Transcript GroupWare - Lotus Notes

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?
 READ codes – facts and tips
 READ code formularies
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Development
 Implementation
 Maintenance
EMIS templates
Future developments
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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

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
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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
G304.
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
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Anatomy of a READ code
5 characters
G…. Chapter heading ( circulatory diseases)
G3… Ischaemic heart disease
G30.. Acute Myocardial infarction
G303. Acute inferoposterior infarction
Benign Essential
Hypertension
(G201)
Hypertensive
Disease(G2)
Circulatory
System Disease
Ischaemic
(G.....)
Heart
Disease(G3)
Secondary
Hypertension(G24)
Acute MI (G30)
Angina Pectoris
(G33)
TIA (G65)
Cerebrovascul Stroke and CVA
ar
unspecified (G66)
Disease(G6)
Subarachnoid Haem. (G60)
Level One
Codes
Level Two
Codes
Level Three
Codes
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
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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?
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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 Other therapeutic procedures
9 Administration
What does it mean when a term
starts [V], [X] etc?
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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
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Context vs. coding:-
Angina ? = have they got angina.
Angina [G33] ? [Free text] = this patient has
angina
Finding the right code
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

Formulary – how to
Written version on paper, on website, in
excel
 Create your own hierarchy in EMIS
 Templates
 Synonym access (@
Wish list:
Import/export a Code formulary option
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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
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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
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 GP4-byte, Version 2 and Version 3
 Read Code Subset Wizard
 Beginner's User Manual
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
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EMIS templates
Data entry forms invaluable for
 Saving time
 Standardising data recording
 Clinical prompts
 Can be shared between practices
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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)
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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.
READ version 3
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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
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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
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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
 Improved formulary creation and sharing
 Code transfer between hospitals and GPs
( starting in pathology EDI)
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Todays session:
Why coding is important?
 READ codes – facts and tips
 READ code formularies

Development
 Implementation
 Maintenance
EMIS templates
Future developments



Visit this webpage for links
www.wansford.co.uk/codes
Email
[email protected]