Local READ Code Formularies and Templates EMIS NUG conference 6th September 2001

1
Local READ Code Formularies and TemplatesEMIS
NUG conference 6th September 2001

• Dr Amrit Takhar
• General Practitioner
• Wansford , Peterborough
• www.wansford.co.uk

2
How many READ codes?

• READ version 2
• (5 byte)
• 107,000

3
Outline of todays session

• Why coding is important?
• READ codes facts and tips
• READ code formularies
• Development
• Implementation
• Maintenance
• EMIS templates
• Future developments

4
Why use READ codes?

• Data quality
• improving standards of care
• income generation (IOS claims)
• Clinical Governance
• Audit and Research
• Decision support systems
• Communication between systems

5
Why use READ codes?

• Link to Templates, Protocols Prodigy
• Link to previous consultations using same code
• Activate drug warnings, interactions,
  contraindications
• Referral letters with coded details automatically
  added
• Helps ensure claim for items of service

6
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.

7
Anatomy of a READ code

• G304.

8
READ code facts

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

9
Anatomy of a READ code

• 5 characters
• G. Chapter heading ( circulatory diseases)
• G3 Ischaemic heart disease
• G30.. Acute Myocardial infarction
• G303. Acute inferoposterior infarction

10
My choices of codes will then be as follows
11
READ code chapters

• Symptoms Chapter 1
• Examination Chapter 2
• Investigations Chapters 3-8
• Administrative Chapter 9
• Diagnoses Chapters A-S
• Medication Chapters a to s

12

• 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

13
What do all the abbreviations in the Read Codes
mean?

• 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

14
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 Other therapeutic procedures
• 9 Administration

15
What does it mean when a term starts V, X
etc?

• 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.

16
Pitfalls

• Context vs. coding-
• Angina ? have they got angina.
• Angina G33 ? Free text this patient has
  angina

17
Finding the right code
18
(No Transcript)
19
(No Transcript)
20
(No Transcript)
21
Formulary benefits

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

22
Formulary how to

• Written version on paper, on website, in excel
• Create your own hierarchy in EMIS
• Templates
• Synonym access (_at_
• Wish list
• Import/export a Code formulary option

23
Formulary by Synonym access

• _at_OM Acute Right Otitis Media,
• Acute Left Otitis Media, Acute Bilateral
  Otitis Media etc
• _at_URTI has various pharyngitis/tonsillitis
• _at_Heart
• _at_Mental

24
Formulary choosing your codes

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

25
(No Transcript)
26
(No Transcript)
27
READ code prioritiser (GPASS)
28
READ code browsers

• http//www.cams.co.uk/browsers.htm
• Suite of browsers, including
• Tree Browser
• Read Code Comparison Tool
• Read Codes GP4-byte, Version 2 and Version 3
• Read Code Subset Wizard
• Beginner's User Manual

29
(No Transcript)
30
(No Transcript)
31
(No Transcript)
32
Implementation options

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

33
EMIS templates

• Data entry forms invaluable for
• Saving time
• Standardising data recording
• Clinical prompts
• Can be shared between practices

34
EMIS templates

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

35
(No Transcript)
36
(No Transcript)
37
Template options

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

38
(No Transcript)
39
Template sharing

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

40
Sharing templates

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

41
(No Transcript)
42
(No Transcript)
43
(No Transcript)
44
(No Transcript)
45
(No Transcript)
46
READ version 3

• 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

47
READ version 3

• 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
• 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

48
(No Transcript)
49
The Future of coding

• Changing to SNOMED CT
• Improved formulary creation and sharing
• Code transfer between hospitals and GPs
• ( starting in pathology EDI)

50
Todays session

• Why coding is important?
• READ codes facts and tips
• READ code formularies
• Development
• Implementation
• Maintenance
• EMIS templates
• Future developments

51
Visit this webpage for links www.wansford.co.uk/co
des
Email Amrit_at_btinternet.com