1	Secondary Uses of Clinical Data in Primary Care Sheila Teasdale MMedSci FBCS Strategic Director PRIMIS+ University of Nottingham Editor, Informatics in Primary Care
2	Outline Primary care in the UK Computerisation in primary care Uses of primary care clinical data National Diabetes Audit National vaccine campaigns Health status monitoring Quality & Outcomes Framework Issues arising from these initiatives
3	UK primary care
4	UK primary care ~10,000 family practices ~30,000 family physicians (GPs) independent contractors provide 85–90% of care patient registration system GP gatekeeper role 99.99% use EHR
5	Computerisation in primary care
6	Drivers for computerisation in general practice 1970s First GP systems introduced 1% 1980s Accredited systems reimbursed 15% 1990 New GP contract – data-driven 65% 1998 Information for Health strategy 85% 2000 The NHS Plan 90% 2001 Building the Information Core strategy 95% 2002 Delivering 21^st Century IT Support for the NHS 98% 2004 New GMS Contract – QOF 99% 2006 Current position 99.99%
7	Number of suppliers 1985 – 120 suppliers 2005 – 7 suppliers EMIS (3 systems) 53% In Practice Vision 20% iSOFT (4 systems) 18% Phoenix 3% Microtest 3% Seetec 2% HealthySoft 1%
8	Characteristics of GP EHRs used with patient at office visit – clinically focused structured and coded records electronic prescribing some decision support warnings, reminders, contraindications, etc. electronic lab results ~40% practices are paper-light national registration system linked with PAP smear, mammography screening systems and childhood vaccination system sophisticated reporting tools no billing!
9	Uses of primary care data
10	Uses of primary care data primary use: direct clinical care secondary uses: preventive care and health promotion clinical audit and clinical governance medicolegal requirement national screening campaigns national preventive campaigns national audits payment
11	National Diabetes Audit
12	National Diabetes Audit [1] built on National Service Framework combining data from GP and hospital at individual patient level, anonymised second annual report September 2006 500,000 records audited covered 43% of practices looking at quality of care
13	National Diabetes Audit [2] Is everyone with diabetes diagnosed and recorded on a practice diabetes register? estimated 20% of diabetic patients undiagnosed under-diagnosis of women under-recording of ethnicity
14	National Diabetes Audit [3] For people with diabetes what is the increased risk of specific complications? Angina x 5 Cardiac failure x 3.5 Myocardial infarction x 3.2 Stroke x 2.8 Renal failure x 3 Amputation (minor) x 11 Amputation (major) x 7
15	National Diabetes Audit [4] What proportions of people with diabetes receive key processes of diabetes care? 80% of patients had most routine checks better for older patients 61% eye and foot exams 42% urinary albumin
16	National Diabetes Audit [5] What proportions of people with diabetes achieve treatment targets? 58% good blood glucose control 88% BP lower than 160/100mmHg 24% BP lower than 135/75mmHg 68% acceptable cholesterol level 10% more men than women known undertreatment of women with statins www.icservices.nhs.uk/ncasp/pages/audit_topics/diabetes
17	Vaccination campaigns
18	Monitoring of influenza and pneumococcal vaccine uptake Influenza vaccine 2005/06 Over 65s: 6,122,744 75.3% Under 65 at risk: 1,443,893 48% www.immunisation.nhs.uk/article.php?id=448 Pneumococcal vaccine 2006 www.hpa.org.uk/infections/topics_az
19	Health status monitoring
20	Monitoring of smoking and obesity rates Department of Health requirement Local Delivery Plans reported quarterly 2005 data 39 million patients aged between 15 and 75
21	Smoking smoking status: 58% recorded in last 15 months smokers: 14% of population 25% of those with status recorded preferential recording for smokers now improved by Quality and Outcomes Framework
22	Obesity BMI measure: 30% recorded in last 15 months obese (BMI 30 or more): 8% of population obese 28% of those with BMI recorded preferential recording for obese now improved by Quality and Outcomes Framework
23	Quality & Outcomes Framework
24	New GMS Contract 2003 includes pay-for-performance scheme: “Quality and Outcomes Framework” 25–35% of practice income depends on 136 quality indicators chronic disease management (10 conditions) practice organisation (five areas) patient experience £1.8 billion ($3.4 billion) extra funding
25	76 clinical indicators Coronary heart disease and heart failure (15) Stroke and transient ischaemic attack (10) Hypertension (5) Diabetes (18) Epilepsy (4) Hypothyroidism (2) Mental health (5) Asthma (7) Chronic obstructive pulmonary disease (8) Cancer (2)
26	Identifying data elements for indicators expert group – ‘quality gurus’ negotiated clinical consensus not always easy to measure: “The percentage of patients receiving treatment for hypertension whose blood pressure is 150/90”
27	Identifying data elements for indicators expert group – ‘quality gurus’ negotiated clinical consensus not always easy to measure: “The percentage of patients receiving treatment for hypertension whose blood pressure is 150/90”
28	Identifying data elements for indicators expert group – ‘quality gurus’ negotiated clinical consensus not always easy to measure: “The percentage of patients receiving treatment for hypertension whose blood pressure is 150/90”
29	Identifying data elements for indicators expert group – ‘quality gurus’ negotiated clinical consensus not always easy to measure: “The percentage of patients receiving treatment for hypertension whose blood pressure is 150/90”
30	Identifying data elements for indicators expert group – ‘quality gurus’ negotiated clinical consensus not always easy to measure: “The percentage of patients receiving treatment for hypertension whose blood pressure is 150/90” became: BP 5. The percentage of patients with hypertension in whom the last blood pressure (measured in last 9 months) is 150/90 or less 56 points for 70% achievement
31	Identifying data elements for indicators expert group – ‘quality gurus’ negotiated clinical consensus not always easy to measure: “The percentage of patients receiving treatment for hypertension whose blood pressure is 150/90” became: BP 5. The percentage of patients with hypertension in whom the last blood pressure (measured in last 9 months) is 150/90 or less 56 points for 70% achievement
32	Identifying data elements for indicators expert group – ‘quality gurus’ negotiated clinical consensus not always easy to measure: “The percentage of patients receiving treatment for hypertension whose blood pressure is 150/90” became: BP 5. The percentage of patients with hypertension in whom the last blood pressure (measured in last 9 months) is 150/90 or less 56 points for 70% achievement
33	Exception reporting for clinical indicators Patient refused Not clinically appropriate Newly diagnosed or recently registered Already on maximum dose of medication
34	Potential for gaming 15-month measurement period January–March activity covers two years … batch data entry minimise prevalence ® maximise points BUT adjusted using ‘national prevalence’ over-use of exception reporting
35	Practice performance on QOF 2004-05: 50% practices achieved maximum points 2005-06: 97.1% practices achieved maximum points
36	This year’s data
37	Issues arising from these initiatives data quality and its improvement the effects of standardising clinical coding comparability across practices perverse incentives effect of secondary uses on quality of care security and confidentiality