Points, QOF & QMAS

1. Points, QOF & QMAS VTS Awayday 10/11/04

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

3. Screen showing NSMC view -

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

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

14. Read Codes - 2 • Use Read Code at top of hierarchy • Do not use “H/o …” codes • Do not use “PMH of …” • We use Priorities rather than Problems • 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

15. Disease Registers • Crucial for the new Contract • 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 • Virtual registers best i.e. the diagnostic code • Need to clean registers – to correct inaccuracies and to determine prevalence • System needed for capturing new patients/diagnoses

16. Asthma • Those prescribed asthma related drugs in past 12 months with Read Code H33 • 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 • Need to validate with those with respiratory drugs but no diagnosis

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

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

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

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

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

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

23. Hypertension • Large numbers and therefore workload • 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)

24. Hypothyroidism • Those on levothyroxine with recorded diagnosis of hypothyroidism • Read Code C03 & C04 • New contract requires TSH in last 15/12

25. Stroke & TIA • 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

26. Mental Health • 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 • Read Code 9H8 = On severe mental illness register • Remember Lithium monitoring

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

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

30. Exception Reporting - 3 • 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 • - ACE / A2 contraindicated – needs contraindications or • allergies to BOTH drug types annually • - Buttons within Guidelines to enter all these

31. Exception Reporting - 4 • Who should be excepted at the High level –patient unsuitable and informed dissent? • No national or local guidance • Practice needs to take a view about this • May be appropriate to write a practice protocol

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

33. Medication Review • 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 • Additional specific disease area medication reviews - buttons

34. Smears – what is needed? • Performance – age 25-64 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 • Audit

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

36. Remember non-clinical 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 not primarily clinical e.g. Health and Safety, Complaints Procedure • Potentially a lot of work for the practice manager • Very tricky without some practice management

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

38. Some of the North Street team

39. What is QOF? - 1 • Quality Outcomes Framework • The new Contract “scoring” system • Clinical and administrative components • Clinical criteria translate to clickable buttons within Guidelines

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

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

42. So what is QMAS? • Quality Management and Analysis System • The software that will interrogate • practices’ (compatible) IT systems • Can be run from now, fully live by 3/05 • Once registered, can get current level of points or forecast level for 31/3/05

43. How points are assessed - 2 • Year-end report used for payment calculation • Prevalence will be taken into account • Between 2 and 18 Quality Indicators for 11 Clinical Categories, 1 Organisational Category, 1 Additional Services category • Validated by QOF assessment visit

44. How points are assessed – 3 • First 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. Denominators • Denominators and Indicators take Exceptions into account • Exceptions do not affect Virtual Disease Registers

45. QOF Assessment Visits - 1 • Start 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 member • Havering PCT planning 2.5 hours – how realistic? 4 may be more likely

46. QOF Assessment Visits – 2 • Visiting 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 data • Will 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, • low bureaucracy

47. QOF Assessment Visits - 3 • Will 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 points • There may be other agendae including a change agenda

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

50. Data for NSMC on QMAS as at 9/04