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

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


1
Local READ Code Formularies and Templates EMIS
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
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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

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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

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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

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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

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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.

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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

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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
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