Visits - 1 Start in 10/04 – NSMC will be visited in 1/05Start 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 memberQOF 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 likelyHavering 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 pointsVisiting 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 dataMay 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 anyWill 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,Stated aim is to be light-touch, high trust, low bureaucracy low bureaucracy

QOF Assessment Visits - 3 Will interview representative team from practice & will discuss aspects other than points e.g. patient experienceWill 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 pointsNot a full quality review but will seek to validate QOF points There may be other agendae including a change agendaThere may be other agendae including a change agenda

(Some of the) Unresolved issues Information for visits & amount of preparation by practicesInformation for visits & amount of preparation by practices Time for visits & disruption to normal activitiesTime for visits & disruption to normal activities Confidentiality of clinical dataConfidentiality of clinical data Formative vs. summative usageFormative vs. summative usage Possible aims of PCT vs. aims of practicesPossible aims of PCT vs. aims of practices What happens to all the “other” data?What happens to all the “other” data? Preparation & workload of visiting teamsPreparation & workload of visiting teams Membership and payment of teamsMembership and payment of teams

Data for NSMC on QMAS as at 9/04

Clinical domains - Points

Organisational domain - Points

Total Points