Read codes in new contract
The series by Dr John Couch that concluded last week examined in great detail how practices could best benefit from the quality and outcomes element of the new contract – here Dr Chris Martin looks at Read codes
The point was stressed time and again throughout Dr Couch's recent series on the quality and outcomes framework that it is not enough for practices to deliver a high-quality service – the information must be recorded reliably, consistently and in a readily retrievable form. The way you use Read codes is central to this.
This feature, which complements Dr Couch's series, aims to help GPs use codes effectively.
Read code recap
The most commonly used version of Read coding is version 2, which I will briefly describe here.
The Read coding system is hierarchical with five levels or branch points. A letter or a number represents a category or subcategory of disease, symptom or other data item. Each Read code V2 will have five alphanumeric characters for each of the five levels.
H.... represents 'respiratory disease'
H3... represents 'chronic obstructive pulmonary disease (COPD)' as a kind of respiratory disease
H33.. represents 'asthma' as a kind of COPD and so on.
The importance of this structure is that it allows a hierarchical search on a computer.
A search for G20.. will find all cases of essential hypertension, but
a search for a Read code G.... will identify all cardiovascular diseases including essential hypertension.
It should be immediately obvious what the potential catches are. 'H3...' represents the term 'chronic obstructive
pulmonary disease', but a search for this and its subcodes will include 'H33..'or 'asthma'. This makes some taxonomic sense, but is useless for the purposes of the new contract where 'COPD' is taken to mean 'chronic bronchitis or emphysema' and not 'asthma'. This will be why it has been arbitrarily decided to use 'H32..' ('emphysema') to represent 'COPD' for the contract purposes so that it will not get confused with asthma.
Many entries for COPD in clinical records will have used the 'H3...' code rather than 'H32..'. This will be missed on the proposed search software being developed to administer the contract reporting. A similar catch is the use of the code 'G2...' ('hypertensive disease'). The new contract reporting software will use 'G20..' only. It would be worthwhile doing a search for 'H3...' or 'G2...' entries and systematically correcting them.
The preferred spirometry codes for COPD do not include the codes recording the values of the test such as those starting with '339..' which would seem to be the ones most useful and hence historically used more often. You may need to do a search on your clinical database to find instances where you have used these codes and amend them as appropriate.
Searching for codes can seem frustrating and impossible. If you can't find a code when you type it in, check you have not substituted a zero for a capital O, a number 1 for the letter l or capital I, or vice-versa.
Certain codes will be key to the quality criteria because they occur across different quality criteria. These are the codes for smoking status, influenza vaccination and medication review.
While the contract reporting software should cope with the abundant variety of smoking codes, the sheer number
and the different ways they are interpreted make it extraordinarily unlikely that the searching and reporting will be error free.
Consequently, it would be wise to stick to the 'preferred codes' for 'smoker', 'never smoker', 'ex smoker' and 'smoking advice given'.
The preferred code for influenza vaccination is '65E..'. The key point is how to record 'exceptions': those who are allergic, refuse the vaccination or have some other reason not to have it.
The best policy is usually to keep it simple and to have one code such as '8I2F.'('influenza vaccine contraindicated') rather than use a more specific code for all the different flavours of contraindication.
Medication review recording is likely to emerge as a difficult and contentious issue. The 'medicines management' quality indicators relating to medication reviews will be assessed by a notes review by assessors.
However, practices are likely to want to be able to audit their medication reviews easily and will want to use their computer to do this. Also, asthmatics, epileptics and people on the 'mental health' register have clinical quality indicators relating to review.
An asthmatic epileptic will thus need three codes entering for each review, one for 'medication review', one for asthma review and one for epilepsy review!
Here are some key rules for managing Read coding to ensure reliability and consistency and to minimise work.
Keep it simple: use the coarsest possible code such as H33.. for asthma rather than H330. for 'allergic asthma'.
Agree on a standard list of codes for use within the practice to ensure consistency.
Keep the list of agreed standard codes as short as possible.
If it doesn't fit on a sheet of A4 people won't stick to it.
The full, published list of codes that will be picked up by the reporting software runs to 55 pages – you do not need to use them all!
Use computer templates and macros for entering Read codes whenever possible as searching for them 'by hand' is frustrating and error prone.
Chris Martin is a GP in Laindon, Essex