Use of Read codes in diabetes management in a south London primary care group: implications for establishing disease registers
BMJ 2003; 326 doi: https://doi.org/10.1136/bmj.326.7399.1130 (Published 22 May 2003) Cite this as: BMJ 2003;326:1130
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Gray et al (1) are presumably unaware of all the facilities and
functions that are available on current General Practice clinical IT
systems. Software such as Vision provided by In Practice Systems has a
register for chronic diseases such as diabetes independent from Read
codes. In my group practice, 695 patients are on the computer diabetes
register with 364 (52.4%) of these having a C10 Read code for diabetes.
The register negates the need to use the author’s incomplete and complex
hierarchical Read code and medicine search criteria that would
significantly underestimated our diabetic population.
Software suppliers also provide within their systems embedded
templates and guidelines on Diabetes Management Plans (2). These are in a
structured format so that data is entered in a logical and comprehensive
manner during a consultation, without the need for the clinician to make
decisions on choosing the most appropriate of over 95 possible Read codes
in the C10 hierarchy. In response to the new GMS contract negotiations,
the software companies have already rewritten their programmes to take
into account the quality and outcome frameworks for chronic disease
management. The clinical IT systems will be updated once the contract has
been agreed and if they are followed in practice will automatically
standardise data entry, providing accurate information for audit and to
calculate income.
From a primary care point of view one of the major hindrances in
collecting quality data is that secondary care is reluctant to move from
paper based recording and correspondence. Such communications contain
valuable information but in a non-searchable free text format. Expensive
and labour intensive add on IT functions are available which can scan
documents and then use OCR software to identify and extract data that can
be recorded in Read codes. A more innovative project in Birmingham (3) has
tried to address this problem differently by developing an electronic
diabetes database and register, which can be accessed via an intranet
system using an internet browser. This approach provides a single source
of information and a shared-care view of data collected between the
hospital and primary care of a common diabetes dataset. The system is live
and data can be updated in real time. The database can be made available
on a secured Internet site to allow patients to view reports and graphical
representations of their management and results.
References
1
Gray J, Orr D, Majeed A. Use of Read codes in diabetes management in a
south London primary care group: implications for establishing disease
registers. BMJ 2003; 326: 1130-2
2
In Practice Systems. Diabetic care.
www.inps.co.uk/software/diabeticcare/_diabeticcare/fdiabeticcare.htm
(accessed 30 May 2003)
3
Audit Commission; commissioning diabetes services. Birmingham Health
Authority Diabetes Information Service. www.diabetes.audit-
commission.gov.uk/CASESTUDIES/examples/birmingham4.htm (accessed 30 May
2003)
Competing interests:
None declared
Competing interests: No competing interests
We thank Dr McAlpine for his contribution. Our data was collected
during 2001 which would make our prevalences very similar. Jeremy Gray
Competing interests:
None declared
Competing interests: No competing interests
Gray, et al report a diabetes prevalence of 2.53%, although the
ascertainment date is not defined. The authors comment that a study using
electronic record linkage in Tayside found a prevalence of diabetes of
1.9% - lower than theirs. We wish to point out that the prevalence figure
in the Tayside study was for 1st January 1996. Our study showed that
electronic record linkage of a variety of independent data sources gave a
sensitivity and positive predictive value of 0.96 and 0.95 respectively.
This was more sensitive than general practice registers (sensitivity
0.91/positive predictive value 0.98) in identifying diabetes (1). Over the
6 years since our study was published, the prevalence of diabetes in
Tayside (population ~385000) has risen to 2.90%, an average annual
increase of 0.16%.
(1) Morris AD, Boyle DIR, MacAlpine R, Emslie-Smith A, Jung RT,
Newton RW, MacDonald TM for the DARTS/MEMO Collaboration. The diabetes
audit and research in Tayside, Scotland (DARTS) study: electronic record-
linkage to create a diabetes register. BMJ 1997;315: 524-8.
Competing interests:
None declared
Competing interests: No competing interests
An important implication not mentioned by the authors is to do with
the fact that many patients transfer between practices for a variety of
reasons, including relocation and that this system is changing. Many of
these patients will have diabetes, however the results are possibly valid
for other diseases as well.
In the last month a beta test of software has been announced as part
of the GP2GP project, supported by most of the primary care computer
suppliers. This will involve the electronic transfer of a patients record
from practice to practice, a step to the electronic record. It will
involve the transfer any existing codes to the new practice as well as
information on consultations and other data.
In theory this reduces the workload of each new practice which would
orindarily have to resummarise the patients record when it eventually
turned up. However the implications of this study are that the receiving
practices shouldn't trust the data they are receiving because it may be
inaccurate, imcomplete or coded differently to how the receiving practice
would like it.
Proceedures and protocols will have to be put in place to make sure
that this is dealt with correctly and practices should be aware of this
potential problem.
Competing interests:
None declared
Competing interests: No competing interests
Standards for Coding in General Practice
Dear Sir,
Re:
BMJ 2003;326:1130 (24 May)
Information in practice
Use of Read codes in diabetes management in a south London primary care
group: implications for establishing disease registers
Jeremy Gray, director1, Douglas Orr, researcher1, Azeem Majeed, professor
of primary care2
We take issue with the conclusion of the authors that ' The use of
Read codes for diabetes needs to be standardised and coding levels
improved if valid diabetic registers are to be constructed and the quality
of care is to be monitored effectively.'
In fact, we have shown that standard read codes for recording disease
already exist and are widely used in primary care .Many software systems
used by GP practices to record clinical information already use standard
data entry screens to help clinicians to manage patients with chronic
diseases such as diabetes, asthma and coronary heart disease. Templates
provide clinicians with reminders to check details such as blood pressure,
cholesterol, HbA1c etc, and automatically record information using
standard read codes, meaning that clinicians never need to see or have to
choose a read code. Over 94% of GPs in Scotland now use a computer system
to record clinical information, and 36% use it to record their management
of chronic disease (1). In addition, clinical criteria for template
screens have been developed by the Clinical Effectiveness programme of the
RCGP in Scotland, (SPICE –pc) and are thus national standards. (2) A
group representing users of all the clinical systems used in primary care
in Scotland has been formed to agree on standard codes and templates for
use in practices, called SCIMP (Scottish Clinical Information Management
in primary care). A minimum set of codes for use in primary care was
agreed in 1999 and are now in widespread use across Scotland, providing a
national standard for the recording of diagnostic codes. (3)
The SCIMP
group recently carried out a study to investigate whether practices will
be ready for the data reporting requirements for the new contract using
CHD as an example, looking at electronic GP records of all CHD patients in
five Scottish Practices validated by manual searches in 50 randomly
selected patients in each practice. The study measured the recording of
family history, smoking status, BP, diabetes testing, aspirin therapy and
cholesterol measurement. The results showed that it is extremely easy for
practices with completely electronic patient records to extract a disease
register. Extraction of a complete data set takes several days if it
involves checking through paper records, whereas setting up and running a
search from electronic records is possible in less than two hours. If
practices use the same clinical system and identical data entry templates,
the data can be directly compared. We have shown that in Scotland, there
is a high level of testing and recording of all the important information
regarding patients with recorded CHD, irrespective of whether practices
have fully electronic, paper based records, or a mixture of the two. If
practices have fully electronic patient records, the information can be
extracted easily, but unless there is a standard template, the information
can only be viewed in isolation and is of little value for comparative
purposes.
When information is entered onto clinical records using standard
templates, it can be extracted and amalgamated electronically. In
Scotland, the information from SPICE-pc templates is collected and
reported by PCCIU (Primary Care Clinical Informatics Unit) at Aberdeen
University. (3)
In Spring 2003, information was collected from 173 practices, with
data from 1,052,770 patients. Of these,
39,771 were shown to have CHD (4.4%),
23,485 had diabetes (2.6%),
46,679 had active asthma (5.2%) and
73,357 were hypertensive and aged >35. (14.5%)
This information was sent by the practices by email or disc, taking on
average 10 mins by email, or 30 mins by disc.
A similar function is provided by the PRIMIS unit in England, which
gives advice on data recording and standard queries or searches, and
extracts reports and amalgamates results across practices. (4)
References:
[1] Morris L. Dumville J, Campbell L M, Sullivan F A survey of
computer use in primary care: general practitioners are no longer
technophobic but other primary care staff need better access. Informatics
in Primary Care (2003) 11: 5-11
[2] SPICE-pc: www.ceppc.org/spice/index.shtml
[3] SCIMP:www.ceppc.org/scimp/index.shtml
[4] PRIMIS:www.primis.nhs.uk
Yours sincerely,
Dr Libby Morris MBChB, Chairman of SCIMP
Dr Robert M Milne MBChB, FRCGP, Senior lecturer, University of Aberdeen,
Director of PCCIU
Dr L. Malcolm Campbell, Senior lecturer, University of Glasgow Director
of Quality Standards, RCGP Scotland
Address for correspondence
Dr. Libby Morris,
RCGP (Scotland),
25 Queen Street,
Edinburgh,
Scotland
Competing interests:
None declared
Competing interests: No competing interests