East of England QOF Development Network

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East of England QOF Development Network

• Thursday 29th May 2008
• Hilton Stansted Airport

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Welcome and Introduction

• Rebecca Thornley
• PCCA, NHS East of England
• NHS Primary Care Contracting

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East of England QOF Development Network

• Thursday 29th May 2008
• Hilton Stansted Airport

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Where are we with QOF?

• Philip Leech
• Medical Advisor
• NHS Primary Care Contracting

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Progress on QOF health, illness and planning
prevention in primary medical care
Philip Leech
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So much going on.

• Pharmacy WP
• (Primary and Community Care strategy)
• NIT report
• BME report
• Big Darzi

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Dickson 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.

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So 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.

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Despite 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
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The 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.
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What do we want to achieve and where do we want
to achieve it?
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Both 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
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So what are the issues we need to address to
ensure QOF continues to improve quality of care
for patients ?
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Is 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!)
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Population Health Measures
Partnership Vision and Strategy Leadership and
Engagement
Frontline Health Services
Community Engagement
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Achieving 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

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Where should we be looking?
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individual risk management
Indicators for
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How 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.

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How 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.

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Code 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."

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Three 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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East of England QOF Development Network

• Thursday 29th May 2008
• Hilton Stansted Airport

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Refreshments are being served in the foyer area

• Please be ready to start the next session at 11.10

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Using QMAS Apollo

• Paul Carnduff
• Insight Solutions

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Apollo QMAS Exceptions

• Paul Carnduff
• Insight Solutions

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Who 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

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Who 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

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Ethical 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

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Agenda

• Apollo toolkit
• QMAS
• Exception coding
• Triangulating with other sources
• Suggestions

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Apollo 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

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Apollo 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

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Apollo 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

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Apollo 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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What 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

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What 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

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What 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

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Manipulation 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

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Apollo 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/

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Exception 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

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Exception Reporting

• Can either
• Remove patient from the whole register
• Group Exceptions
• Or
• Remove patient from individual indicators within
  a disease register
• Single Indicator Exceptions

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Prevalence

• 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

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QMAS and Exceptions

• Breakdown of Exception Codes
• Gives an opportunity to compare
• Also shows exclusions as an exception

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Group 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

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Group 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

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Single 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

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Maximum 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
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Expiring / 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

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Condition 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

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Multiple 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

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Management 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

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Identifying Codes used

• Apollo Software Exception report gives full
  details dates, codes etc. for group exceptions
• Free text is not be attached to report

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Summary

• 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

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Overview 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
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Contract

• 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

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Vision 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

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EMIS 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.

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Other Support software

• MSDi
• QMS
• Apollo SQL
• Chart (PRIMIS)
• Not accredited with QMAS

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Suggestions

• 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

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Suggestions

• 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

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Suggestions

• 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

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East of England QOF Development Network

• Thursday 29th May 2008
• Hilton Stansted Airport

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Panel Discussion and QA

• Thursday 29th May 2008
• Hilton Stansted Airport

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Lunch is being served in the Restaurant

• Please be ready to start the next session at 13.30

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Round Table Discussions

• Hot Topics
• QMAS and Apollo
• Exception Reporting
• Action Planning/Further support requirements

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East of England QOF Development Network

• Thursday 29th May 2008
• Hilton Stansted Airport

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Next Steps
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Thank you for attending

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