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Presented by Katrina Otto
Train IT Medical Pty Ltd
www.trainitmedical.com.au
katrina@trainitmedical.com.au
Data Quality, Coding and
Essential Clinical Data
- using Bp Premier -
Learning Objectives:
UNDERSTANDING
CODINGVALUE
1. Enter essential clinical data to meet RACGP general practice and
Digital Health standards.
2. Understand the importance of clinical coding and how it is used
in Bp Premier.
3. Undertake clinical assessment in Bp Premier with a focus on
chronic disease management.
4. Improve effective use and data quality in General Practice.
“Maintaining clear and accurate patient
health records is essential if your
practice is to provide high quality care.
A good health summary helps clinicians
provide safe and effective care.”
RACGP
Quality data
Accreditation Changes:
- linked to ‘improvements’
Practice Incentive Payment
(PIP) changes:
- linked to data
Improvedata
Improverelationships
Improverevenue
Improvehealth
outcomes
“Health professionals should remember
the main purpose is to support safe and
high quality healthcare for individual
patients and practice populations”
- RACGP Quality Health Records in Australian Primary Healthcare
1.2 Main purpose of Health Records
‘Reason for Prescription’ – what would your data say?
▪ NO DATA
▪ FREE TEXT
▪ CODED
NO DATA
FREE TEXT
CODED
What is essential data? Now is the time to have your say.
Learning Objective 2:
UNDERSTANDING
Understand the importance of clinical coding and
how it is used in Bp Premier.
Patient
My Health Record
Health Care Home
Prevent near
misses
Essential Data for safe handover of care for your patient
eReferralSpecialist
Clinical handover
Demographics
• Verify identity at each contact
• Update demographics including contact details
• Update emergency contact
• Record next of kin
• Record Aboriginal and/or Torres Strait Islander Status
• Record ‘ethnicity’/other cultural background
Improving proactive patient care
“Practice staff must ask the patient for the information, rather
than provide the identifying information and then ask the patient
to confirm the information.” RACGP Standards for general practice – 5th edition, p64
https://www.racgp.org.au/download/Documents/Standards/5th%20Edition/
racgp-standards-for-general-practices-5th-edition.pdf
https://www.racgp.org.au/download/Documents/Standards/5th%20Edition/racgp-standards-for-general-practices-5th-edition.pdf
Verify patient details
73%of people self-checking in
identified incorrect
demographic information in
their patient record
Jayex
Learning Objective 2:
Understand the importance of clinical coding and how it is used in Bp Premier.
“A good health summary helps
clinicians provide
safe and effective care.”
RACGP
Health Summary
• Allergies and adverse drug reactions
• Current medications
• Past History (chronic conditions & significant events)
• Immunisations
• Family History
• Health risk factors
• Social history (including cultural background)
Download the ‘Data Quality’ Checklist
Standard 1.3 “Expect to Share”
“Health Professionals should expect to
share their health information with
colleagues and with patients to
facilitate safe and effective health care”RACGP Quality Health Records in Australian Primary Healthcare
Past History List [coding]
Only for chronic conditions & significant events
Significant active
or inactive
conditions
Different from Reason for Visit (Past Visits)
Only tick ‘Add to Past History’ if you are adding a new significant diagnosis
Can choose
‘Another’ for more
than one reason for visit.
You can untick default ‘preferences’
Criterion C7.1 – Content of patient health record, RACGP Standards for general practices 5th edition.
Add, Edit or Delete to clean up the Past History List
Clean up uncoded and free text data
Bulk Cleanup
Clean up uncoded items
“..use consistent coding of diagnoses…..so that
continuous improvement of clinical care and patient outcomes
can be achieved.”
Accreditation Compliance
Data Quality Report Card ie Allergies, Smoking Status etc
Data Quality Dashboard
How can practices measure data collection progress?
To measure the effectiveness of improvement activities it is helpful to use data analysis tools.
Learning Objective 3:
CODING
Undertake clinical assessment in Bp Premier with a focus on chronic
disease management.
Analyse your current registers
Build a Register of patients with a particular condition e.g. Diabetes etc
Identify at-risk patients – kidney disease
Observations & results
• Enter all observations in relevant section:
Bp, BSL, spirometry, height, weight, etc
• Enter screening results – CST, FOBT, Mammogram
• Mark results as given
• Delete recalls when complete
SMOKING | SPIROMETRY | CODED DIAGNOSIS
Respiratory data
MEDICATION | COPD TEMPLATES | CARE PLANS
Diabetes Assessment:
Record observations
Learning Objective 4:
Improve effective use and data quality in General Practice.
Clean up data to improve quality:
1. Mark deceased patients as ‘deceased’.
2. Inactivate patients by searching for patients not
seen for two years.
3. Delete Sample patients.
4. Delete records with no clinical data.
5. Merge duplicate patient records.
Coding enables searching of your database
Learn more about Bp Searches/SQL queries
Business Process Improvements
Identify all patients with a chronic condition without a GP Management Plan
www.nevdgp.org.au
Set your KPIs – track improvements
Tips: Encourage a team effort to achieve the goals by setting a target on the
graph & place graph in the staff room/noticeboard to encourage a proactive
approach.
Enter Screening Results
Identify all eligible patients NOT screened for FOBT, Cervical Screening (CST) or Mammograms
Enter results from patient record
Download cheatsheet
Clean up Templates
✓Design a labelling ‘system’ eg.
Referral – Sydney Breast Clinic
Referral – Sydney Eye Hospital
Referral – Sydney Day Surgery
Referral – Sydney Hospital
✓Restrict access
Label your list to suit merging to sms or letter.
Control the list! > Setup > Configuration > Reminders.
Clean up Recalls & Reminders
Save time, money & minimize risk
With a list like this how do you identify true recalls ie. Clinicallysignificant (ieprobability of harm & we must follow-up/medico-legal/must keep the doctor informed & document every single contact attempt?
Mark results as given
Clinical Note-taking
• Date of consultation
• Clinician conducting the consultation
• Method of consultation eg. face to face,
phone
• Reason for consultation
• Relevant clinical findings
• Follow-up of matters raised in previous
consultations.
• Recommended management plan &
preventive care
• Expected process of review (if necessary)
• Consent (if necessary eg. care plan,
uploading health summary, medical student,
procedure).
https://www.racgp.org.au/download/Documents/Standards/5th%20Edition/racgp-standards-for-general-practices-5th-
edition.pdf
PIP payment changes:
Q: “How will the new PIP Incentive Payment work?
A: Practices will be paid for focusing on quality.
The quality will be determined by the information (i.e. data) about the care
that has been provided.
With time, practices will be paid for demonstrating data driven quality
improvement.”
Accreditation:
Quality Improvement (QI) Module
https://www.racgp.org.au/download/Documents/Standards/5th%20Edition/racgp-standards-for-
general-practices-5th-edition.pdf
PDSA/QI sample related to clinical coding
What is our GOAL(what are we trying to accomplish)
Raise Awareness of Clinical Coding
▪ Code diagnoses
▪ Enter reason for visit
▪ Enter for reason for medication
▪ Maintain updated allergy detail
What measures will we use? (i.e. data) Data Extradition Tools e.g. Pen CAT
What ideas can we use?(how are we going to achieve our goal)
List ideas here to work on in table below
Start a Quality improvement folder
Team meeting
Attend education e.g. webinars / face to face sessions
Post-education follow-up team discussion
GP & RN team review of clinical documentation (opportunistic or planned)
Pen CAT / Polar Data Quality Audit
IDEASPLAN
How will we do it – who,
what, where and when?
DODid we do it
STUDYWhat happened?
ACTWhat is our next step?
1.
2.
3.
4.
5.
Extra Resources – Data
RACGPRACGP Standards for General Practices 5th editionUsing Data for Better Health Outcomes
PIP eHealth Incentive
Australian Digital Health Agency:Importance of Data QualityData Cleansing & Clinical CodingData Quality Checklist
Train IT MedicalData Aggregation using Pen Clinical Audit Tools (blog)Cancer Screening & Prevention – Free Resources (blog)5 Steps to Data Quality Success (blog)Pen CAT4 summary sheet
OtherCAT4 Recipes
Learning Resources – Cancer Screening
Train IT Medical Free Resources – Cervical Screening Program
National Cervical Screening Program - Dept of Health - FAQs
Cervical Screening Changes FAQ - Video - Dr Sally Sweeney Hunter New England
Central Coast PHN (HNECCPHN)
NPS Information & FAQs
NPS free eLearning
Cancer Council Australia Cancer Guidelines Wiki
'Cancer Council study confirms starting cervical cancer screening at age 25 is safe'
Cancer Institute NSW 'Information for Health Professionals'
Untold Stories - Cervical Cancer Screening - Audio-visual stories
(Family Planning NSW). Spoken in Arabic, Assyrian, Dari, French, Hindi, Karen, Khmer, Mandarin, Nepalese & Vietnamese.
'Changes to cervical screening will benefit Australian women' RACGP media release
NCPHN Cervical Screening Workshop Presenter Slides
.
Keep in touch! With best wishes, Katrina Otto
katrina@trainitmedical.com.au
Twitter: trainitmedical
Facebook: trainitmedical
www.trainitmedical.com.au
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