EMIS and QOF Business Rules v39

Over the weekend EMIS released v39 of the QOF Business Rules live onto practice systems. There have been reports of changes to practice figures. In some cases these have been quite substantial. I have done a bit of digging and there seem to be at least two separate things going on either of which can have signficant effect on the figures.

First I would just like to say that mistakes happen. This is a huge project and it is almost unimaginable that it would work first time perfectly. Having said that some fairly urgent work needs to be done to make sure that patients are identified correctly.

The root of the problems is that most of primary care is expected to move from Read codes to Snomed CT over the next few months. I am a big fan of Snomed CT and hope to release a book in a few weeks with an introduction for users. However it is quite different to Read codes. All clinical data will be translated ("mapped" in the jargon) from Read to Snomed but this process is sometimes not exact. Read has lots of problems and solving these in a modern coding system will mean some things are changed. This change is generally for the better but all change breaks stuff.

Version 39 of the business rules is the first to use Snomed CT. The objective is that all practices will be using this by the end of March so it makes sense that Snomed is used here. This has meant trying to translate all of the Read codes searches to Snomed CT. This is more complicated than simply translating the codes as it is the structure and relationships in Snomed that are key. For example asthma is listed under COPD in Read whereas it is correctly separated in Snomed. This makes the searches different in each.

This is where the first problem arises. To take an example "Post concussion syndrome" now puts a patient onto the dementia register. This is clearly rubbish but the problem is within Snomed. Postconcussion disorder is listed as a type of dementia which will put the patient on the register. This can be dealt with by specifically excluding it in the business rules but was missed this time. As I said there will be some errors in the first version but hopefully this will be rectified by NHS Digital soon, although a fairly comprehensive review of the thousands of included concepts is probably needed. Snomed also needs fixing although this is like to take a bit longer. Snomed has two releases of its international edition a year and business rules will need reviewing with each new release.

The second problem is down to the fact that practices have not moved to Snomed yet. One of the features of Read is that each code could have several "synonyms". The quotes are there because these synonyms quite often carried different meanings. For instance H30 was supposed to mean "Bronchitis Unspecified" but it could also mean "Recurrent Wheezy Bronchitis". These synonyms map to difference concepts in Snomed CT which seems reasonable. The former maps to Bronchitis and the latter to Chronic Asthmatic Bronchitis. This is included in the COPD register, presumably as a form of chronic bronchitis. However, as we are not using Snomed yet EMIS has translated these back to Read codes. The EMIS business rules system does not seem to know about Read synonyms - they have never been part of QOF business rules. The effect has just been to put everybody with a H20 code onto the register including Bronchitis Unspecified.

For similar reasons patients that have a record of the code "Tired all of the time" are being put onto the depression register.

There is inevitably going to be some pain on transferring from Read to Snomed. There is more of this sort of thing to come. In the next few days I would like to see NHS Digital fixing the rules and EMIS adding synonym support to their business rule calculator. In the longer term there is some fixing to do in Snomed although one of its great strengths is that fixing is possible, unlike the rigid structure of Read.

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