Local READ Code Formularies and Templates EMIS NUG

Local READ Code Formularies and Templates EMIS NUG conference th 6 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? n READ codes – facts and tips n READ code formularies n Development u Implementation u Maintenance EMIS templates Future developments u n n

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

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

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.

Anatomy of a READ code G 304.

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

Anatomy of a READ code 5 characters G…. Chapter heading ( circulatory diseases) G 3… Ischaemic heart disease G 30. . Acute Myocardial infarction G 303. Acute inferoposterior infarction

Hypertensive Disease(G 2) Circulatory System Disease Ischaemic (G. . . ) Heart Disease(G 3) Benign Essential Hypertension (G 201) Secondary Hypertension(G 24) Acute MI (G 30) Angina Pectoris (G 33) TIA (G 65) Cerebrovascul Stroke and CVA ar unspecified (G 66) Disease(G 6) Subarachnoid Haem. (G 60) Level One Codes Level Two Codes Level Three Codes

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

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

What do all the abbreviations in the Read Codes mean? n n n n 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

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 Otherapeutic procedures 9 Administration

What does it mean when a term starts [V], [X] etc? n n n 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.

Pitfalls n Context vs. coding: - Angina ? = have they got angina. Angina [G 33] ? [Free text] = this patient has angina

Finding the right code

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

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

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

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

READ code prioritiser (GPASS)

READ code browsers http: //www. cams. co. uk/browsers. htm Suite of browsers, including: • Tree Browser • Read Code Comparison Tool • Read Codes GP 4 -byte, Version 2 and Version 3 • Read Code Subset Wizard • Beginner's User Manual

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

EMIS templates Data entry forms invaluable for u Saving time u Standardising data recording u Clinical prompts n Can be shared between practices n

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

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

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

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

READ version 3 n n n 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

READ version 3 n Qualifiers allow addition of detail to "core terms". For example; Inguinal herniorrhaphy using sutures may be qualified by; Priority -Scheduled Revision status -Repair of recurrence n 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

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

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

Visit this webpage for links www. wansford. co. uk/codes Email Amrit@btinternet. com