Primary Care Clinical Terminology Usage Report

ID

S70

Version1.0.0
TypeCapability Specific Standard

Status

Effective

Effective Date

 


Description

Supports the collection and submission to NHS digital of information about usage of clinical coded terms.

The purpose of this report is to collect data from each GP IT System Supplier on the frequency of use of clinical coded terms, both terminology (SNOMED CT, Read v2, CTV3) and local codes, recorded through their system for fully registered Patients over a 12 month period for all entries which are part of the GP record, aggregated across the selected Practices.

This data on the frequency of usage of clinical terms is to inform which codes are in actual use to:

  • support the clinical assurance process with respect to data migration and GP2GP
  • support the production, maintenance and clinical assurance of the cross maps for primary care
  • facilitate the development of guidance with respect to terminology codes and local codes

Elements of the data submitted will be published and made publicly available once processed to protect any patient and commercially sensitive data.


Requirements

General

Requirement IDRequirement Text Level
PCTUR01Data is to be provided where the Solution is hosted either via Public or Private Cloud, or in a Co located or Provider data centreMUST

PCTUR02

Data can be provided where the Solution is locally hostedMAY
GP-BI.2-02Report will be provided on an annual basis
 MUST
GP-BI.2-03

Report will cover the period from 00:00 on 1st August to 23:59 on 31st July of the following year

i.e. a report produced in August 2017 would cover the period from 1st August 2016 to 31st July 2017

 MUST
GP-BI.2-04

Report will be provided by the end of September of the year in which the reporting period ends

i.e. a report for the period 1st August 2016 to 31st July 2017 will be submitted by the end of September 2017

 MUST

Practices

GP-BI.2-06Report to include aggregated data on code usage across all Practices in the Supplier estate
MUST
GP-BI.2-07

Report will only include aggregated data on code usage for Practices which went live with the Supplier system at least 2 months prior to the start of the reporting period

i.e. for a report for the period 1st August 2016 to 31st July 2017, the Supplier system will have gone live in the Practice prior to 1st June 2016

MUST

Patients

GP-BI.2-08aReport to include aggregated data on code usage for Patients who were fully registered with a Practice as at the end of the reporting period 
MUST
GP-BI.2-08bReport to include aggregated data on code usage for Patients who were fully registered with a Practice but died during the reporting periodMUST
GP-BI.2-09

Report will include codes entered during the reporting period via a different system e.g. where a Patient has moved to a new Practice and their record has been transferred via GP2GP

MUST

Codes

GP-BI.2-10

Report will only include coded data recorded during the reporting period

NB. this is to be determined by the system audit date

MUST
GP-BI.2-11Report to exclude codes not normally used by or visible to users i.e. those inserted by the system (e.g. metadata codes to identify record component types)
MUST
GP-BI.2-12

Report to include all codes visible to the user as part of the Patient Record, including:

  • codes entered directly by users into the system
  • codes received via pathology laboratory links
  • codes received from other feeder systems
MUST
GP-BI.2-13 Report to include all coded items newly entered within the reporting period, including where identical entries have been added prior to the reporting period
MUST
GP-BI.2-14Where dual coding is in place, report will include the code from the primary coding scheme which was actually selected by the user 
MUST

Format

GP-BI.2-16Suppliers will provide the Terminology Usage Report and the associated Metadata Report MUST
GP-BI.2-17Reports will be provided in a TAB-delimited UTF8-MB3 text file (NOT comma separated, quote delimited or Excel spreadsheet).
MUST
GP-BI.2-18The first row of the reports will contain the column names as specified in GP-BI.2-21 and GP-BI.2-22
MUST
GP-BI.2-19Report columns will always be submitted in the order as specified in GP-BI.2-21 and GP-BI.2-22MUST
GP-BI.2-20Reports will be submitted via Secure Electronic File Transfer (SEFT)
MUST
GP-BI.2-21

The Metadata Report to be formatted as follows:

Column 1: PracticeCount. Number of Practices included in the report as per GP-BI.2-06 and GP-BI.2-07

Column 2: PatientCount. Number of Patients included in the report as per GP-BI.2-08a and GP-BI.2-08b 

MUST
GP-BI.2-22

The Terminology Usage Report to be formatted as follows:

Column 1: CodeID.  5 character READ/CTV3 code, 18 digit SNOMED ConceptID or local code identifier that uniquely identifies the local OR national terminology concept e.g. N2450, XM1NJ, 18876004, EGTON460, Y7121

Column 2: TermID. 2 character READ termcode, 5 character CTV3 termcode, SNOMED DescriptionID or local term identifier for the actual description text selected by the user e.g. 12, YaYBJ, 31828016, 99

Column 3: TermDescription. Longest available preferred display term string encoded for by ConceptID+TermID e.g. 'Finger Pain', 'Vertigo', 'Herpetic Stomatitis'

Column 4: EPREntryCount. Aggregate count of the number of discrete new entries made using ConceptID+TermID across the selected Patients and Practices during the reporting period

MUST
 GP-BI.2-23

For the Terminology Usage Report, the following pseudo code to be used:

For all Patients fully registered with a Practice on <end date> AND those who were fully registered but died during the reporting period ("<start date>"-"<end date>") as per GP-BI.2-08a and GP-BI.2-08b

ANALYSE

GROUPED_BY CodeID AND TermID AND TermDescription

FROM JOURNALS (ALL)

WHERE RECORD_DATE IN ("<start date>"-"<end date>") AND CODE IN ("%")

Where <start date> = 1st August <YYYY> and <end date> = 31st July <YYYY+1>

MAY
GP-BI.2-24

The actual query used for the Terminology Usage Report will NOT:

  • Double count
  • Sample different fragments of the same full coded Electronic Patient Record content
  • Include codes attached to 'system' tables

Where the TermID does not exist or is not persisted, no data (an empty field) will be returned for the TermID column

MUST


Capability

Applicable Capability

All supplier Solutions will need to meet this Standard if they are delivering the Patient Information Maintenance Capability.


Roadmap

Items on the Roadmap which impact or relate to this Standard

Suppliers will not be assessed or assured on these Roadmap Items as part of Onboarding