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 Inbox

Download cheatsheet

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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