Clinical Audit and QOF Reporting

Transcription

1 Vision 3 Clinical Audit and QOF Reporting Copyright INPS Ltd 2013 The Bread Factory, 1A Broughton Street, Battersea, London, SW8 3QJ T: +44 (0) F:+44 (0) W:

2 Copyright Notice 2013 INPS All Rights Reserved. No part of this document may be photocopied, reproduced, stored in a retrieval system or transmitted in any form or by any means, whether electronic, mechanical, or otherwise, without the prior written permission of INPS. No warranty of accuracy is given concerning the contents of the information contained in this publication. To the extent permitted by law, no liability (including liability to any person by reason of negligence) will be accepted by INPS, its subsidiaries or employees for any direct or indirect loss or damage caused by omissions from or inaccuracies in this document. INPS reserves the right to change without notice the contents of this publication and the software to which it relates. Product and company names herein may be the trademarks of their respective owners. INPS Ltd. The Bread Factory 1a Broughton Street London SW8 3QJ Website:

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5 Contents The new contract, QOF and QMAS 8 QOF 8 QMAS 9 How will data get into QMAS? 9 What does QMAS do with the data? 10 Regional Differences 10 England 10 Scotland 10 Registering with QMAS 10 esmtp messaging 10 Wales 11 Recording refusal to influenza vaccination 11 How to alter existing Flu refused records 12 Method 1 - using Bulk History Add 13 Method 2 - using Groups in Consultation Manager 14 Northern Ireland 15 New Users in Northern Ireland - Checking for GPC before starting 15 Reporting Tab in Clinical Audit 17 ngms Contract QMAS and Monitoring Audits 18 Overview of ngms audits 18 Importing new QOF audits 20 Upgrading from previous versions 21 Generate Interim Reports on Upgrade 21 Automatic Resubmission of Failed Reports 22 Single QOF set of audits and four different views 22 Audit Source 22 Repositioning Audit Source 23 All Audits & ngms Monitoring 23 ngms Reporting 24 QOF Results Last Reported 25 QOF Results Last Interim 25 ngms QOF audit structure 25 Criteria for ngms Contract Audits 26 Virtual disease register 27 Denominator 27 Exceptions 28 Domain-specific and indicator-specific exceptions 28 Domain-specific (High Level) exceptions 28 Indicator-specific exceptions 29 Exceptions for patients recently registered or recently diagnosed 30 What are Exception Codes? 30 Rules for Exception Reporting 30 Example of Exception Reporting 31 Exception Reporting to QMAS Version 3 QMAS Returns Audits 31 Indicator 32 5

6 Negatives 32 Reference date 33 Baseline date 33 Prevalence, Base Start Date and Data Analysis 34 Reminders 35 Activating a reminder 35 Editing text of a reminder 36 Upgrades of audits and reminders 36 Reminders generated with audits 36 Reminder text with date fields 37 Reminder text 39 Within Consultation Manager 40 Generation of Audits 41 Daily generation of audits 42 Daily generation of QOF audits for up-to-date data 42 Scheduling the daily generations 42 Patient groups from audits 43 Reports to QMAS 43 Monthly Reports 44 If no monthly reports are submitted to QMAS (England) 45 In Scotland 45 View Results on QOF Reporting tab 45 Exporting audit data to Excel 46 Generate and Resubmit monthly report manually 47 If the button says Generate under Monthly: 47 If the button says Regenerate under Monthly 47 Resubmit 48 View Results on QMAS website 48 Interim Reports 49 Generate interim report to QMAS 49 View results of interim report 49 Submit interim report to QMAS 50 Interim Reports for Previous Years 50 Generate Interim Reports on Upgrade 50 National Prevalence Day Report 52 Random anti-fraud checks by QOF Teams 55 Hosted Systems 56 Hosted practices can generate audits or make requests 56 Requests 57 Automatic Reminder Generation 57 Interim Report request 58 Advanced Generate 58 Notes 59 GP Communicator 60 How GPC handles QOF reports 60 GP Communicator, Tools - Options - Audits & QOF tab 60 QOF Report messages to and from NMAS 61 Acknowledgement message changes in DLM Acknowledgement message changes in DLM

7 Mail Gateway 63 The role of Mail Gateway 63 Run Mail Gateway at least twice a day 66 Exit from Mail Gateway discouraged 67 Clinical Audit Automatic Shutdown 68 Registering with QMAS 69 If registration to QMAS is successful 69 If registration to QMAS is not successful 71 FAQS 72 What does QI mean? 72 What are these ngms contract QMAS audits for? 72 Which READ codes are used for each QI and what does % mean after a code? 72 Synonyms 72 What does in any clinical area mean? 73 Do I have to keep entering the READ codes or is once enough? 73 Are these the audits we will use for GMS Payments in April? 73 What do the denominator and indicator lines show? 74 Why are patients with exception codes recorded still being shown on the register?74 Why are my figures much lower than expected? 74 My figures reported to QMAS are different to normal audit figures 75 How can I tag the patients in the "negative" groups who I need to contact? 75 How can I make sure I enter the correct READ codes on patients' records? 75 For Indicators involving therapy, why are some patients taking appropriate medication NOT being picked up? 76 What does "newly diagnosed since 1/4/2003" actually mean? Different indicators seem to be processed differently 76 How are the flu vaccination dates worked out? 78 Monthly reporting and normal audit generation: 78 Interim reporting 78 How do I print help screens? 79 How do I view a list of audit patients in Clinical Audit? 79 How do I find a list of audit patients for printing or mail merge? 79 To print a group of patients found in an audit 79 To mailmerge a group of patients found in an audit 80 INDEX 83 7

8 The new contract, QOF and QMAS For background information, refer also to ( Following negotiations between the NHS confederation, acting on behalf of the General Practitioners Committee of the BMA, family doctors voted in 2003 to accept a new contract for the delivery of general medical services. This new contract changes the way GPs are paid. QOF The Quality & Outcomes Framework (QOF) provides substantial rewards for GMS and PMS practices signed up to the QOF for the provision of high quality care. QOF measures achievement against a scorecard of 146 evidence-based indicators, allowing a possible 1000 points (including 20 points for holistic care). The QOF requires practices to report on their achievements on a month-by-month basis. 20 disease registers and many quality indicators and their associated percentage target populations (denominators) are reported. No patient data whatsoever is submitted the monthly reports are purely based on numbers. At the end of the QOF period (1st April - 31st March), practices are paid for the points they have achieved. The QOF consisted of 4 domains and 3 other quality payments: Clinical - coronary heart disease, left ventricular dysfunction, stroke or transient ischaemic attacks, hypertension, diabetes, chronic obstructive airways disease, epilepsy, cancer, mental health, hypothyroidism and asthma - worth up to 550 points. With Business Rules version 8, new clinical domains were introduced: heart failure, palliative care, dementia, depression, chronic kidney disease, atrial fibrillation, obesity, learning disabilities, smoking. Organisational standards - 56 indicators in 5 areas (records and information, patient communication, education and training, practice management and medicines management - worth up to 184 points. Patient experience - 4 indicators in 2 areas (patient survey and consultation length) - worth up to 100 points. Additional services - 10 indicators in 4 areas (cervical screening, child health surveillance, maternity services and contraceptive services) - worth up to 36 points. The QOF also rewards breadth of care through: Holistic care payments (which measure overall clinical achievement) worth up to 100 points Quality Practice payments (which measure overall achievement in the organisation, patient experience and additional services domains), worth up to 30 points. Achievement against the access standards is also rewarded with 50 bonus points. PMS practices will be deducted a number of points in the first and second year of the QOF in recognition of enhanced baselines. 8

9 The QOF reporting is strictly governed by the Dataset and Business Rules specification released by the National Programme (NPfIT). In Practice Systems Ltd had to pass three very rigid conformance tests to ensure we complied with this specification. QMAS The QMAS (Quality and Outcomes Framework Management and Analysis System) provides the vehicle for reporting by the practice. It is a new national system that supports the QOF framework for use by practices in England. DLM 185 allowed practices in England to register with QMAS within Vision, and DLM 188 for Scottish practices after November 2004 (see Registering with QMAS (page 10)). For regional differences, see England (page 10), Scotland (page 10), Wales (page 11) and Northern Ireland (page 14). QMAS is accessible by all practices that have registered and allows you to view your results for the year-to-date. QMAS will also provide the information required for payment purposes to the PCT. QMAS calculates the payments to all practices and in turn feeds the information to the NHAIS Payment Agency who pay the practices: Points achieved against aspiration Pounds achieved against aspiration Disease prevalence adjustment Weighted list size in accordance with your financial entitlements National disease prevalence National target population averages There is an excellent bulletin about QMAS on the DOH website ( QMAS have a website at How will data get into QMAS? Achievement data for the clinical domain is reported automatically on a monthly basis from GMS certified GP clinical systems to QMAS. All monthly reporting until the end of February is cumulative, and only the final year-end report (for March) will be used for payment calculations. Achievement data for non-clinical domains (the organisational, patient experience and additional services indicators) will be added by the practice using the QMAS web-based forms accessed on NHSNet. The aspiration data recorded by practices in the Interim Aspiration Utility (IAU). This data is stored in QMAS to allow practices to see their current achievement against their aspiration. For Vision practices, all reporting on those areas of the QOF which can be analysed via Clinical Audit is fully automatic and electronic. This applies to all clinical categories, and the smoking and BP indicators within Records. QMAS is linked to the NHAIS Exeter payment system. To allow achievement calculations to be made correctly, Exeter systems supplies the following to QMAS: Practice name National practice ID 9

10 GMS/PMS contract status Practice capitation Additional service opt-outs Details of new practices. What does QMAS do with the data? QMAS analyses the data and calculates the practice's QOF achievement. PCTs and practices can see the results of the calculations by viewing an Achievement Report (see View Results on QMAS website (page 48)). Retrospective clinical achievement reports will be available for April onwards once a GMS certified clinical system is available at the practice. Regional Differences England England and Scotland follow the same method in that practices register with QMAS from within Vision. When given the go-ahead, the Register button, on the QOF Reporting tab of Clinical Audit, is pressed (see Registering with QMAS (page 10)). For regular monthly QOF reports, a receipt report should be received from QMAS within 6.5 hours of sending the report for England practices. It is important that Mail Gateway - Run Now is run at least twice a day on the first of the month, and 14th March, or that Mail Gateway is running all the time - see Run Mail Gateway at least twice a day (page 66). Scotland Registering with QMAS Practices in Scotland register with QMAS via Vision. Registration (see Registering with QMAS (page 10)) fails unless the Practice Identifier code is edited to exclude the initial letter S, for example, if your code is S12345, edit it to This Practice Identifier code should be edited in Control Panel File Maintenance Practice Details. esmtp messaging Scotland are replacing QMAS with QOF Calculator during August This is the same application used in NI (PCAS) and Wales (CMWeb). No QOF acknowledgements are returned and there is no registration message. QOF Reports will continue to be sent from practices using elinks QMAS_Queue. Outgoing QOF reports will automatically be marked as successfully acknowledged by Vision and the GPC message moved to the audit folder, rather than pending. The QOF report status in Vision will always be reported as ack d; no automatic retransmissions will occur from attention folder. Whilst QMAS is still in use, the practice will receive QOF acknowledgements. These will be processed and either moved to 10

11 GPC audit (report OK) or attention (report failed) folder. However it will be not be matched to the original outgoing message. The age range for cervical cytology in Scotland is Wales From DLM 220, Wales are adopting the same QMAS system as N Ireland from MSDi. The Clinical Audit QOF tab is now enabled for Welsh practices and the automated monthly MIQUEST QOF extract is no longer run. Welsh practices have access to the full range of QOF functionality in Vision 3 using the same message flows as N Ireland: There is no QOF Registration message. There are no QOF Acknowledgements. They use the same QOF Clinical Audit version as England. They use DTS as the message transport. A new DIS trading partner for Wales only will be created automatically in GPC with the following values: GMS Clinical Address DTS Wales=rqfw3gp1 GMS Clinical Address Reference Wales=DIS0W Welsh practices can continue to extract their monthly data for Contract Manager from MIQUEST by using the Vision 3 MIQUEST application manually. QMAS in Wales is called CMWeb. Welsh practices should refer to their respective Health Boards for issues relating to the CMWeb, such as tracking the status of last submissions. Recording refusal to influenza vaccination This is relevant for Welsh practices currently using MIQUEST queries for QOF Reporting. Currently, MIQUEST is not picking up influenza refusal records if they have been added in Immunisations-Add. The workaround is to add the refusal in History Add. When an entry is made on Immunisations using 68NE No consent - influenza immunisation indicating that a patient has refused influenza vaccination, the data is not being stored in a manner that will enable MIQUEST to pick it up. Normally, starting from Immunisation Summary, Add-Immunisations, or an ngms Contract Guideline, you would select the Type of Immunisation as Influenza on Immunisations -Add, and then change the Status to Refusal to start or complete course. While we are currently investigating the solution to this problem, the workaround when you want to record a refused influenza immunisation is to make an entry using History rather than Immunisations. Either Add - History and select 68NE No consent - influenza immunisation or 9OX5 Flu vaccination declined by entering #68NE or #9OX5 in Read Term for Characteristic. 11

12 Or, from a ngms Guideline, such as CHD, Stroke, Diabetes, COPD or Asthma, make sure to press the Flu vaccination declined - Hx button (which goes to History) and NOT the Flu vaccination refused - Imms (which goes to Immunisation). How to alter existing Flu refused records 1. First create a group from an ad-hoc search for immunisation records with 68NE or 9OX5 2. So that any existing Immunisation records with either 68NE No consent - influenza immunisation or 9OX5 Flu vaccination declined can be picked up by MIQUEST, we suggest that in Search and Reports, you make an ad-hoc search as follows: Add Immunisations (Add Entity). Search on the two relevant READ codes: Highlight Read code for immunisation, press Add New and enter 68NE, Enter, repeat for 9OX5. Click OK. 12

13 Remember to save the group with a suitable name in Group Output 3. Then add a history entry to the patients in the group Now you can add an equivalent history to each patient, either using Bulk History Add, or going through the group in Consultation Manager. If the group is very large, then choose the Bulk History Add option, but Note - it will enter the same date on each patient's record. If the number of patients in the group is small, use the group function in Consultation Manager which goes through each record individually, letting you add a history record and customise the event date to the date of the original immunisation refusal record. Method 1 - using Bulk History Add 1. For Bulk History Add, go into Patient Groups from the Reporting menu. 2. Click on (Browse Filter) then select User under Select Group Category. 3. Click on to sort the groups by date then find the Immunisations No Consent group you created above. 4. Highlighting the group, click on. A brief screen displays in transit confirming how many patients are in the group. 5. A standard History Add screen is displayed. Complete this in the usual way, using either 68NE No consent - influenza immunisation or 9OX5 Flu vaccination declined and click OK. 13

14 6. In Consultation Manager, a new Consultation is started - select Administration. The new entry should be seen as the latest history entry on either Journal view or Filtering medical histories. Method 2 - using Groups in Consultation Manager The second method is more long-winded as it goes through each patient's record, but the outcome is to add an accurately dated history entry to correspond with the original immunisation record. 1. In Consultation Manager, select Consultation - Select a Patient group. 2. Find and double click on the group created in the ad-hoc search. 3. Highlight the first person in the group and click on on the Patient Groups toolbar. 4. When the patient's patient record is displayed, select Add - Medical History and enter either 68NE No consent - influenza immunisation or 9OX5 Flu vaccination declined and click OK. Change the Event Date to the date of the original immunisation refusal. Click OK. 5. Click on. for the next patient in the group. 6. Repeat steps 4 and 5 until you have worked through the group. 14

15 Northern Ireland Northern Ireland is implementing QOF reporting in conjunction with software supplied by MSD. It does not use QMAS and has opted to use a similar system developed by MSDi (PCAS), which imports the standard UK-wide QOF data extracts. In addition, the "transport mechanism" used in Northern Ireland to move the QOF Reports from GP system to the central QMAS equivalent system differs from the "transport mechanism" used in England, as DTS is not available. In summary: With DLM 195, Northern Ireland implemented messaging for QOF Reporting to replace the floppy disk process. Practices in Northern Ireland use the same QOF Clinical Audit version as England. QOF Regular (monthly), Interim and National Prevalence Day reports are to be ed as an attachment via SMTP to a common mailbox. There are no changes to the content of the XML report. The name of the XML file attachment will conform to the format PracticeId_yyymmddhhmmss.xml. A new Trading partner for this message type will be created by GPC on first use, with the prefix QOFNI. QOF Registration message is not required as all Northern Ireland practices are automatically set as Registered. QOF Acknowledgment messages will not be delivered. All QOF Reports are assumed to have been received on submission and will not be sent to the Pending folder. No automatic submission retries are required. Monthly reports are always shown as Acknowledged in Clinical Audit viewer. QOF messages will be able to be retransmitted from GPC. The existing floppy disk application will still work (supplied by MSD). QMAS in Northern Ireland is called PCAS. NI practices should refer to their respective Health Boards for issues relating to the PCAS, such as tracking the status of last submissions. New Users in Northern Ireland - Checking for GPC before starting Northern Ireland practices do not need to use Vision to register with QMAS. For Northern Ireland sites with GPC, the QOF Reports will be automatically generated at month end, as for England. The results can be viewed using View Results on the QOF Reporting tab, but the report is not submitted electronically. Practices who do not have GPC must continue to generate the reports manually. For all practices in Northern Ireland: 1. First check whether you have GPC or not. From the Vision front menu, click on Messaging, then click on GP Communicator. If GPC has not been configured, then you will see an error message. 2. Your next step depends on whether GPC is present or not. 15

16 If you do have GPC, then your QOF reports will be automatically generated at the end of the month automatically. Three things you must do: 3. In Control Panel File Maintenance Practice, initially check you have entered your practice ID in National Identifier. It is 6 characters in the format Z00xxx. This is an essential code to have entered for GMS contract audit data to be transmitted electronically. 4. Either leave Mail Gateway running all the time (polling), or schedule it to run at least twice a day on report days (the first day of the month, National Prevalence day) in order for the QOF Report to be transmitted. 5. In GPC, on the report days, check in the Outgoing folder that the QOF Report message has been sent. It will be marked in Mail Gateway as Acknowledged once sent. If rejected, it will be marked as rejected. 6. Once your Northern Ireland practice starts to receive Vision updates electronically by means of DLMs (Downline Manager), it is important before this becomes operational that you check in GPC the times scheduled for DLM (Tools - Options - Clinical Scheduler - Configure Download Manager). The times selected will be shown on the Mail Gateway screen. Refer to the on-screen help within GPC. 7. From GP Communicator, Tools - Options - QOF Reports, Schedule times that the monthly ngms Contract audit reports can be generated from Clinical Audit and submitted AVOIDING a clash with scheduled backup or other scheduled functions. It also gives you the option to generate your usual monthly Clinical Audits (InPS, NSF, etc) at the same time as the ngms audits are performed and sent to QMAS. If you do not have GPC: Then on the first working day after the month end, go into Clinical Audit, QOF Reporting tab, and click on the Generate button on the right under Monthly. You will need to do this every month until you receive GPC. Once the report has been generated, you then need to follow the instructions given to you by MSD. 16

17 Reporting Tab in Clinical Audit The QOF Reporting tab in Clinical Audit relates to the ngms audit: Registration for English and Scottish practices only, this lets you request registration to QMAS (Quality and Outcomes Framework Management and Analysis System) for subsequent report submissions. See Registering with QMAS (page 10) or Multiple Practices - QMAS registration (page Error! Bookmark not defined.) Reporting this lets you generate and view QOF reports (all regions), Note - you cannot generate the National Prevalence Day Report will now forms part of the 31st March QOF Report. Monthly reports are submitted ad hoc Interim reports (England and Scotland only).. See Monthly Reports (page 44) and Interim Reports (page 49). A monthly report can also be generated manually if for some reason the automatic generation has failed. National Practice Identifier - see Multi-Practices (page 60) See also: View Results on QOF Reporting tab (page 45) Generate and Resubmit monthly report manually (page 47) National Prevalence Day Report (page 52) 17

18 ngms Contract QMAS and Monitoring Audits Overview of ngms audits ngms audit means the whole clinical audit which consists of QOF reporting lines, non reporting lines (the negatives, additional exception summaries etc) that complement the reporting lines, and the data quality lines. There are no longer separate monitoring and reporting categories. What there is now are different views of the ngms audit group. Monitoring and Reporting Views the "monitoring" view, where "today" is used for the QOF Reference date and hence is equivalent to cut-off date in other audits. "Today" can mean the date of the last clinical audit generation, which if practices choose, can be on a daily basis. It may of course have last run on a prior day. For the monitoring view, you select All Audits and ngms Monitoring view from the Audit Source (page 22) on the toolbar. the "reporting" view, where the QOF rules definition of Reference date (page 33) is used, and the next 1st April is used as the reference date, rolling forward each year. So data "in the last 15 months" from 1st April 2008, for example, will be counted from January For the reporting view, you select ngms Reporting view from the Audit Source on the toolbar The Clinical Domains The ngms Quality Outcome Framework audits have five sections: QOF Clinical, QOF Additional, QOF Organisational, Data Quality, Expiring Exceptions. There are 20 clinical categories. Clicking on the main heading can expand each. How the Audit Lines are Structured The top line within each clinical category is the total practice population, ie your patient register of active registered patients. The next line in each of the clinical categories is the disease register line (on a purple pink background). This is a Virtual disease register (page 27). The register is NOT subject to exception reporting, ie all patients with a given disease will appear on the virtual disease register. For example, CANCER01 REGISTER - cancer patients diagnosed (with valid QOF codes) after 01/04/2003. The Denominator (page 27) (dark blue on a light blue background) for a clinical category represents the target population for that indicator. Each indicator is scored against different denominators (target populations). For example, CANCER03 DENOMINATOR: from the cancer register, all patients with cancer diagnosed in the last 18 months. This is followed by separate lines for each of the Exceptions (page 28) (in dark grey - the light grey ones do not get sent to QMAS). These are patients who, for various reasons, should not be counted towards the achievement percentages. For example, CANCER03 EXCEPTION 1: Cancer patients diagnosed between 01/04/03 and the last 18th months are excluded. Then comes the numerator (also called the Indicator (page 32) and coloured dark green). This takes the resulting patients from the denominator group and finds those that fulfill the criteria for the Quality Indicator. For 18

19 example, CANCER03 NUMERATOR - cancer patients (from denominator group) who have had a review within 6 months of confirmed diagnosis. The numerator line shows the achievement that can be made. For example, CANCER03 (40-90%, 6 pts) shows that if between 40% and 90% of the patients eligible have achieved the indicator, then 6 points will be awarded. Negatives (page 32) lines (in red) find patients from the resulting denominator group who do not fulfil the criteria. For example, CANCER03 NEGATIVE - Patients with cancer in the last 18months and no review within 6 months of confirmed diagnosis. Negative lines have Reminders (page 35) which can be activated and produce a yellow post-it display in Consultation Manager when a patient is selected, for example, "CANCER: no review within 6 months of latest diagnosis". For automatic generation of reminders when the audit is run, tick the box Generate Reminders in GPC - Tools - Options - Audits & QOF. QOF Audit Criteria Criteria for each Quality Indicator are listed in the Clinical Audit on-screen help under QMAS Returns Clinical and Monitoring Criteria. Throughout the help text, there are hyperlinks to these READ codes. Use the Back button on the Help toolbar to return to your starting point. The Monthly Report to QMAS QOF Report is the xml file transmitted to QMAS (or other system depending on the country) which contains the mandatory reporting data generated from the ngms clinical audit The disease register, denominator and indicator and exception lines of the ngms Contract QMAS audits are automatically generated on the first day of each month and a report sent off to QMAS with denominator and indicator figures, and exception reporting. See Monthly Reports (page 44). Data for a National Prevalence Day Report (page 52) will be taken from the QOF Report submitted on 31st March. Daily Generation You can optionally generate the ngms audits daily (see Daily generation of audits (page 42)). Other Points The mouse scroll wheel can be used to scroll down the Clinical Audit screen. It would be a worthwhile exercise to tidy up Clinical Audit, i.e. remove any audits which are no longer required. This should significantly reduce processing time for the audits. To do this, go into Clinical Audit and click on File - Maintenance Mode. Highlight the audit line, or audit heading you no longer want, and right click, selecting Delete Searches. Providing Clinical Audit has been tidied up sufficiently, your practice may want to consider automatic generation of the non-ngms audits together with the monthly QOF Report generation. This can be activated in GP Communicator - Tools - Options - Audit & QOF. 19

20 Future Updates to the QOF Audits Future versions of the ngms Contract audits are sent by DLM. New ngms audits should be imported automatically after a DLM upgrade. If some reason they are not, you can run an Interim Generation or wait until the last day of the month when they will be imported at the next manual or automatic QOF audit generation at month end to avoid destroying the current month s statistics. See Importing new QOF audits (page 20). INPS will re-author the ngms audits from time to time to conform to the latest Dataset and Business Rules published by the NPfIT. Whenever new audits are imported are deleted, you are urged to run Remove obsolete patient groups from the Group Applications menu in Patient Groups. Importing new QOF audits The new ngms audit should have been automatically imported and generated immediately after the DLM upgrade has completed for both LAN and hosted systems. If you find that the new ngms audit has not been imported, then follow these instructions. If updated QOF audits are part of a DLM, you can import these audits in one of two ways: Either run an Interim Audit at any time to import them immediately Or wait until the end of the month when they will be imported automatically To do an Interim Generate, go to the QOF Reporting tab in Clinical Audit. Click on the Generate button on the bottom left of the screen under Interim (and under the Baseline date window). You will eventually see a message: QOF audits are available for import. Would you like to use the audits for this generation? Yes/No. 20

21 If you answer Yes, you are then given the chance to run a normal clinical audit generation afterwards: Once the audits have been imported a normal Clinical Audit generation will be required. Would you like this to run automatically immediately after the interim generation? Yes/No. When the audits have imported, you will see the usual message: Statistics are out of date and need to be regenerated. When you click on this, the normal Clinical Audit generation will start. Upgrading from previous versions New versions of audits will be delivered by DLM and will be imported at the next month end. Generate Interim Reports on Upgrade An Interim report is generated and submitted automatically when Vision is upgraded with a new version of the QOF Schema or Business Rules. This is to allow the HSCIC to monitor the deployment of system upgrades. If INPS distributes a new version of the QOF Audits that do not require a compulsory Interim report, the new audits will not be imported until the next automatic QOF Report. If an manual Interim report is requested before then the following new prompts will appear: Practice with their own server - When you try to un an interim generation, if there is a new version of the QOF Clinical Audits awaiting import, you will be given the choice as to whether or not to import them. If you choose to import them, you will be informed that this requires that a clinical audit will therefore need to be generated. You will then be given a choice to run it immediately after the QOF interim or to not run it now. You can cancel the generation at all stages. If you have selected to run the normal Clinical Audit generate after the QOF interim generation, then once the QOF Interim has finished its generation cycle, the normal Generate tab will become active and a normal generate will start. Hosted Practice - When you try to run an interim generation, if there is a new version of the QOF Clinical Audits awaiting import, you will be given the choice as to whether or not to import the new audits. 21

22 Figure 1: Interim Report - View Results Automatic Resubmission of Failed Reports If there are any QOF Regular reports with a submission status of failed when a new version of QOF audits are imported, these will be automatically regenerated and resubmitted at the next QOF Regular generation. Single QOF set of audits and four different views Audit Source The previously single ngms Reporting and Monitoring audit has been completely re-authored and merged into one set. What you now have is different views for the Monitoring or Reporting results, selected from Audit Source under the toolbar. Note - Until a daily generation of the reporting audits has happened, there will only be one view - "All Audits & ngms Monitoring". The other views will be visible once each has been run. Note - The Extract Audit option does not currently display any audits it is purely in preparation for the General Practice Extraction Service (GPES) implementation. 22

23 Repositioning Audit Source On the View menu in Clinical Audit, ticking Audit Source displays the Audit source line above or beside the toolbar; and unticking it hides Audit Source. Figure 2: Clinical Audit - Audit Source - Extract Note - The Extract option does not currently display any audits it is purely in preparation for the GPES implementation. You can drag this Audit Source selection box to another location by clicking on Audit Source. You may want to do this so you remind yourself which view you are looking at. Point the cursor at the rectangle to the right of the Audit Source box and drag, releasing the mouse button over a clear background. If you drag it back to the toolbar, drop it over the menu options to place it above the toolbar. All Audits & ngms Monitoring This view shows all Clinical Audits with statistics up to the end of last month and the ngms Monitoring Audit showing daily statistics (including 23

24 data up to the most recent daily generation), based on a QOF Reference Date of "today" inclusive. Until you run a daily generation, the only view you will see is All Audits & ngms Monitoring. Selecting this All Audits & ngms Monitoring view from Audit Source will display all existing audits (including INPS. HPA etc). with data shown up to the end of last monthly generation. The monitoring view of the ngms audits is shown, generated up to the last daily generation. If you want to activate Reminders (page 35) on monitoring date audits, select the All Audits & ngms Monitoring view before you start. This is the view to select before you run a Generation. When All Audits & ngms Monitoring view is selected, the tabs for Generate and Audit Manager Export are enabled. ngms Reporting You will only see this view after the daily generation has been run. Selecting this ngms Reporting view shows the ngms audit only based on the standard QOF Reporting date of next 1st April. Note that this is the same audit as shown in the monitoring view, including the non-reporting and data quality audit lines. Like the Monitoring view, it also includes data up to the most recent daily generation. Note - this is not the view of the last submitted QMAS Report (for this, see QOF Results Last Reported). If you want activate Reminders (page 35) on the reporting view, first select ngms Reporting from the Audit Source. There is no Generate tab in this view. 24

25 QOF Results Last Reported You will only see this QOF Results Last Reported view after the end of the month generation and report to QMAS. Selecting this view shows the data from the most recently generated monthly QOF Report. This is a historical view; no data added since that report was generated will be included in the results you see. This view shows ONLY the QMAS reported lines so there are no data quality audit lines, or greyed out exception lines. Note - the Prevalence of QOF Results Last Reported contains a single period, ie for the report last generated. There is no Generate tab in this view. QOF Results Last Interim You will only see this QOF Results Last Interim view if you have run an interim generation. This view shows data reported in the last generated interim report, if any interim has been run. On the QOF Results Last Interim view, go to the QOF Reporting tab to find the date the last interim report was run. Like the QOF Results Last Reported view, only a single period is shown in Prevalence. ngms QOF audit structure There are five sections to the ngms audit, and these are further subdivided: QOF - Clinical The clinical categories: CHD (coronary heard disease) HF (heart failure) Stroke BP Diabetes COPD Epilepsy Thyroid Cancer PC (palliative care) MH (mental health) Asthma Dementia DEP (Depression) CKD (chronic kidney disease) AF (atrial fibrillation) 25

26 Obesity LD (learning disabilities) Smoking Clinical categories start with a Virtual disease register (page 27). Then for each audit, there is a Denominator (page 27), Exceptions (page 28), Indicator (page 32) and Negatives (page 32). QOF - Additional Services This covers cervical cytology screening. QOF - Organisational This covers records of patients, with BP recorded, with up-to-date clinical summaries, ethnic origin, smoking status Data Quality Audits for ngms contract This set of audits assist with Data Quality issues for most of the clinical categories, Records and Medicines Management. None of this data is reported to QMAS. Expiring Exceptions for ngms contract This shows domain-specific expiring exceptions and indicator-specific expiring exceptions. See Domain-specific and indicator-specific exceptions (page 28). Criteria for ngms Contract Audits The criteria used for the ngms contracts is detailed in the on-screen help within Clinical Audit. Click on Help - Index - Contents - Introduction - ngms Contract QMAS Returns. This includes the Read codes used for each quality indicator. The QMAS and Monitoring audits are now in the same group, and the criteria in the help file are combined, as in all cases they are the same (except the crucial difference throughout of the reference date). 26

27 Virtual disease register In each of the clinical categories, the first indicator is a virtual disease register (coloured purple on a pink background on the audit). The contract does not require you to have an actual disease register, but to be able to provide a virtual one. The virtual disease registers are NOT subject to exception reporting, ie all patients with a given disease will appear on the virtual disease register. Denominator A "denominator" group is the first line in the remaining indicators for a clinical category. This is the target population - coloured dark blue on a light blue background. Each indicator is scored against different target populations (denominators). The denominator is made up of two groups which form the resulting denominator group: Patients who are eligible, with the disease diagnosis or age/sex criteria (eg Patients with Diabetes) for whom indicator data is present (eg who have had a blood pressure check in the last 15 months); or patients who are eligible, minus those who are excepted. For example, in the case of COPD9: The denominator group is those patients with COPD and those with indicator data present, eg spirometry recorded within 3 months before and anytime after diagnosis of COPD; or patients with COPD minus patients with exceptions such as the high level 9h codes and newly registered patients. This results in an amended denominator group. 27

28 The indicator group then looks at the patients within this resulting denominator group that have indicator data present, eg spirometry recorded within 3 months before and anytime after diagnosis of COPD. Exceptions Under the denominator line is a group of exceptions - coloured grey. Both the indicator and denominator take relevant exceptions into account. These are patients who should not be counted towards the achievement percentages. However, the most important thing to bear in mind with potential exceptions is that a patient who fulfills the indicator criteria will always be counted even if an exception applies. For example, a patient with CHD, who recently registered and has had a BP recorded in the last 15 months, will be counted towards CHD05 even though an exception (registered in last 3 months) is present. Possible exceptions will apply only if indicator data is not present. One indicator which differs from this rule is Cytology - patients with hysterectomies will always be excepted, even if a vault smear test is recorded. From October 2005, practices that make automated clinical submissions to QMAS will submit exception details from the QMAS Returns audits (see below - Exception Reporting to QMAS Version 3 QMAS Returns Audits (page 31)). Most exceptions, but not all, are reported to QMAS. The exceptions that are not sent to QMAS have been included in order to clarify the figures, mostly breaking down exceptions into further lines. Domain-specific and indicator-specific exceptions The Expiring Exceptions audits are in two parts: Domain-specific expiring exceptions ('patient unsuitable' and 'informed' dissent'); and Indicator-specific expiring exceptions: having one of the exception codes for treatment or procedure declined, maximum tolerated medication dosage, drug allergy or contraindication, declined/ refused, not indicated or not tolerated. All of these lines require a record within 15 months of the reference date (1st April next) so may need recording annually. Domain-specific (High Level) exceptions Domain-specific (High level) exceptions, once recorded, will apply to all indicators within the category. Chapter 9h of READ has exceptions code per category: Patient unsuitable, and Informed dissent. These need to be based on clinical decisions, and practices must be able to provide evidence for excepting patients at this level. This must be recorded annually, and will only be counted if the latest record is within the last 15 months of next 1st April. If a patient falls into more than one clinical category, and should be excepted from all, separate exceptions need to be recorded for each category. 28

29 Indicator-specific exceptions Indicator-specific exceptions depend on the quality indicator: having one of the exception codes for treatment or procedure declined, maximum tolerated medication dosage, drug allergy or contraindication, declined/ refused, not indicated or not tolerated. Drug allergies only need to be recorded once in the patient records - these are called persistent exceptions, eg drug allergies, adverse effects. Other exceptions must be recorded annually and are called expiring exceptions, and usually from READ chapter 8I. Note - for CHD09, patients taking aspirin, another antiplatelet or an anticoagulant, contraindications to ALL THREE drug groups must be recorded for a patient to be excepted from these indicators. They can, however, be a mixture of persisting and expiring contraindications. eg aspirin allergy (persisting), clopidogrel not tolerated (expiring) and warfarin declined (expiring). So the clopidogrel not tolerated and warfarin declined should be recorded annually. Similarly for STROKE12 where additionally dipyridamole must be recorded as a fourth option. The same underlying rule applies to ACE inhibitor / A2 antagonist therapy (CHD11, HF03, DM15). Patients not taking either of these two drugs need contraindications recorded to BOTH drug groups. Again, one can be persisting and the other one expiring. 29

30 Exceptions for patients recently registered or recently diagnosed Patients registered recently (in last 3 or 9 months) are excepted in the last 3 (or 9) months before next 1st April. For exception lines where the patient is excepted because of the new diagnosis in the last 3 (or in some cases 9, depending on the domain) months, the exception will look at 3 (or 9) months before next 1st April. This allows you identify newly diagnosed patients earlier so you can start whatever is needed. Where a partnership changes, patients may have to be transferred within the practice. In Registration (Transfer menu), there is the option to do this: Partnership Reallocation, which does not change the acceptance date. PCT confirmation should be obtained to ensure there are no problems with date restrictions, for example, if patients were registered prior to a new GP's start date. See also What are Exception Codes? (page 30). What are Exception Codes? Target populations and indicators take Exceptions (page 28) into account. There are two levels of exceptions for each clinical category: Top level Domain-specific (Read code 9h) applied to ALL indicators within category Patient unsuitable Informed dissent Indicator level applied to individual indicators only Maximum tolerated medication dosage Drug allergy / contraindication Patient recently registered Patient recently diagnosed Treatment/procedure declined Rules for Exception Reporting For each indicator, the target (denominator) population is made up of: Patients who have HAD the appropriate therapy, action, advice etc, PLUS Patients who have NOT had the intervention and had no exception conditions The best way of thinking of this can be seen in this table, where "X" is the relevant advice, referral, therapy or whatever. The effect of this is that patients who have exceptions still count to give you points, if (despite the exceptions) they have had "X": Has the patient had "X"? Yes No Has the patient ANY exception condition? Counts in NUMERATOR (Indicator) - No Yes Yes No No Counts in DENOMINATOR Yes Yes No 30

31 See also - What do the denominator and indicator lines show? (page 74) and Why are patients with exception codes recorded still being shown on the register? (page 74) Example of Exception Reporting Qualifying data = Hypertension codes; Indicator data = last BP less than or equal to 150/90 in last 9 months. Exceptions = Code in the 15 months before either 1st April next year (QMAS) or the end of last month (Monitoring) for maximum tolerated antihypertensive medication, patients registered in last 9 months, patients first diagnosed in last 9 months. The second bullet point line demonstrates that despite an exception being recorded (maximum tolerated antihypertensive medication), the patient is still counted towards the indicator percentage, because the latest BP record matches the indicator criteria. If the patient has hypertension (G2) and the last BP was less than or equal to 150/90 in the last 9 months, then the patient is counted towards the denominator group AND the indicator group. If the patient has hypertension (G2) and the last BP was less than or equal to 150/90 in last 9 months AND they have a record of an exception of maximum tolerated antihypertensive medication, then the patient is counted towards the denominator group AND the indicator group If the patient has hypertension (G2) and the last BP was greater than 150/90 in the last 9 months, then the patient is counted towards the denominator group BUT NOT the indicator group. If the patient has hypertension (G2) and the last BP was greater than 150/90 in the last 9 months AND they have a record of an exception of maximum tolerated antihypertensive medication, then the patient is NOT counted towards the denominator group NOR the indicator group. For further general information on exception reporting, please refer to the 'Focus on exception reporting' guidance Note - available at: ( Exception Reporting to QMAS Version 3 QMAS Returns Audits Changes were announced to the payment software of QMAS to include the addition of exception reporting information. Practices in England who make automated clinical submissions to QMAS now submit exception details from the QMAS Returns audits. This means practices and PCTs will be able to check exception reporting details on the system. Exception reporting is the process by which patients are excluded from QoF targets, because they have, for example, contra-indications to flu vaccination, to ensure practices are not penalised. After DLM 193, practices that make automated clinical submissions to QMAS will submit exception details from the QMAS Returns audits to QMAS. This will collect information on exception reasons, such as recent registration and the type of exception code recorded together with counts of exception reasons which will show the number of instances within that practice of that exception reason. Exception details will be recorded at each individual 31

32 indicator level in the clinical domain and for several indicators within the non-clinical domains such as cervical screening. Practices will be able to compare their level of exception reporting against PCT and national averages with rates displayed in a summary form based on five generalised categories of exceptions, patient unsuitable, informed dissent, registration date, diagnosis date and other. More detailed information about reasons for exception reporting will also be available. At PCT level trusts will be able to examine details for each individual indicator, aggregated for the practices within the PCT. The PCT will also be able to examine exception details at indicator group level, for example for coronary heart disease, compared with the national exception rates for the same indicator group. Indicator The indicator (also called the numerator) group is coloured dark green. This takes the resulting patients from the denominator group and finds those that fulfill the criteria for the Quality Indicator. The audits provide the percentage calculation for each indicator/denominator pair. Both the denominator and indicator figures are sent to QMAS (see Monthly Reports (page 44)). The payment is based on the indicator figure. For example, in the case of COPD9: Negatives The denominator group is those patients with COPD and those with indicator data present, eg spirometry recorded within 3 months before and anytime after diagnosis of COPD; or patients with COPD minus patients with exceptions such as the high level 9h codes and newly registered patients. This results in an amended denominator group. The indicator group then looks at the patients within this resulting denominator group that have indicator data present, eg spirometry recorded within 3 months before and anytime after diagnosis of COPD. The negative group is coloured red. These are patients from the resulting denominator group who do not fulfil the criteria. Negative lines are not reported to QMAS. The patients found in the "negatives" are flagged with reminders. The reminders are initially inactive but you need to activate as many as you think necessary from either the ngms reporting or monitoring view - see Reminders (page 35). Once reminders are activated, yellow post-it reminders are displayed in Consultation Manager when the patient is selected, eg Asthma newly diagnosed, not confirmed by spirometry or peak flow. This will help you call these patients in for review. To find these patients in order to mail merge, see How do I find a list of audit patients for printing or mail merge? (page 79) 32

33 Reference date The reporting view of the ngms audit use the end of the financial year as the reference date (next 1st April). This date rolls forward each year. It is used to select relevant entries in the quality indicator groups (ie for accepting or rejecting qualifying records) with reference to the year of reporting. The reference date is used for all indicator and exception data. Date ranges vary, but for many of the indicators and exceptions, data needs to be recorded within 15 months of the reference date. This means that for a reference date of 1st April, records on or after 1st January of the previous year will be counted. Most therapy entries are counted within 6 months of the reference date. So, for a reference date of 1st April, therapy recorded on or after the previous 1st October would be counted. Exceptions for recent registration count patients registered with the practice on or after 1st January. The reference date is user definable when you run Interim Reports (page 49). It is possible to change it to today's date, as if today was the end of the financial year, which gives you a How Am I Driving report. However, now that daily generation of ngms audits is possible, this is no longer so useful. When you first run the ngms contract QMAS audits, your indicator figures may be very low. If you run the reports for September, you are only looking at 9 months of recorded indicator data. There are still 6 months of data to come for patients who are seen annually. The only figures used for payment purposes are the ones submitted for March, and they will report on the full 15 month period. And most of the therapy dates in indicators are for 6 months only, so consequently you will not see any figures appearing in those indicators until the October report. However, therapy records which form part of the qualifying data for the disease register (Asthma, Epilepsy, Mental health (lithium) and hypothyroidism) are different. They are based on a baseline date which is by default the end of last month, and therefore the disease registers should be complete on every month's reported figures. Baseline date The baseline date is either the first day of the month for monthly generated audits; or today for daily generated audits. The baseline date acts as a cut-off for the inclusion of patients and initial qualifying criteria for a patient to be included in any of the clinical categories (and is the date used in all Clinical Audits). Any READ codes present in patients' records on or after this date are ignored for reporting purposes. The audits are only counting patients who were registered BEFORE the baseline date. If transferred out, patients will still be counted if they were transferred out ON OR AFTER the baseline date. Qualifying diagnoses / therapy entries are only counted if made BEFORE the baseline date. 33

34 All indicator and exception data is only counted if made BEFORE the baseline date. The baseline date can be changed for Interim Reports (page 49) mid-month. Prevalence, Base Start Date and Data Analysis In the Monitoring and Reporting views for the ngms audit, prevalence will be shown going back only to 01/04/2003, or the standard Base Start Date if later. This is the first year that ngms was introduced. This constraint has been put in to reduce the time needed to perform the counts stage each time a new version of the ngms audit is imported. We find that many practices have a Base Start Date going back many years before this date. If you do not need to see prevalence as far back as this, you can change the Base Start Date in Generate Options or Advanced Generation. Changes to Base Start Date only affect prevalence for new audits. To change prevalence for existing audits, you need to run an Advanced Generation and check the Purge Statistics option. Regardless of how far back prevalence is retained, you can perform age/sex analysis for any period in the past on any of the four ngms audit views. You can view the patient group and view age/sex analysis, incidence and prevalence for all of the four ngms audit views. For example, if you are viewing the QOF Report Last Reported view, showing the last QOF Report you submitted, the patient list shown in the current month tab will be the list that made up the statistics for that audit line in the report. 34

35 Reminders Reminders are yellow pop-up boxes which are displayed in the top right-hand of the patient's record in Consultation Manager. Audit reminders are generated automatically from running a clinical audit. Almost all the "negative" lines in the ngms audits have inactive reminders. You choose which reminders you want to activate. The same reminder text appears in both reporting and monitoring views. You can have a reminder active in one view but not in both, for example, if active in the monitoring view, this will make it automatically inactive in the reporting view. Alternatively a reminder can be inactive in both reporting or monitoring. Some practices prefer to use the monitoring view reminders until December or January, when they switch over to the reporting view reminders up until April. With daily generation, the monitoring view shows you your up-to-date position as if each month end were the end of the contract year. The reporting view, using next 1st April as the reference date, shows how you are really doing in the current contract year. Activating a reminder Reminders will remain active, if already active, when updated versions of new audits are imported, unless there is a significant change in the clinical nature of the audit line. Because of the re-authoring of the QOF audits in DLM 270, none of the reminders will be activated at first after this DLM. For the ngms audit, you can activate a reminder for an audit line in either the monitoring or reporting view, but not both at the same time. If you want to activate any of the monitoring view lines, set the view in Audit Source on the Clinical Audit toolbar to All Audits & ngms Monitoring under Audit Source above the toolbar. If you want to activate any of the reporting view line reminders, set the Audit Source view to ngms Reporting. One suggestion is to use the ngms Monitoring reminders for the first half of the year from April to September, then the Reporting reminders for October to March. Note - the text of reminders is the same for both Reporting and Monitoring. QOFDATE is used within the reminder text in some cases and will automatically display when viewed in Consultation Manager either 1st April for a Reporting reminder or the date of the last generation for Monitoring reminder. You can have a reminder active in one group (eg monitoring) and this will make it automatically inactive in the other set of audits (eg reporting) (or vice versa). 35

36 Alternatively a reminder can be inactive in both reporting or monitoring. The same reminder text appears in both views but may appear with a reference date difference when viewed in Consultation Manager. 1. First select either the ngms Reporting view, or All Audits & ngms Monitoring view, from Audit Source at the top near the toolbar. 2. Find the audit line with the pale yellow which shows it is currently inactive. 3. Right click on the audit line and select Active Reminder. 4. This places a tick beside Active Reminder and the reminder icon will now be darker yellow. Next time you generate the statistics, the reminder will be created and thus appear in Consultation Manager when you select a patient who appears in that audit line. Note - if selecting Active Reminder for a line with no reminder, the Edit Reminder form will be shown. Editing text of a reminder You can edit the text of a reminder if you want by right clicking on a line with a reminder, and selecting Reminder. Type free text, or alter existing text in the reminder window, check that Active is ticked, then select OK. The use of date fields in reminder text is explained in See below under Reminder text with QOFDATE etc. Upgrades of audits and reminders Your reminder settings should be retained even when the ngms audits are upgraded, the exception being where there is some significant change to the unique ID of the audit line. One tip is to keep your reminder text in a Word document so it is easy to cut and paste them in again after an import. Tip Add a yellow flag to each of the disease register lines with just the disease name (CKD, DM etc). This gives you a mini problems list within the reminders which can also be extremely helpful. Reminders generated with audits If you tick the box Generate Reminders in GPC - Tools - Options - Audits & QOF, reminders will be generated at the same time as the audits. Reminder generation is now incremental; instead of wiping out all reminders at the start, it now compares the new group patient list (patient groups associated with audit lines are no longer saved) with the current list of patients with that reminder. If patients are no longer in the group, their reminder is deleted; if there are new patients, their reminder is added. If the reminder is no longer active, all the reminders for the group are deleted. If you are no longer generating reminders, a problem arises because the associated patient groups are not saved and so the Why? function (in Consultation Manager) cannot work. It also means that current reminders become out of step with the latest patient data. The rule is that if you use reminders, you must keep them up to date by checking the automatic reminder generation option in the Audit/QOF tab in 36

37 GPC or new Schedule option in Mail Gateway; or manually run reminder generation afterwards in Clinical Audit. Reminder text with date fields Reminder text is the same in reporting and monitoring audit views. Date fields such as QOFDATE can now be added to reminder text, which when displayed in Consultation Manager, will automatically insert the date instead of saying "before reference date". This feature is available for all audits, and not just ngms. For example, previous reminder text might have read: "CHD: last cholesterol in 15 months to reference date >5.0mmol/l or NO cholesterol" which now becomes: "CHD: last cholesterol in 15 months to QOFDATE >5.0mmol/l or NO cholesterol", and translates in Consultation Manager as (where 28/01/2008 was the day the audits were last generated): For Monitoring, the last date QOF reports were generated, eg "CHD: last cholesterol in 15 months to 28/01/2008 >5.0mmol/l or NO cholesterol " 37

38 For Reporting, " CHD: last cholesterol in 15 months to 01/04/2008 >5.0mmol/l or NO cholesterol " Upper case must be used for the date field but it can be placed anywhere in the reminder text. For ngms audits only, the following can be used: QOFDATE - 1st April next (reporting) or last generation date (monitoring)(qof audits only) BASELINEDATE - Same value as CUTOFF which is last day of previous month for monthly generations, today for daily REFERENCEDATE - 1st April for the current financial year (QOF audits only - and only useful for the ngms reporting audit) FLUCYSTART - Start of flu period current financial year, 1st September FLUCYEND - End of flu period current financial year, 31st March FLUPYSTART - Start of flu period previous financial year, 1st September FLUPYEND - End of flu period previous financial year, 31st March Non-nGMS audits can also use: CUTOFF - Set to the last day of the previous month (non ngms audits only). and quarters 1-4 start and end dates: Q1_START, Q1_END, Q2_START, Q2_END, Q3_START, Q3_END, Q4_START, Q4_END 38

39 Reminder text Hovering with the mouse over an audit line with a reminder will show the reminder text, if Audit Line Tooltips is ticked in the View menu. If unticked, this is switched off. 39

40 Within Consultation Manager Yellow pop-up reminders are displayed in the top right of a patient's record screen in Consultation Manager (see on-screen help in Consultation Manager for full details). Within Consultation Manager, you can right click on a yellow reminder for the following: Why - Only relevant for Clinical Audit Reminders to find the source of the reminder. This is disabled for Group Reminders. Cancel - As well as the right mouse menu and Cancel, you can also cancel a reminder by double clicking on the reminder line; either has the effect of crossing the reminder line through. All reminders can be cancelled on an individual patient basis. Cancelled audit reminders for a patient remain cancelled until the patient is removed from the group (when the reminder is deleted), the reminder is uncancelled by the user, or reminders are regenerated in an Advanced Generation in the Clinical Audit module. Delete - You can only delete Group Applied or Manual Reminders. Edit - Remember you can only edit Group Applied or Manual Reminders. Edit the text in the dialog box. If a Group Applied or Appointments generated reminder if edited in this way, it becomes a "manual" reminder and ceases to be a "group" reminder. Add - Allows you to add a reminder for the currently selected patient. Close - Hides the yellow reminder box. This can be re-displayed by selecting View - Reminders. 40

41 Generation of Audits The following lists the generation of ngms audits: Daily generation of audits ngms audits that qualify for daily generation can be generated every day. Practices are able to select on which days to run the generation. Any newly imported non-qof audits, not yet generated, will also be run. See Daily generation of audits (page 42). Generation of monthly mandatory QOF Reports Vision automatically generates the Regular QOF report on the 1 st day of each month. Users have no choice over this. This report must be completed within 24 hours of the start of the day. See Reports to QMAS (page 43). Before 2008, a National Prevalence Day Report was run on 14 th March to calculate prevalence by QMAS. Although this report will still run, QMAS will ignore it. Instead, from 2008, data for NPD will now be taken from the QOF Report submitted at year-end on 31st March. Generation of Interim QOF Reports Vision can generate an Interim report when selected by the user. This report must be completed within 24 hours of the request. See Interim Reports (page 49). For VES practices, Interim Reports for prior periods will generate an Interim Report request (see Interim Report request (page 58). Monthly Clinical Audit Generate Audits that do not qualify for daily generation must be generated once per month, as close as possible to the 1 st day of each month. This process must also generate the daily audits at the same time to avoid another generation having to be run that day. You can opt to run the monthly generation of non-qof audits automatically at the end of each month AFTER the QOF monthly run. See Scheduling the daily generations (page 42). Newly imported audits - If you import non-qof audits, you can Generate these from the Generate tab on Clinical Audit, or you can wait for the next scheduled daily generation of QOF audits which includes newly imported audits. Note - QOF audits cannot be manually imported and are always downloaded via a DLM. 41

42 Daily generation of audits Daily generation of QOF audits for up-to-date data Up until now, you have been generating data from QOF audits up to the last day of the previous month. After the download of DLM 270, an automatic daily generation of QOF audits will give you up-to-date data for both reporting and monitoring, at least no older than 24 hours. This shows statistics from data present at the last generation. Daily generation is optional but by default, once you have the DLM installed, the daily generations will start automatically and continue every night unless you alter the days in the schedule. The dates run are recorded on the Generate tab in Mail Gateway. LAN practices default will start the daily generation every night at midnight. You can edit the start times and also which days of week it is run. See Scheduling the daily generations (page 42) on page. VES practices will have the daily generation run automatically every night. You can choose which days but there is no option to choose at what time it is run. See Scheduling the daily generations (page 42) on page. If there are any newly imported non-qof audits waiting to be generated, these will be run in a daily generation along with the QOF audits. Currently only the ngms audit will be generated daily. Scheduling the daily generations Please see GPC Mail Gateway on-screen help for further information. 42

43 Patient groups from audits Clinical Audit Generate no longer saves the patient group for each audit line during the Counts stage. This reduces the total time needed for a generation and cuts down the number of patient groups in Vision databases. When viewing the patient lists for a line in Clinical Audit, by clicking on the [month/year] tab, the program generates the list automatically, based on the dates used for the last generation so that the list reflects the counts. For example, if you are browsing lines from a monthly audit, it will generate the patient list based on the end of last month date. If it is a daily audit, this list will be based on the last daily generation date. For all other applications that reference patient groups in Vision 3, a Clinical Audit browser will allow you to view all clinical audits, including each of the four ngms audit views, which will then generate the patient group to reflect the date of generation relevant to that audit. There will be a small delay as the system generates these patient groups on the fly, ie as they are needed. Any patient groups generated this way remain saved but will be deleted again at the next generation. The audit browser can be found in Patient Groups (Select an Audit Line), Searches and Report (Group Input), and Consultation Manager (Select a Patient Group). The exception to the saving patient groups rule is those lines with an active reminder. These lines will have their patient group saved during reminder generation. This is so that when viewing patient reminders in Consultation Manager, clicking on the Why? option displays the patient's qualifying records for that group without delay. Sub searches, $GLO & $SUB, such as patients with asthma, or blood pressure recorded, will still be saved. If you do specifically want to save a patient group as it currently is for later use, go the [month/year] tab in Clinical Audit, click on the audit line to show the patients in the bottom left-hand pane, right click and select Save This Group. This can also be done in Patient Groups. Reports to QMAS There are two ways of reporting to QMAS: regular, automatic Monthly Reports (page 44) and manual Interim Reports (page 49). The figures from both these reports can be viewed in Clinical Audit under the QOF Reporting tab. In addition, there is a National Prevalence Day Report (page 52) which is part of the 31st March submission to QMAS. Note - In order for the monthly reports and National Prevalence Report to be submitted to QMAS, Mail Gateway must be running and scheduled for transmission. You must not close Gateway after generation. Mail Gateway must be run at least twice a day in order to pick up the receipt report from QMAS. See Run Mail Gateway at least twice a day (page 66) 43

44 Monthly Reports Regular (monthly) reports will be generated and submitted automatically by Mail Gateway at the first opportunity each month. This is done by running Clinical Audit in silent mode on the GPC workstation when there is the next Mail Gateway session, as soon after midnight on the last day of the month, taking into account any times you have specified to avoid (see GP Communicator (page 60)). Note - Clinical Audit does not need to be active or open for the monthly report to generate but Mail Gateway needs to be running and scheduled for transmission For the first month following successful registration, Mail Gateway will submit reports for each previous month of the current financial year. For example, if Registration is submitted and accepted in August 2008, Regular reports will be submitted for May, June, July & August Subsequent Regular reports are single month only. For monthly reporting to QMAS, the baseline date is defined as the first day of the month. This is in effect the same date that has always been used in traditional clinical audits as the cut-off date. The reference date in monthly reporting is fixed to the end of the current financial year, which is defined as next 1st April. Mail Gateway shows when audits are being run: Under QOF Report section, it says (in red): The Clinical Audit is now running. Started [date time]. Note - Practices must not close Gateway after generation. Note - too that you will not be able to exit Vision while the Mail Gateway and Clinical Audit are generating the ngms Contract reports There is no way to tell directly on Clinical Audit if a monthly report has been generated until you click on View Results (see View Results on QOF Reporting tab (page 45)). Note - an XML file is produced after the monthly report generation from Clinical Audit. If Mail Gateway is open, then this XML file - the report - is submitted directly to QMAS. If Mail Gateway is closed, when it next re-opens, it regenerates and submits a regenerated report. It never submits a report just sitting there, so there is no opportunity to amend the XML file for submission. When a normal Clinical Audit generation is run (using the Generate tab in Clinical Audit), all lines will be generated, including the ones run as part of the QOF Reporting. Depending on the time elapsed between QOF Reporting and normal audit generation, and the amount of back-dated information having been recorded, there could be a difference between the submitted figures for the disease register, denominator and indicator lines and the figures seen against the same lines in Clinical Audit. For this reason, it is advisable to perform the normal audit generation as close as possible to the automatic QOF reporting run to avoid confusion. You can automate the whole process via GPC (see GP Communicator (page 60)). 44

45 If no monthly reports are submitted to QMAS (England) It is likely that QMAS automatically responds with a "missing" message. Next month s run does not happen if last month s has not been submitted. QMAS will probably send a notification if report missing. A Regenerate button can be run at any time by the practice. This resubmits the last monthly file. Wait for a couple of hours, then click on View Results and see if last month is now shown as Acknowledged. If so, your QOF report has been submitted and its receipt has been acknowledged, No further action is required. If it is not shown as Acknowledged, restart Mail Gateway (close and re-open) and click on the top Run Now button. Wait 10 minutes. Click on View Results button under Monthly in Clinical Audit. Acknowledged means the QOF report has been submitted. If it says Submitted, click Run Now in Mail Gateway and wait an hour, then click Run Now again; check again in View Results. If it says Rejected, contact the Helpline. In Scotland In Scotland, there is a new system called the QOF Calculator (DLM 310). Outgoing QOF reports will automatically be marked as successfully acknowledged by Vision and the GPC message moved to the audit folder, rather than pending. The QOF report status in Vision will always be reported as ack d; no automatic retransmissions will occur from the Attention folder. View Results on QOF Reporting tab Once a monthly or interim or Year End (March 200x) report has been run, you can check the QOF Report has been submitted. 1. In Clinical Audit, on the QOF Reporting tab, click on View Results under Monthly. 2. This XML Viewer shows the figures for a monthly report that have been submitted to QMAS. You can view results only after the monthly report has been submitted to QMAS. 3. Each quality indicator is listed in turn. It then shows for each the denominator figures as blue lines and the indicator figures as white or yellow lines. It gives the month the report was run and clearly shows the reference and baseline dates. 4. Scroll to the right of the screen to make sure that last month is in the far right column and shows the status of Acknowledged. If the status says Submitted, then QMAS has your report but has not yet acknowledged it. You can manually click Run Now in Mail Gateway, wait an hour or so, and click Run Now again. Then look again in View Results on the QOF Reporting tab under Monthly. If it says Acknowledged, then the QOF Report has been submitted and has been acknowledged and there is no further action. If it still says Submitted, you may need to contact the Helpline. If the status says Rejected, you should contact the Helpline. 45

46 When viewing results, a right mouse click has a Print option. View Results shows only the last month s figures, or in the case of the catch-up reports, all the months figures from April up to the last full month, eg August. When the next month is run, eg, September, then View Results only shows September figures, the last report submitted. Note - you can also view the outgoing report in GP Communicator. See QOF Report messages to and from NMAS (page 61). Exporting audit data to Excel You can view the QMAS reports from the QOF Reporting tab by clicking on the View Results button. Once the report is displayed on-screen, right click and Print, or choose Export to Microsoft Excel - as long as you have an up-todate version of Microsoft Excel and Outlook. Make sure to right click at the top of the report, around the heading Clinical. This ensures all the figures are exported. If you right click within the report, eg, Asthma 06, only those lines will be exported. Microsoft Excel will open and automatically populate. Wait for the receipt acknowledgement to arrive from QMAS before exporting to Excel - before acknowledgement, the figures are in a different order (cytology first) whereas after acknowledgement, the report is listed in the order of the quality indicators, eg CHD first followed by Stroke and so on. 46

47 Generate and Resubmit monthly report manually If you do not run Mail Gateway, manual generation can be achieved by pressing either the Generate or Regenerate button in the QOF Reporting tab in Clinical Audit. If the button says Generate under Monthly: 1. Make sure everyone is out of Clinical Audit. 2. On one machine only, click on the Monthly Generate button and wait until the process has completed. 3. Restart Mail Gateway and click on the top Run Now button. Wait 10 minutes. 4. Shut down and restart Mail Gateway and click the top Run Now button. 5. Wait 2 hours. Click Run Now again. 6. Click on the View Results button under Monthly on the QOF Reporting tab, and scroll across to view the month just generated. If it says Acknowledged, the QOF report has been submitted and has been acknowledged. No further action is required. If it says Submitted, click Run Now in Mail Gateway and wait an hour. Click Run Now again. Click on the View Results button again under Monthly on the QOF Reporting tab in Clinical Audit. If it says Acknowledged, then no further action is required. If it says, Submitted or Rejected, then contact the Helpline. If it says Rejected, then contact the Helpline. If the button says Regenerate under Monthly 1. Click on View Results under Monthly. If the status is shown as Acknowledged under the month just generated, then your QOF Report has been submitted and its receipt has been acknowledged and no further action is required. 2. If it does not say acknowledged, then restart Mail Gateway, and click on the top Run Now button. Wait 10 minutes. 3. Follow the steps from step 4 in If the button says Generate under Monthly: (page 47). Once a Regular report has been generated, either manually or automatically by Mail Gateway, the button changes to Resubmit. 47

48 Resubmit The Resubmit button does not need to be used for a normal submission; Mail Gateway will automatically submit the report. This button may be required for a manual resubmission if the original message is lost from GPC. View Results on QMAS website Every time achievement information is submitted by your practice to QMAS, a report is created, and kept on QMAS for viewing. Practice users can view the practice's achievement against aspiration reports on the QMAS website, accessed via the NHSNet. A practice cannot view another practice's reports. PCT users can view each of their practice's achievement against aspiration reports. Initially two people per PCT and one person per practice (where the PCT has nominated somebody) will have access to QMAS. The QMAS User ID and Password is issued by QMAS to your PCT's QMAS User Administrator, who will assign an appropriate QMAS role to your user ID. Users can either enter and/or view data. A practice user who has viewing rights only can view the practice achievement against aspiration reports. A practice user who can view and update data can also enter clinical and non-clinical achievement data. There are three sorts of reports: Monthly, created at month end and showing progress make towards the year-end aspiration target for achievement. These will be available for viewing probably from the second day of a month. Ad Hoc - These are the Interim Reports (page 49), reflecting achievement in between the monthly report. How am I driving? These are Interim Reports (page 49) that reflect achievement as if today as the last day of the financial year. Note - The QMAS training website is at ( - this shows screenshots of how the reports will look. In autumn 2005, a number of small changes are being made to the reporting layouts on QMAS, mainly to help practices and PCTs to understand the disease prevalence figures, particularly at year end. QMAS will now show raw disease prevalence values at practice, PCT, strategic health authority and national level rather than the square root figures that were displayed in the first year. 48

49 Interim Reports An Interim report can be generated at any time by the practice following registration. Daily generation of ngms audits will make interim QOF Report generation less useful. These can still be run, and submitted for view in QMAS. If the audits are being generated for today, the report will be produced almost immediately since the underlying searches will already be up-to-date. This includes VES practices who previously had to submit a request to generate the interim report overnight. If you want an Interim report for a prior financial year, this will take longer as this always involves regenerating the searches using the audit from that year. The patient groups from these searches are stored using different names (prefixed $QPS) so that they remain separate from the current year group. On a VES, a prior year Interim report will always generate an overnight request. Generate interim report to QMAS 1. On the QOF Reporting tab, on the left-hand Interim report section, first select the Baseline date (see below about generating a report from previous years). The Reference date stays at the next 01 April. The Baseline date is user-definable, and it is a requirement that practices can generate figures on any baseline date (though the baseline date cannot be later than the reference date). By default, the interim reports are run on a baseline date of today ie looks at data entered up to today, so this is the practice s status as at today. This may help with additional workload management for the rest of the month. The Reference date is next 1st April. The figures as such are therefore cumulative, building up to April. For example, you may have 10% valid for an indicator in September, 15% by October, 25% by December, and 80% by March. Note - there is no point is putting the baseline date into the future, as future data has not been entered yet. 2. Then click Generate to create the report. Interim generation can be interrupted by pressing Escape. View results of interim report Once generated, you can view the results in the Interim report by clicking the View Results button. This clearly shows the baseline date and reference date you have chosen. The Clinical Audit figures are the original figures from the last normal run. Right mouse click has a print option. 49

50 Submit interim report to QMAS To submit an Interim report to QMAS, click on the Submit button under the Interim heading. Interim reports are not automatically submitted by Mail Gateway. Once an Interim report has been submitted, no further Interim reports can be generated until an acknowledgement has been received from QMAS. Prior to submission, Interim reports can be generated as often as required; however only the most recent set of Interim results are retained to View and Submit. The interim report gives figures, but no negatives. It is not possible to view patient groups for interim reports, only statistics. There is a possibility next March that you have run an interim report and you see that the figures show an achievement of 89% and you need another two patients - View Results only shows figures, not patients. Interim Reports for Previous Years From DLM 220, practices can generate and submit QOF Interim reports for prior financial years. The application will calculate the relevant QOF year from the user supplied report Baseline date. QOF years run from Baseline dates of 2nd April to 1st April (an anomaly arising from the fact that monthly reports are generated retrospectively on the 1st day of the following month). The earliest valid date will be 02/02/04 (the first year of QOF). For years prior to , Vision 3 will generate Interim reports using schema version 0.6 and Business Rules V7.0. Note - the QMAS system will validate submitted reports for the correct schema corresponding to the Baseline date. After the final QOF Regular report of each year has been generated for 1st April, that year s schema and Clinical Audits (which implement the Business Rules) will be archived into a new folder. These are then used to generate prior year submissions for that year in the next financial year. Generate Interim Reports on Upgrade An Interim report is generated and submitted automatically when Vision is upgraded with a new version of the QOF Schema or Business Rules. This is to allow the HSCIC to monitor the deployment of system upgrades. If INPS distributes a new version of the QOF Audits that do not require a compulsory Interim report, the new audits will not be imported until the next automatic QOF Report. If an manual Interim report is requested before then the following new prompts will appear: LAN Practice - When you try to un an interim generation, if there is a new version of the QOF Clinical Audits awaiting import, you will be given the choice as to whether or not to import them. If you choose to import them, you will be informed that this requires that a clinical audit will therefore need to be generated. You will then be given a choice to run it immediately after the QOF interim or to not run it now. You can cancel the generation at all stages. If you have selected to run the normal Clinical Audit generate after the QOF interim generation, then once the QOF Interim has finished its generation cycle, the normal Generate tab will become active and a normal generate will start. 50

51 VES Practice - When you try to run an interim generation, if there is a new version of the QOF Clinical Audits awaiting import, you will be given the choice as to whether or not to import the new audits. Figure 3: Interim Report - View Results 51

52 National Prevalence Day Report A National Prevalence Day (NPD) report is run for every practice to calculate prevalence by QMAS. This report runs on 14th March but from 2008, QMAS will ignore this and instead use data from the end of year 31st March QOF report submitted to QMAS. Practices need do nothing specifically towards an NPD Report other than submit their usual 31st March (end of year) QOF report to QMAS. The following is an Scottish extract from ( June 2008 INTRODUCTION The Quality & Outcomes Framework (QOF) is a system to pay general practices for providing good quality care to their patients, and to encourage further improvement of the quality of health care delivered. It is a fundamental part of the new General Medical Services (GMS) contract, introduced on 1st April The QOF, which is a voluntary part of the new GMS contract, measures achievement against a range of evidence-based indicators, with points and payments awarded according to the level of achievement. Prevalence data collected by general practices as QOF registers forms an integral part of the framework in determining the level of payment awarded to individual practices. Prevalence is a measure of how common a particular disease or condition is within a given population at one point in time. This release reports the national prevalence of the individual diseases and conditions within the clinical domain of the QOF for 2007/08, as at "National Prevalence Day", 14th February These figures are calculated by QMAS, the IT system that supports QOF reporting, as part of payment calculations. More detailed and revised final prevalence information, along with full achievement and exception-reporting information from the QOF for 2007/08 will be published on 30th September This is to allow sufficient time for all practice data submissions for the 2007/08 year to be finalised and formally signed off. KEY POINTS The reported prevalence rates for hypertension (high blood pressure) and hypothyroidism have both risen gradually in each year since the introduction of the QOF in 2004/05. The rate for hypertension has increased from 11.5% in 2004/05 to 13.1% in 2007/08. Meanwhile the rate for hypothyroidism has risen from 2.8% to 3.2% over the same period. These increases are likely to be due at least in part to improved case ascertainment by practices. QOF-reported prevalence of Chronic Kidney Disease (CKD) stages 3-5 has risen to 2.5% from an initial figure of 1.8% for 2006/07. An increase was expected, due to improved availability across Scotland in the clinical tests required to make the formal diagnosis of the stage of CKD. 52

53 INTERPRETATION Prevalence rates reported from the QOF are based on disease or condition register data recorded in the payment calculation system (QMAS), as at a date referred to in the QOF as "National Prevalence Day". National Prevalence Day is the 14th February in each year up to and including This date is to change to the 31st March in 2009 to bring it into line with the date to which other elements of QOF data relate. Individual practices submit their register sizes to the QMAS IT system. QMAS then calculates a national prevalence figure from these cumulative totals. It does so as long as at least 90% of practices nationally have been able to submit data for each individual register. For the purpose of this publication the figures are shown as rates per 100 people. The practice list sizes used as the denominator for these rate calculations are as at 1st January in each year. Some QOF registers were subject to definitional changes between 2005/06 and 2006/07, with the result that prevalence rates for 2004/05 and 2005/06 are not directly comparable with prevalence rates for 2006/07 and 2007/08. Other registers were newly introduced in 2006/07 and thus only two years of comparative data are available. This is discussed further where applicable to individual registers. QOF prevalence data are of interest to a range of people including general practices, NHS Boards, governments, public health practitioners, researchers and charities. They do need to be interpreted carefully, for example due to the way in which they are calculated. It should be noted that QOF prevalence rates are crude rates, calculated across all ages, with no adjustment made for variations in age profiles between different practices, regions or countries. Furthermore, whilst some QOF registers are age-restricted (e.g. obesity, diabetes), QOF prevalence rates are calculated using the whole practice list size as the denominator. This means that the prevalence rates in these instances are are lower than they would be if based on an age-restricted population denominator. For 2004/ /07, final figures are shown (based on signed-off, finalised data fro all available data from general practices). Added to these are initial figures for 2007/08, as calculated within the QMAS system to support practice payment calculations. Final figures for 2007/08 will be published as part of ISD s full report on the QOF for 2007/08 on 30th September 2008 and may differ from those published here. DETAILED FINDINGS Unchanged Registers (comparable over 4 years) Seven QOF registers have maintained a consistent definition since April Directly comparable prevalence statistics across the first four years of the framework have been provided in the following areas: asthma, cancer, coronary heart disease (CHD), chronic obstructive pulmonary disease (COPD), hypertension, hypothyroidism and stroke and transient ischaemic attack (TIA). The prevalence of CHD as reported by general practices through the QOF has remained constant over the 4 years, at 4.5%. For COPD the figure has remained at around 1.8% since 2005/06. Rates for asthma and stroke & TIA appear consistent with 2006/07, at 5.5% and 2.0%, respectively, although in both cases the figures are a little higher than in the first two years of the QOF. The reported prevalence rates for hypertension (high blood pressure) and hypothyroidism have both risen gradually in each year since the introduction of the QOF in 2004/05. The rate for hypertension has increased from 11.5% in 2004/05 to 13.1% in 2007/08. Meanwhile the rate for 53

54 hypothyroidism has risen from 2.8% to 3.2% over the same period. These increases, as well as the increases for asthma and stroke & TIA, are likely to be due at least in part to improved case ascertainment by practices. The QOF-reported cancer prevalence rate has also increased over each of the four years, from 0.5% to 1.1%. This reflects the fact that the QOF cancer register is a cumulative register, required to count all patients diagnosed with cancer since 1st April Therefore, this rise largely reflects an overall accrual of new cases in each passing year rather than indicating a true large increase in cancer prevalence. New and Redefined Registers (comparable over 2 years) The remaining fourteen QOF registers are comparable only over two years, 2006/07 and 2007/08. In four cases this is because their definitions were changed between 2005/06 and 2006/07, these being diabetes mellitus, epilepsy, left ventricular dysfunction and mental health. In the other ten this because the registers were introduced to the QOF for the first time in 2006/07. These are atrial fibrillation, chronic kidney disease (CKD), dementia, conditions assessed for depression, depression, heart failure, learning disabilities, obesity, palliative care and conditions assessed for smoking. In six cases, initial reported prevalence for 2007/08 has remained the same as the final figures calculated for 2006/07. These are epilepsy (0.7%), Left Ventricular Dysfunction (0.6%), selected Mental Health conditions (schizophrenia, bipolar affective disorder, other psychoses; 0.8%), Atrial Fibrillation (1.3%), Heart Failure (0.9%) and patients in need of Palliative Care (0.1%). For a further six registers, initial reported prevalence for 2007/08 has increased to at least a small degree relative to 2006/07 (diabetes, conditions for depression screening, CKD, learning disabilities, obesity, conditions assessed for smoking). For the final two (dementia and depression), the initial figures for 2007/08, are very slightly lower than the final rates calculated for 2006/07. More detail on each of these is given below. QOF-reported prevalence of diabetes mellitus has increased from 3.5% in 2006/07 to 3.7%. Whilst this may in part reflect improved case ascertainment by practices it is likely also to reflect a genuine increase in the occurrence of diabetes in the Scottish population. The register for the depression 1 indicator counts patients with diabetes and/or CHD. The indicator then measures whether patients with either or both of these conditions have been assessed for depression. The proportion assessed will be published in September. Nationally, 7.2% of patients registered to general practices at 14th February 2007 had either diabetes, or CHD, or both. This rose to 7.4% at 14th February This can be explained largely by the rise in reported diabetes prevalence over the same period. Reported prevalence of Chronic Kidney Disease (CKD) stages 3-5 has risen to 2.5% from an initial figure of 1.8% for 2006/07. An increase was expected, due to improved availability across Scotland in the clinical tests required to make the formal diagnosis of the stage of CKD. QOF-reported prevalence of learning disabilities has increased from 0.4% in 2006/07 to 0.6% in 2007/08. This is lower than estimates of overall population-based prevalence given in QOF guidance (around 2% across all ages). However, not all such persons may become known to general practices. 54

55 Obesity rates reported by general practices (related to patients aged 16 or over with a body mass index of 30 or more) rose from 7.0% in 2006/07 to 7.4% in 2007/08. Both figures are lower than the generally accepted rates of over 20% as shown elsewhere (for example, those summarised by the Scottish Public Health Observatory (ScotPHO) at ( Some of this will be due to the fact that QOF prevalence rates use the whole practice population as their denominator and do not exclude patients aged less than 16, meaning that the prevalence rates are lower than they would be if this age group was excluded from the population denominator. However, this will not account for a great deal of the difference. Another likely reason is that not all persons who are definitionally obese may necessarily be recorded as such by general practices, for example if they are relatively young and have not experienced any particular health-related difficulties. However, there is likely to be scope for case ascertainment of obesity by practices to improve over time. The QOF includes an indicator to count patients assessed for smoking status with one of six chronic conditions, these conditions being CHD, stroke/tia, hypertension, diabetes, COPD or asthma. The prevalence rates based on this register cannot be used to calculate a national prevalence of smoking, rather they indicate how many patients have at least one of the six chronic conditions specified. The proportion assessed for smoking will be published in September. In 2006/07 the proportion of patients who had at least one of the six conditions was 20.4%, whereas the initial figure for 2007/08 had risen to 22.4%. An element of this observed increase is likely to be the increase in the recorded rate of hypertension amongst practice patients. Initial QOF-reported prevalence rates of dementia and depression have decreased slightly relative to 2006/07. For dementia the overall rate has changed from 0.6% to 0.5%; for depression the figures are 6.2% and 6.1% for 2006/07 and 2007/08, respectively. The change for dementia, although small, nonetheless seems contrary to expectations that further case ascertainment over time may lead to increases in reported prevalence rates of dementia from QOF registers. However, the final figure for 2007/08 may possibly differ from the 0.5% calculated initially. Random anti-fraud checks by QOF Teams 28/03/08 INPS have received a number of enquiries from practices who have already started to worry about the Random Anti-fraud Checks being carried out by their QOF teams from the PCT. These visits cover a number of items but the two that practices have alerted us to are concerning backup and viewing QOF data as of the end of the last financial year. The issue about backup is easy. The HSCIC Documentation clearly states that: "The whole GP clinical system must be backed up onto offline storage (e.g. tape, CD, DVD) on or within 4 weeks of the 1st April each year. Where a copy of clinical data has been taken in order to generate the final achievement report, both the original and the copy must be included in the backup. Backups are to be labelled explicitly "QOF Achievement - Archive Data", together with the 6 digit national practice id and date of backup, kept where the practice can retrieve them within 48 hours should they need to, and protected for 7 years before disposal. The format of the GP clinical system backup must be such that it can be used to reconstruct the system (application and data) on replacement hardware (e.g. in the event of a disaster). One of your ordinary backup tapes, suitably labelled and 55

56 securely stored away from the practice site will suffice to meet this requirement. Should the practice wish to ensure that backups could be used to recreate their system, then taking advantage of the Tape Verification Service offered by the Data Services team will do this for you. As far as viewing the data that was reported to QOF is concerned, it is straightforward to access previous QOF data in Clinical Audit: 1. Switch to the Age Sex tab. 2. Change the month and year to what you want to revisit 3. Highlight a blue denominator line. 4. The patients will be shown in the bottom left-hand pane. 5. Double click on a patient name to view clinical details on the right. Hosted Systems Note - this section is only relevant for practices on hosted systems Hosted practices can generate audits or make requests Hosted practices can run certain generations automatically, but others require a request logged to the hosted support team. The requests should be ready by the following business day. The following audits are or can be generated for hosted practices: In addition: Daily generation of audits on days specified (see Scheduling the daily generations (page 42)), although hosted practices cannot specify the time that the daily audit generation is made. Generation of mandatory QOF Reports - Generated automatically on the first day of each month, and for the National Prevalence Day Report, on 14th March. Run as part of the daily generation. Generation of Interim QOF Reports. If the sub-searches are up-to-date, then the Interim Report will be generated immediately; otherwise an Interim Request will be submitted. If an Interim generation is required for a previous QOF Year, then an interim report request will be made. Monthly Clinical Audit Generate. This will be run after the QOF Report generation. Monthly reminders generation - Run as part of the monthly generation. Regenerate reminders - Submit Reminder request, run requests. Advanced Generation - Submit Advanced Generate request, to generate newly imported Clinical Audits; and generate last month's clinical audit figures during the month. 56

57 Requests From the above, requests have to be made by hosted practices for Interim Reports for prior periods, Regeneration of Reminders, and Advanced Generations. Note - these cannot be requested if the following day is a QOF Reporting day (1st of each month or 14th March for NPD) or if the Clinical Audit Generate is due to be run for the month (normally by the second day of each month). Automatic Reminder Generation Using Reminders in Clinical Audit is a practice option; they do not get automatically generated without this option being exercised. For VES practices, Reminders can be generated at the same time that the monthly Clinical Audit Generate is run by checking the relevant option in GPC,(not in Clinical Audit). In GPC, select Tools - Options from the menu and then click on the QOF Reports tab. Tick the Generate reminders box if they want this to happen; this remains in force unless changed by the user. The same Generate Reminders option also appears in the Advanced Generation form. Checking this box will set the appropriate flag in the request, but for that run only. 57

58 Generate Reminders request This can be done from the Generate tab in Clinical Audit. This will be requested by the practice if they have been editing reminders on clinical audits; reminders can be enabled, removed or the text changed. Interim Report request An Interim Report, if the sub-searches are up-to-date, will be generated. However, if an interim is required for a prior period, then an Interim Report Request has to be made. This is requested in the Clinical Audit QOF tab in the Interim frame. Enter the required Baseline date and then click Generate. Instead of running the generation immediately, a request will be logged with the VES support team. Once you confirm the request, you can exit Clinical Audit. You can cancel the request at any time before it is fulfilled, and the buttons in Clinical Audit will change their caption from Generate to Cancel. When the Interim Report and Reminders have been generated, the buttons will revert back to their Generate captions, indicating that the request is now completed. You can then View Results if an Interim Report were requested. Advanced Generate VES practices can request an Advanced Generation, to regenerate last month's clinical audit figures for the month. The option is run by clicking the Generate tab and then selecting the Generate - Advanced Generate menu option. Advanced Generate is used to force a Clinical Audit generate process without waiting for the normal end of month generate. For VES practices, the request will be handled later in the day. The automatic running of the regular monthly QOF reports, the National Prevalence Day Report, and the monthly Clinical Audit Generate are managed by the VES support team. The QMAS reporting requirements 58

59 are still met but under control of VES. You will retain use of full clinical audit analysis. Notes It is a QOF requirement that a new Interim report cannot be generated until the previously submitted report has received an Acknowledgement from QMAS. However it is a user option to submit an Interim report. When you try to run an interim generation, if a new version of the QOF audits is awaiting import, you will be given the choice as to whether or not to import the new audits. Cancelling Requests All three requests can be cancelled by clicking the Generate button again, but only before the request has been serviced. The running of QOF reports and Clinical Audit Generation will happen over different days. This is because of the impact of many practices automatically running Clinical Audit at the same time would be detrimental to the performance of bureau systems. VES practices must run Mail Gateway as soon as possible on a QOF Reporting day run to submit the QOF report to QMAS, and later in the day to check for and process incoming QOF acknowledgements. 59

60 GP Communicator How GPC handles QOF reports GPC handles the ngms Contract QMAS Registration and Report messages for England, Scotland and Northern Ireland. In England and Scotland: GPC picks up all QMAS registration and QOF report submissions generated by Clinical Audit and transmit them to the DIS (QMAS messaging interface) It receives acknowledgements back from the DIS and in England, passes them back to Clinical Audit for tracking. GPC processing of QMAS messaging errors is similar to EDIFACT messages, although there are some QMAS specific requirements. In Northern Ireland: GPC picks up QOF report submissions generated by Clinical Audit and transmit them to the DIS. No receipt reports or acknowledgements are sent back from DIS. GP Communicator, Tools - Options - Audits & QOF tab See Scheduling the daily generations. 60

61 QOF Report messages to and from NMAS For English practices, when the monthly QOF Reports are generated and sent to QMAS (NMAS - National Messaging Assurance Service) during the next Mail Gateway session, the practice would expect to receive a receipt report from NMAS to acknowledge that the reports have been received. The QMAS systems implemented in Wales and N Ireland exclude QOF Acknowledgement in their message flows. In general, there will be outgoing QOF Reports message and incoming Receipt reports from NMAS. If you click on an Outgoing QOF Report, addressed to QOF Reporting DIS, then click on the Contents button, you will see that in addition to the Plain Text and Audit Trail tabs, there is also an XML Viewer tab. This summarises the figures in the QOF Report for each QOF quality indicator, eg, CHD02 Denominator [x], CHD02 Indicator [y] and so on. If you then right click within this screen, you can use the usual options of Print, Export to Microsoft Excel, View source, etc. 61

62 Acknowledgement message changes in DLM 220 New acknowledgement codes There are new acknowledgement codes in DLM 220. The following list of codes are interpreted by Vision 3 as a successful QOF submission; all other codes are interpreted as a failed submission Successful 0021 Received System Report received but not used 2000 Successful system registration request 2006 Already registered 3001 Duplicate regular report 3008 Duplicate Nat. Prev. Day report 3009 Nat. Prev. Day report delivered outside allowed period Acknowledgement message changes in DLM 310 There is a new QOF system in Scotland, called the QOF Calculator. Outgoing QOF reports will automatically be marked as successfully acknowledged by Vision and the GPC message moved to the audit folder, rather than pending. The QOF report status in Vision will always be reported as ack d; no automatic retransmissions will occur from the Attention folder. 62

63 Mail Gateway The role of Mail Gateway Mail Gateway is responsible for automatically running the monthly Regular report for the ngms Contract QMAS audits, once a month as soon as possible on or after the first day of the month. This is done by running Vision Clinical Audit (or MIQUEST in Wales) in silent mode on the GPC workstation. It will also run the daily generation automatically every night as scheduled (see Daily generation of QOF audits for up-to-date data and Scheduling the daily generations). There are two tabs in the middle right pane: QOF Report and Generation. The QOF Report section gives information about the dates that the regular and interim (if any) QOF Reports are sent to QMAS for the current year. The status of the audits is shown, for example, Sent or Ack'ed. The Generation tab shows in detail the progress of a generation, whether it is daily or monthly QOF Report generation. For example, under Audit Generation, it may say Processing Daily Audit Report Started - 14:41. This will be shown in red. In the bottom left pane under Generation Progress, it details how far the generation has reached, for example, Preparing generation, followed by Counting "Smoking last 'informed dissent' recorded 63

64 64 more than 15 mths before reference date" for 18 June 2008 (the final date being the date of generation). Under Monthly in the middle right pane, it shows the last time the monthly generation was run and when the next daily generation is due, for example, Monthly Mar Next daily run today at 01:01, last run 17/06/2008.

65 Note - a message Waiting for Clinical Audit to be closed is shown in the bottom left if a generation is due to run, and is held up because some one is using the Clinical Audit module. The Schedule button specifies the days and times of the daily generation - see Daily generation of audits (page 42) and Scheduling the daily generations (page 42). 65

66 Run Mail Gateway at least twice a day Mail Gateway can be configured not to run during certain times, to avoid backup clash, and to run all Clinical Audits at the same time, removing the need for you to run the Generate process manually every month (see GP Communicator, Tools - Options - Audits & QOF tab (page 60)). In order for the monthly reports and National Prevalence Report (14th March) to be submitted to QMAS, Mail Gateway must be running and scheduled for transmission. You must not close Gateway after generation. Mail Gateway must be run at least twice a day in order to pick up the receipt report from QMAS. We recommend that you run Mail Gateway at least twice a day. We do NOT recommend that you only run Mail Gateway, ie the Clinical Schedule, just once a day. This will be particularly disadvantageous if you are an English practice sending ngms Contract reports to QMAS on the first day of each month. VES practices must run Mail Gateway as soon as possible on a QOF Reporting day (1st of each month and 14 March) to submit the QOF report to QMAS. It must also be run later in the day to check for and process the incoming QOF Acknowledgements. 66

67 The rules for England state that, within 6.5 hours of submission of the ngms reports from the practice to QMAS, a receipt report should be received by the practice from QMAS, acknowledging QMAS have received the reports. If a receipt report is not received by the practice within 6.5 hours, perhaps because Mail Gateway is closed, then the system automatically has to resend the reports. If you only transmit once a day via Mail Gateway, then you need to alter this to at least 2 transmissions a day (in GPC - Tools - Options, Clinical Scheduler), otherwise you will continue sending daily resubmissions of your reports. Alternatively, if you are scheduled to run one transmission at, say 9 am, then make sure you make a manual Run Now (under Clinical Schedule on Mail Gateway) at, say, at lunchtime, in order to pick up any receipt report Note - the rules for Scotland state that the receipt report delivery time is 48 hours. Exit from Mail Gateway discouraged When Mail Gateway is shutdown by a user, a check will be made to see if one of the QOF reports (regular or National Prevalence Day report) is required to be run on or before the next business day: If today is Sunday - Thursday, the next business day is the following day; If today is Friday or Saturday, the next business day is Monday. Note - this is based on the assumption that Mail Gateway is always started at least once on a business day, Monday Friday. If between today and up to and including the next business day, the date is either the 1 st of the month or 14 th March (for National Prevalence Day report), you will be warned that you must leave Mail Gateway running. When a QOF report is due, closing down Mail Gateway will produce two additional screens requiring your confirmation: 1. The first screen will inform you when the next report is due and that you should leave the application running. You will have to click on a check box to confirm you understand this, to continue the close down. 2. A second "Are you sure" screen will be displayed for final confirmation. 67

68 Clinical Audit Automatic Shutdown In previous versions, an attempt to run a Clinical Audit or QOF Report generation by one of the schedulers (Mail Gateway or VBM) would fail if the Clinical Audit application was in use on any Vision session. In this new version, the generation will now check if the application is in use and will attempt to shut them down gracefully so it can proceed. If this is not successful, the generation will give up after 60 seconds. What the users of the Clinical Audit application will see is a dialogue box requesting them to shutdown; they will have 30 seconds to comply: Silent Shutdown Request - A shutdown has been requested by a silent generation. If you do not shutdown this application, a silent generation will not be able to complete. This may mean that your QOF report is delayed. Do you want to shutdown this application? Yes/No. This application will shut down automatically in 24 seconds. If the screen is unattended, the application will shutdown and the generation will be able to proceed. If they click No, the generation attempt will fail. 68

69 Registering with QMAS Practices in Scotland register with QMAS via Vision. Registration (see Registering with QMAS (page 10)) fails unless the Practice Identifier code is edited to exclude the initial letter S, for example, if your code is S12345, edit it to This Practice Identifier code should be edited in Control Panel File Maintenance Practice Details. If registration to QMAS is successful For English and Scottish practices only, if registration is successful, QMAS send an acknowledgement. Registration has been approved is shown on the QOF Reporting tab on Clinical Audit. Once registered, the QOF Reporting tab shows extra fields for Interim and Monthly Reports and National Prevalence Day Report. The Monthly Reports section has a Generate/Resubmit button; a View Results button (so you can view each month's figures submitted to QMAS), and the year-end of the reference date, eg 2005 means 31st March The Interim Reports has Generate and View Results buttons and shows the dates for the Baseline date and Reference date. There is also a Submit button. 69

70 If registration is successful, and if QMAS recognise that the practice has never submitted a report, catch-up reports will be generated from April to the end of the previous month, so, for example, if September registration, then from April to the end of August. These are submitted to QMAS when there is the next Mail Gateway session. The bold lines in the audits are generated: Disease Register, Denominator and Indicator. Normal monthly generation takes place at the first Mail Gateway session after midnight on the last day of the month, taking into account any times you have specified to avoid (see GP Communicator (page 60)) and unless you have changed the time of daily generation. Clinical Audit does not need to be open for the generation to take place. With every submission to QMAS, there is a QMAS acknowledgement that determines whether a monthly or interim report is next generated. Mail Gateway shows when the last monthly report was run. 70

71 If registration to QMAS is not successful It is possible that due to various factors, registration to QMAS is not successful: There may be a message to say that registration has been rejected. There will most likely be an error message in GPC. The Mail Gateway will say Last run never under QOF Report. 1. QMAS are currently carrying out a reconciliation process (via Tracking Database and other sources) to make all practices known to the Programme. 2. Providing the practice is known to the Programme, there may be some practices who are not allowed to register (e.g. some locum practices). 3. These will receive a Disallowed Submission Source error resolution for these is yet to be defined by the Programme; therefore the error message should just be accepted in GPC. 4. For one reason or another, it may be possible that some practices "slip through the net", i.e. are not known to QMAS. These practices will receive an Unknown Submission Source error. Again, resolution for this is still to be defined; further guidance will become available in due course. The error message should be accepted in GPC Attention. 5. Any other error messages should be referred to Help Line at this point. 71

72 FAQS What does QI mean? QI = Quality Indicator - A specific measure of quality within an indicator group, ie the criteria of an audit line within a disease area. For example, one of the quality indicators for Diabetes Mellitus is DM 8: Percentage of patients aged 17 and over with diabetes who have a record of retinal screening in the 15 months before the reference date. Data entered by the practice is audited to generate statistics and to determine the percentages of patients fulfilling the criteria, and thus the number of points towards an achievable total for GMS payments. Indicators are scored against different target populations. What are these ngms contract QMAS audits for? The ngms Contract QMAS audits report percentages and patient counts on the Quality Indicators for the eleven disease categories quoted in the clinical domain of the Quality and Outcomes Framework (QOF) and selected categories from Organisational and Additional Services domains (see The new contract, QOF and QMAS (page 8)). At the end of each month their statistics will be generated automatically, and silently, and a report of the resulting denominator and indicator figures sent electronically to QMAS. You will be able to view the figures within Clinical Audit. The end of year report sent on 1st April will determine the payment to the practice based on these figures. Which READ codes are used for each QI and what does % mean after a code? Synonyms A list of READ codes for each quality indicator is given in the on-screen help in Clinical Audit. See READ Codes for ngms Contract % determines whether the READ code is hierarchical or not. When viewing the criteria, any READ code with a %, eg G33%, means that is searched together with any of its sub-level codes. Any READ code with a full stop eg G41. or without a % sign searches only that code and its synonyms and does not include hierarchical codes. ALL synonyms are as equally valid for QOF as the preferred term for any of the defined codes. For instance, G BP - hypertensive disease should be valid where G Hypertensive disease is stated. A ruling from NPfIT states that all Read term synonyms must be treated as synonymous with the parent Read code. This means that the searches include all synonyms. Previous audits had excluded G Vertebrobasilar insufficiency (as well as G Drop attack, G Insufficiency basilar artery). For patients with 72

73 these codes, you may want to use an exclusion code (eg, 9h21. Excepted from stroke quality indicators: Patient unsuitable). What does in any clinical area mean? Data in Vision can be placed in a Structured Data Area (SDA) (eg Smoking, BP, Immunisation, Test, Therapy etc) or in any clinical area. Any Structured Data Areas (SDAs) outside those listed within "any clinical area" will be specified, for example, " a Therapy entry of " refers to both acute and repeat prescriptions issued. Do I have to keep entering the READ codes or is once enough? Some audits look at codes only in the past 15 months (expiring codes), and others "ever" (persistent codes), ie, there is a record at some time in the past. This includes: contraindications and allergies for influenza vaccination; contraindications and allergies for anti-platelets, anti-coagulants and Clopidogrel, contraindications and allergies for ACE inhibitors and A2 antagonists. Refusal codes, for example, 8I3S. Exercise tol test refused (to be entered once within 12 months after newly diagnosed angina CHD02) Persistent codes need only ever by entered once. For example, allergies and adverse reactions to influenza vaccination require the following codes to be entered only once (ie, ever): 14LJ. H/O: influenza vaccine allergy U60K4 [X]Influenza vaccine causing adverse effects in therapeutic use ZV14F [V]Personal history of influenza vaccine allergy Expiring codes need to be re-entered within 15 months of the 1st April, as the position may change every year. For example, these are the codes for influenza vaccination that record contraindication, no indication, no consent or declined: 8I2F. Influenza vaccination contraindicated 8I6D. Influenza vaccination not indicated 68NE. No consent - influenza imm 9OX5. Influenza vaccination declined Are these the audits we will use for GMS Payments in April? The Indicator lines of the ngms Contract QMAS Returns audits are the lines that determine the GMS payments, from the audits run on 1st April. The ngms Contract Monitoring audits are based on data entered up to the last day of the last month, and not used for payments, but for identifying patients. 73

74 What do the denominator and indicator lines show? Each quality indicator audit (other than the initial "register" QI in each clinical domain) has two main groups: Denominator (page 27) are the percentage population upon which audits are based (ie the bottom line of a fraction), the set of patients that fall within the scope of a clinical indicator, eg Patients with CHD. The first part of the denominator group (1) includes qualifying data (eg patients with asthma) plus Indicator data present (eg, with BP record in last 15m) Then, those with qualifying data (eg patients with asthma) plus any relevant exceptions present - the patient is deducted from the population, and the remainder forms the second part of the denominator group (2). The final denominator group is the results of (1) and (2). How each indicator is analysed is further illustrated in Exceptions (page 28) and What are Exception Codes? (page 30). Indicator (page 32) have their population made up as follows: Final denominator group + indicator data present. The figure from the quality indicator audit is the numerator. These are the patients that fall within the scope of a clinical indicator whose condition satisfies the criteria set in the indicator, eg patients with asthma (resulting from the denominator group) who have had an asthma review within the last 15 months. Why are patients with exception codes recorded still being shown on the register? The registers (first indicator in all clinical categories) are NOT subject to exception reporting. Why are my figures much lower than expected? In the first half of the financial year my indicator figures in particular are much lower than expected, in some cases even zero. The ngms Contract QMAS Returns audits are using the date parameters specified by the National Programme. This means that all indicator and exception data, as well as "negatives" are based on reference date. The reference date by default is the next 1st April. Looking at some examples this means for 1st April 2009 reference date: BP in last 15 months means AFTER next 1st April 2009 Currently taking aspirin means acute or issue therapy AFTER 1st October 2008 inclusive Registered in last 3 months means AFTER 1st January 2009 inclusive It is worth remembering that the only report used for payment purposes will be the one run for March, by which time the full period will be reported. 74

75 My figures reported to QMAS are different to normal audit figures I have looked at the QOF figures reported to QMAS for last month and compared them with the figures shown within Clinical Audit against each of the QOF indicator lines. Most are the same, but some are different. Why is that? The QOF figures submitted to QMAS were generated automatically at the first Mail Gateway session after midnight of the last day of the month, and they were based on any data present in the system at midnight of the last day of the month. If the normal Clinical Audit generation took place some time after that, say around the middle of the month, it would have been possible that some data was backdated to before the last day of the previous month. This data would then be counted in the normal Clinical Audit figures, but obviously NOT in the ones reported to QMAS as the data was not present at that time. The figures reported to QMAS will "catch up", as they should be counted in next month s submission. However, to avoid this sort of confusion, it may be advisable to perform the normal Clinical Audit generation as soon as possible after the automatic generation of the QMAS figures. The system can be configured to automatically generate all audits when the monthly QOF figures are generated and submitted. This is done in GP Communicator, Tools, Options, QOF Reporting. How can I tag the patients in the "negative" groups who I need to contact? These audits include "negative" lines for patients who do NOT fulfil criteria for a quality indicator line. These lines have a Reminder which can be activated. To attach or reactivate free text reminders, right click on the audit line and select Reminder. Make sure the Active box is ticked, and if required, type any text in the window. Click OK. You can also add your own reminders but remember that these will be overwritten if a new version of the audit is imported). As a tip, if you want to keep your own wording for reminders and to prevent these being overwritten each time there is an audit upgrade, keep the text of the reminders in a Word document which you can cut and paste, using Control-C to copy and Control-V to paste. For help with identifying the group for mail merge, see How do I find a list of audit patients for printing or mail merge? (page 79) How can I make sure I enter the correct READ codes on patients' records? You can download a suite of ngms Contract Guidelines from the InPS website ( (My Vision - Guidelines). There is one for each clinical domain. These contain data filters and data entry points for the specific codes required for QOF reporting purposes. 75

76 For Indicators involving therapy, why are some patients taking appropriate medication NOT being picked up? For indicators involving therapy (e.g. CHD09, STROKE09, ASTHMA all, EPILEPSY all, THYROID all, CHD11, LVD03, DM15), some patients taking appropriate medication are NOT being picked up. There are two possible reasons why medication are seemingly not picked up correctly: The most important point for the first reason is that the Dataset and Business Rules specify drugs by Read code, not by BNF category or Drug Class (as a lot of other audits have done). Some Read codes are not included in the Dataset rules, and therefore these drugs are not counted, even though they fall into the same BNF category/action group as others which are included. Examples of these are: Sinthrome (Oral anticoagulant, but Read code bs21), Phenindione (oral anticoagulant, Read code bs34), Dipyridamole (Antiplatelet, Read code bu1c). The second reason has to do with the date parameters used in the ngms Contract rules. Any indicator data (e.g. for aspirin / other antiplatelet / anticoagulant therapy for CHD09 and STROKE09, ACEI / A2 Antagonist for CHD11, LVD03 and DM15) are calculated against the reference date parameter, which by default is the next 1 st April. The rules state that current medication means medication prescribed in the last six months before the reference. This means that until the October report no such therapy will be counted, and these indicators will display zero figures. However, please do remember that the only report used for payment purposes is the one for March, by which time all qualifying therapy will be counted. Note - To check a drug Read code: from a Therapy list in Consultation Manager, right mouse click on the drug, select Audit Trail, click on the double arrow at the bottom right. Scroll down on the back screen until you get to the Read code. What does "newly diagnosed since 1/4/2003" actually mean? Different indicators seem to be processed differently There are three different rules for newly diagnosed since 1/4/2003: Cancer: In the first instance this is based on the use of episode types FIRST EVER or NEW EVENT on History Add. Any entries on or after 1/4/2003 with one of these episode types will be counted. With regard to the CANCER02 indicator, if there is more than one cancer diagnosis since 1/4/2003, the latest cancer entry will be used for QOF to calculate the six months period within which the review needs to take place. The latest cancer entry must also have episode types First Ever or New Event on History Add. 76 For example, patient with cancer entry 01/06/2003 and 01/05/2004; Review 01/11/2003. This patient does not fulfil the indicator criteria as the review date is NOT within six months of the latest cancer entry. The disease register for cancer is defined as patients with a first or new episode of cancer on or after 1st April Scenario 1 - Patient may have had the same form of cancer before but at a different site. In this case they should be counted on the cancer

77 disease register and for the indicator requiring the review within six months of diagnosis. Scenario 2 - Patient has a recurrence of the same form of cancer. This patient should probably not be counted. Scenario 3 - Patient had a different form of cancer before and now has a first episode of another cancer. This patient should be counted. Scenario 4 - Patient has secondaries - this patient may or may not be counted depending on local agreements and practice policy. Stroke (STROKE13): does NOT use episode types, but any entry on or after 1/4/2008 is classed as a new event. In the case of more than one entry since 1/4/2008, the latest one is used for the indicator calculation, e.g. the referral for further investigation needs to be within three months before and 12 months after the latest stroke. Caution is therefore required when entering diagnosis codes to avoid inadvertently recording a new diagnosis. It may be more prudent to enter monitoring codes when patients are reviewed following a stroke (e.g. 662M. or 662e.). Similar to cancer, the relevant intervention needs to be recorded in relation to the latest event since 1st April 2008, if there is more than one in that time period. This is particularly relevant for newly diagnosed strokes, where the referral for MRI or CT scan needs to be within 3 months before and 12 months after the latest diagnosis. For example, stroke entry 01/05/2008 and 01/06/2009, MRI scan 01/08/2008. This patient would not be counted towards the indicator as the scan does not fall within 3 months before and 12 months after the latest event. A scan on would fulfil the indicator criteria. MI (CHD14)): DOES use episode types, an entry on or after 1/4/2011 should have an episode type of First or New to qualify. As the indicator criteria for New MI is therapy data recorded in the 6 months to reference date (next 1st April) any episodes with the correct type will count. Although a new diagnosis code will not alter the reporting of MI after 01/04/2011 it is probably still more sensible to enter monitoring codes when patients are reviewed following new MI (e.g. 662N). Depression (DEP06 & DEP07) : DOES use episode types, an entry on or after 01/04/2006 should have an episode type of First or New to qualify. Angina (CHD02), COPD (COPD02), Asthma (ASTHMA02), LVD (LVD02): these do NOT use episode types, but search for the first ever entry with the qualifying diagnostic codes and only count those where this first ever entry is on or after 1/4/2003, therefore any patients with diagnoses prior to 1/4/2003 will be ignored. In the case of more than one entry since 1/4/2003, the earliest of these entries will be used for the indicator calculation. For example, a patient with angina entries on 1/5/2003 and 1/10/2004 needs a referral for exercise test or specialist opinion between 1/2/2003 and 1/5/2004 to be counted. If the specialist assessment is on 01/11/2004, this patient does not fulfil the indicator criteria. 77

78 How are the flu vaccination dates worked out? For CHD12, Stroke10, DM18, COPD08, the criteria for flu vaccination is: A Therapy entry of Influenza vaccine n47..% (Excluding n47a., n47b., n47r., n47s., n47t.) between 1st September and 31st March, Or a READ code of one of the following between 1st September and 31st March: 65ED. Seasonal influenza vaccination 65E20 Seasonal influenza vaccin given by other healthcare provider The Monthly QMAS report is taken from the current flu period, ie 1st September 2004 to 31st March. But for the interim reporting, a full 7 months must be reported - even when the reference date does not include the full season (September to March). This is done by including records from the previous reporting year for the "missing" period. Monthly reporting and normal audit generation: In Version 5 ruleset (from DLM 188), flu vaccination dates are now taken from the current flu period, i.e. 1 st September to 31 st March. Examples: May 2004 (i.e. baseline date = 1st June 2004 and reference date = 1st April 2005) No flu records included (not in current flu period) September 2004 (i.e. baseline date = 1st October 2004, reference date = 1st April 2005) Included are flu records from 1st September 2004 to 30th September 2004 January 2005 (i.e. baseline date = 1st February 2005, reference date = 1st April 2005) Included are flu records from 1st September 2004 to 31st January 2005 March 2005 (i.e. baseline and reference date = 1st April 2005) Interim reporting Included are flu records from 1st September 2004 to 31st March 2005 For interim reporting, flu indicators will always report on a full 7 month period, even if that means taking data from a previous flu period. Examples: Baseline and Reference date = 1st June 2004 Included are flu records from 1st September 2003 to 31st March 2004 Baseline and Reference date = 1st October 2004 Included are flu records from 1st October 2003 to 31st March 2004 AND 1st September 2004 to 30th September 2004 Baseline and Reference date = 1st February

79 Included are flu records from 1st February 2004 to 31st March 2004 AND 1st September 2004 to 31st January 2005 Baseline and Reference date = 1st April 2005 Included are flu records from 1st September 2004 to 31st March 2005 If the Baseline and Reference Date are set to... 1st June the flu data will be taken from these months... Current year's Sept-March records PLUS Last year's Sept-March records 1st Sept st March 2004 = 7 months 1st October st February st April st September - 30 September 2004 = 1 month 1st February 2004 to 31st March 2004 = 2 months 1st October st March 2004 = 6 months 1st September 2004 to 31st January 2005 = 5 months 1st September 2004 to 31st March 2005 = 7 months How do I print help screens? To print a single help screen, right click and select Print. To print a range of help screens, right click on a heading title in the left-hand column, and select Print. Choose between Print the selected topic, or Print the selected heading and all subtopics. How do I view a list of audit patients in Clinical Audit? 1. In Clinical Audit, highlight the audit line you want to view. 2. On the Age Sex menu option, make sure Show Patients is ticked. 3. The patients will be shown in the bottom left pane. Double click on a name to show their clinical details in the bottom right pane. How do I find a list of audit patients for printing or mail merge? To print a group of patients found in an audit 1. In Clinical Audit, first highlight the audit line you want to print. 2. If you have either the Month/Year tab or the Age Sex tab, the patients are listed in the bottom left-hand pane. 3. Right click within this pane and select Print This Group. 79

80 To mailmerge a group of patients found in an audit 1. In Patient Groups, use Select an Audit Line (from the Browse Options menu) to find the audit line you want. 2. At the Patient Groups - Groups or Clinical Audit Search Browser, you can use the expand all / collapse all icons up. to open the list entirely or close it 3. For QOF audits, select the view you want from the Audit Source box: All audits & ngms Monitoring - This view shows all Clinical Audits with statistics up to the end of last month and the ngms Audit showing daily statistics (including data up to the most recent daily generation), based on a QOF Reference Date of "today". ngms Reporting - This view only shows the ngms audit (including data up to the most recent daily generation) based on a QOF Reference Date of standard end of year (1st April). QOF Results Last Reported - This view shows what you sent in the last submitted report to QMAS, either the Regular (monthly) report or National Prevalence Day report. 80

81 4. Drill down to find the audit line you want in exactly the same way as you would in the Clinical Audit module. Click on a main blue line Audit Group (eg, QMAS Returns and Monitoring Audits) to expand the red clinical area lines beneath (eg QMAS Returns - Clinical ). Click on a red line to expand the clinical categories beneath, which are green headings (eg CHD QMAS indicators). Click or double click on the required audit line, coloured black, for your selection (eg CHD01 REGISTER), if a single click, then click OK. 5. If you tick the box Reminders only, the list redisplays with only those audit lines with active reminders. 81

82 . 6. If a QOF audit is selected, the group is created there and then, on the fly. The system takes a moment to save the group if a saved copy does not yet exist; otherwise it will save the group from the last audit generation. Note that if the audit you select has not yet been generated (for example, a newly imported INPS audit), you will see the message: This Clinical Audit has not yet been generated - the Patient Group is not yet available. OK 7. To return to the list of all groups: either click on to clear the filter, or select Browse Options - Clear Filter, or use Control C. 82