Transcript Points, QMAS & QOF - Barking and Havering VTS

Points, QOF &
QMAS
VTS Awayday 10/11/04
Relevant issues:
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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
Screen showing NSMC view -
Guidelines
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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
Read Codes - 1
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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
Read Codes - 2
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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
Disease Registers
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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
Asthma
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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
Cancer
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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
COPD
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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
CHD
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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
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
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Diabetes
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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
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 antiepileptic drugs for other reasons
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Hypertension
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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)
Hypothyroidism
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Those on levothyroxine with recorded
diagnosis of hypothyroidism
Read Code C03 & C04
New contract requires TSH in last
15/12
Stroke & TIA
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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
Mental Health
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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
Exception Reporting - 1
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From whole domain or individual
indicators
What could be exception coded?
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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
Exception Reporting - 2
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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
Exception Reporting - 3
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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
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
Other data to collect
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BP every 5 years age 45+
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Smoking status age 15-75
Medication Review
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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
Smears – what is needed?
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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
Capturing data / Summarizing
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Agreement in-house about Codes
Issues around new diagnoses
Protocol for data entry
External sources - hospitals
New patient checks
Community nurses?
Nursing homes?
Housebound?
Remember non-clinical protocols
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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
How can we make all this work?
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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 setup money
Some of the North Street team
What is QOF? - 1
• Quality Outcomes Framework
• The new Contract “scoring” system
• Clinical and administrative
components
• Clinical criteria translate to
clickable buttons within Guidelines
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
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
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
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
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
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
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
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
(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
Data for NSMC on
QMAS as at 9/04
Clinical domains - Points
Organisational domain - Points
Total Points