Thursday, 30 August 2007

Med Reviews update

Are averaging about 30-40 a month. 3000 patients on the list. Search looks at birth month, on current repeat masters, no med review in QOF reference date. Save as a group. Open in Con Man as a list and work through each, check safe and sensible, reauthorise all for 1 year, tidy up medreview reminders as discussed previously, add a 'Med Rev Done' record, move on. can do 30 in about 90 minutes.

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Wednesday, 29 August 2007

Setting up Recalls for QOF

This is the latest iteration of a recall process. I am not entirely happy with it as it is difficult for non technical users to really get their heads around. Being able to use Vision 3 searches well is a bonus, but not a skill everyone intuitively acquires. Anyway, ever onward. Oh for Contract Manager.....


Chronic Disease Areas

We will use Vision 3 Recalls for managing recalls (invitations, screening) for the following QOF areas:
  1. Asthma
  2. COPD
  3. CKD
  4. Thyroid Disease
  5. Mental Health
  6. CHD
  7. Hypertension
  8. Epilepsy
  9. Stroke / TIA
  10. AF
  11. Dementia
  12. Heart Failure
  13. Diabetes

The following areas are not managed using the Recall system:
  1. Palliative Care
  2. Smoking
  3. Obesity
  4. Cancer
  5. Depression
  6. Learning Disabilities

Chronic Disease Registers

Although Vision prompts you to use these, we do not use them for our patients with chronic diseases. The actual QOF registers are 'virtual', that is determined by a series of QOF rules based on Read codes. Thus if we use the Vision Disease Register entity for managing any of our QOF stuff we will not be using the actual QOF cohort we need to look at and thus not doing what our contract requires us to.
To create a 'Disease Register' group, we need to use the Monitoring Audits, identify the line that shows the register and save that group.

Why Recalls

The Recall system can be used to ensure that patients are sent invitations for review of these chronic diseases. It will allow us to confidently record 3 invitations and, if required, 'Failure to Attend' events which the qualifies the individual to marked as an 'exception report' for that disease.

General Process

Every patient with one of the above QOF areas will have a Recall record added and maintained for that area, generally based on their Birth Month.
Recall searches run monthly will identify who has QOF recalls for that month.
These lists are then reviewed manually to identify those suitable for review in the surgery, those who are housebound or in care homes, and those who do not require calling in at this time.
Invitations are then sent either by letter or phone and recorded into Vision.
Those who do not need recalled at this time have their recall deleted and a new one added with the next date on which they should be called.
Searches should also be run to identify those patients who still have outstanding recalls from the previous month, with previous invites. These lists also need manually reviewed and then actioned according to their status. Possible outcome will be to add another invite, to delete the old recall and create new (assuming QOF requirements completed) and other queries which may arise.

What is important!

MM and PM will manage most of the recall admin, primarily MM.
Everyone needs to manage the day to day recalls. In particular, when a patient has been seen for a condition, they should have their recall deleted and new one created for the following year.

Creating Recalls

We need a process of ensuring everyone with one of the QOF diseases above has an annual recall set. The initial process of setting these up has been completed, but we need to identify those patients who do not have recalls present but do have the conditions. This can occur from new patients joining the list, or new diagnoses.
These searches should be run monthly.
When new patients join with the QOF diseases a recall should be added for their conditions. This should be based on birth month, and use the standard Recall codes used by Glenburn as per the Recall and Invites Guideline. MM should do this after the notes have been summarised or when the condition becomes apparent.

Finding Patients with No recalls

Monthly we should run the searches below and review the patients found. These searches identify patients on the QOF disease registers with no 'in year' recall.
Each search requires you to first identify and save the appropriate group from the clinical monitoring audits and input that group into the search. When we enter a new QOF year you will need to change the date of the search - it should always run from 1st April of the QOF year inclusive.
Patients identified in this way should then have recalls added using the Month of Birth for this QOF year using the agreed Read Term from the guideline for this condition. The first example below is CHD but the process is the same for each disease area:

CHD

  • Identify the CHD register from Clinical Audit Monitoring Audits: CHD1
  • Save this group
  • Open the Search and input this group. Search is 'RECCHDX' and is in 'Paul's Searches'
  • Change the date if into a new year! The search should run from 1st April of QOF year Inclusive
  • The search will identify which patients from this group do not have a recall for CHD present for this QOF year.
  • Print out the report. The patients are also saved to the group 'RECCHDX No Recall for CHD'
  • This list should then be reviewed by MM and recalls added as appropriate.

All searches for this are under 'Paul's Searches'. Ensure you have the correct Input group, recall code and date before running the search.

Run searches for all areas as above.

Finding Patients for First Invite

Monthly we need to run the 'Recalls for Calendar Month All QOF' for the month ahead - i.e. In August we should run the searches for September.

We can run this search in advance as required (and should do so to avoid being unable to send invites x 3 to people due recalls in March for the 07-08 year!!!).

This list is then printed out and should ideally be reviewed by the GPs and PNs and MM for comment, then MM can do final revision.

Tasks from this list are to:
  • Change recall dates to future ones when the patient does not require an invitation
  • Ensure housebound patients reviews are allocated to someone to complete.
  • Ensure patients being recalled have the specific condition
  • Review each patients QOF related criteria and identify and complete these criteria as far as possible.
  • Send and record a 1st invitation for each area in question when the patient has to be seen.
  • Again, when the patient's QOF criteria are complete the patient's recalls for each completed condition should be deleted and a new recall entered using the patient's day and month of birth.

When Patients are Seen

When a patient attends the surgery (or has their QOF related information collected and recorded) they do no longer require an in year QOF recall. Any that apply should be deleted and a new recall added for the following year.

Finding Patients for Second Invite / Third Invite

Monthly we must run searches to look for patients who still have QOF Recalls outstanding from previous months. Remember - patients who have had their QOF criteria completed should have their recalls deleted and new ones added for the following year. Thus patients who have recalls remaining from previous months can be assumed to not have attended (or have been actioned) and they will need their notes reviewed.
The searches are located under 'Paul's Searches' but you will need to change the date each time!

Sending and Recording Invites

When a patient does require an invitation for a QOF review, this should be done using Vision, Add Correspondence and an appropriate letter.
The invite should be recorded using an appropriate Read Code as defined in the Vision Guideline and Recall Spreadsheet.

Letters should be recorded as Medical History and Priority 9 only. Do not record a letter sent using a 'Recall' - there is no need to do this and it simply adds more spurious recalls to the record. Verbal and phone invites can also be added using the guideline - please free text the invite number if known.
Where a patient has received 3 invitations to attend and has not done so, the patient should be brought to the attention of one of the doctors for consideration of adding an Exception code for that QOF area.
Patients with multiple QOF reviews should ideally receive only one appointment for all these items to be looked at.

Managing Specific QOF Disease Area Requirements - Some Searches

Hypertension

BP4
Requirement is to have checked the BP of people with HBP in 9 months from QOF year end. This means we (for QOF purposes) must have checked their BP after 1st July.
Hypertension recalls for QOF therefore should be set to July or later. Those with a birth month of April, May or June should have their recall set to July, August and September respectively.
BP5
Requirement is that patients with hypertension last BP measured should be <=150/90 after 01 July.
Patients with HBP and last BP in previous 9m > 150/90 can be identified from the monitoring audits.
A search should be run on these patients every month to identify those whose last BP reading was over 4 weeks previously and who do NOT have a future recall date. This assumes that every patient who has a high reading has follow up arranged for no more than 4 weeks - in other words, if over 4 weeks since last they are lost to follow up and should be invited back. If they have a future recall (but still before 31/3/2007) then they can be assumed to be going to be picked up by the monthly recall searches anyway
The search requires that you Save the Monitoring Audit for BP05 Negative last 9 months patients as a group as 'BPNEG9M' and use it in the Hypertension search 'Last BP over 4w high for review'
This group then needs reviewed by someone (MM, PN, GP?) to ensure patients are getting some kind of review. If no apparent review then they should be contacted and asked to attend again.
This will mean they should get 1st, 2nd and 3rd invites accordingly.

Asthma

ASTHMA8
Diagnosis from 2006 - need to look at the group in monitoring audits and review the patients individually.

ASTHMA6- review in past 15m

If we actually aim to do a review every 12 months then we can use the monitoring audit group of MONITORING: ASTHMA 06 NEGATIVE2: % of eligible patients with asthma with NO asthma review in last 12 months, save them as 'ASTNEG12' then run the search to see which of these people have no recall in QOF year. This report will print out with all recalls in the patient's record - sorry! We only want to look at the asthma ones tho :-).

Also Run the 'Asthma 6 No recall Due and Letters' search to identify which patients from the due group have had invites, and what they were. If a patient on the due report does not appear on the letter report then they have had no invite sent and they must have their record checked. Similarly some of those with invites may have been missed and any that are outstanding need actioned from here.

COPD

COPD9 - Confirmed by spirometry

Monitoring audit identifies these patients. Get them in!


COPD Generally

We can run a search to identify who has been missed for recall. Save the COPD register from the monitoring audits as a group named 'COPDREG'.

Run the COPD search. This identifies patients who have no future recall for COPD and this should be the group who are have been invited (or missed for invite). If they have a future recall, we can assume that the usual recall searches will pick them up.

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Tuesday, 28 August 2007

quiet

Hi all, quiet here innit? Sorry, been busy. Thanks to Kathie for prodding me to action :)

Medication reviews remain a big bug bear for me, and I am trying to sort them in Vision 4 so they make a little more sense and are ideally less intrusive yet more clinically useful. Depends what folk want I guess. GPASS does Medication Reviews as a check box on the Repeat Masters screen. And that is it. 'Tick. Medication Review Done'. Not a lot of scope there for doing better stuff, like managing Epilepsy Reviews or other condition specific reviews, nor for allowing clinicians with special interests or clinics to use medication reviews as a tool within their own niche field.

Anyway, at the end of the day it is a QOF requirement first and an extended clinical requirement second. Explaining to people what they are doing in V3 is hard enough!

So, what do folk want out of medication reviews? Any pressing concerns? Just a 'tick box'? Or something more elaborate? V4 is a clever system, so we can potentially do quite clever stuff. But, medicine being complex, the cleverer we make it the steeper the learning curve for the users. Or, at least, the understanding curve. Coz we can make it do lots of stuff behind the scenes, and for most users this will probably be fine and deliver on the QOF MED requirements, but if you want to change its behaviour, you need to have a clue how it is working in the first place...

Med Reviews can be done simply already. It is doing them better that is the challenge!

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Wednesday, 15 August 2007

e-coli

Paisley has been stricken by the E.Coli 0157. Nasty germ. Impact here has not been insignificant with several of our patients affected either directly or indirectly by this disease. Not, thankfully, any fatalities from our list but people unwell and in hospital. And positive cultures.

So, Vision wise, useful stuff is:

Get keywords onto Read Terms sorted. So, prefix 'stool' to various useful Read Codes:


Specifically I use 'stooltolab' for samples being sent and 'okstool' (or 'stoolok') for 'Faeces normal'.

Symptoms wise, 'codiar' and 'covom' and, lastly, 'd+v' get '19F2.00 Diarrhoea' and '1992.00 Vomiting' and '19FZ.11 Diarrhoea & vomiting, symptom respectively:


Gastroenteritis was discussed in a previous post, but 'geinf' gets me 'A081200 Gastroenteritis - presumed infectious origin'.

We can map 'ecoli' to 'A070.00 Escherichia coli gastrointestinal tract infection' and hope it is not a term we have to use too often.

Mostly we get to use 'oewell' (a favourite keyword) for '212A.00 O/E patient well' and 'advok' (another favourite) for '8C9..00 Reassurance given'.

Another useful one is 'idc' which I use for '65P..11 Contact - infectious disease' which, whilst not ideal, suffices for trapping those folk who like their deli meats from our local Morrisons. :-(

DXS is useful too...but I am working on my laptop where DXS is not running. Back in the surgery tomorrow though.

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