INFORMATION STANDARDS GOVERNANCE PROCESS INFORMATION STANDARD FINAL PROPOSAL FOR NEW OR CHANGED (INCLUDING RETIRED) INFORMATION STANDARD National Procedure Codes for Diagnostic Imaging 11 th December 2008
INFORMATION STANDARD FINAL PROPOSAL FOR NEW OR CHANGED (INCLUDING RETIRED) INFORMATION STANDARD This document should be completed using the GUIDANCE ON COMPLETING THE INFORMATION STANDARD FINAL PROPOSAL NOTIFICATION SUBMISSION TEMPLATE REVISION HISTORY Date of this revision: Version no. Revision Summary of Changes date 0.1 10/10/08 First daft 0.2 30/10 Draft following discussion with S Greenway N 0.3 12/11 Following comments from SG N 1.0 11/12 Submission to WIGSB Changes marked SUBMITTED BY: Document completed by: N J Elcock (Nick.Elcock@wales.nhs.uk) Role & organisation: Organisational Readiness Manager, IHC FEEDBACK TO BE PROVIDED TO: Feedback will be provided on the Proposal within 10 days of the WIGSB meeting. If the feedback is to be directed to another nominee please provide the name and contact details below. Name: Email: SUBMISSION PURPOSE Proposal submitted for: Formal Approval If this Proposal submission is not for formal approval then please state the specific aspects on which you would like more detailed comments. Specific Areas for WIGSB to comment on when not submitting for formal approval at the Proposal stage Page: 2 of 15
SECTION 1: BACKGROUND 1. Information Standards Reference Number [From Information Services Division] IGRN 2008 / 035 2. Name of Information Standard National Interim Standard Descriptions for Clinical Imaging Procedures 3. Type of change The formal adoption of an existing NHS England Standard. (This assumes that the NHS England ISB adopts the standard as planned in November 2009) 4. Type of standard [Select all that apply] Operational already in use in a direct patient care setting in 2 NHS Wales Trusts and widely used in England and Scotland. 5. Introduction Currently, there is no agreed standard for the description or coding of diagnostic procedures used in radiology information systems (RIS) and picture archiving and communication systems (PACS) across Wales. IHC is currently working with HSW and all Trusts in Wales to implement a standard RIS system in all radiology departments across Wales as the first part of the development of an All Wales Radiology Management System. This system (RadIS2) will provide much greater potential to share patient information between radiology departments to improve patient care. It also provides an opportunity to collect consistent management information from all radiology departments for planning future service delivery. But this potential cannot be fully realised without a national standard set of procedure codes. A new all-wales standard is therefore required in order to support the safe sharing of diagnostic images and reports between NHS Wales Trusts and between separate departments within newly merged Trusts and to allow management views of radiology service which span several departments and organisations. 6. Sponsor Dr Owen Crawley, Chief Scientific Officer, WAG. 7. Developer The standard has been developed by Connecting for Health. Implementation and subsequent support within Wales will be managed by Informing Healthcare. 8. IImpllementatiion Date Page: 3 of 15
Diagnostic Imaging Departments in NHS Wales are asked to implement national codes as soon as is possible after the implementation of RadIS2. Given current plans, this should be achievable by 30 th September 2009. Page: 4 of 15
SECTION 2: BUSINESS JUSTIFICATION 9. Purpose The Diagnostic Services Strategy was published in 2004. The main thrust of the Strategy was to propose: That future planning and modernisation of diagnostic services including deployment of major equipment and new technology should be within a national or regional framework; A firmer grip on standards and on managing demand and capacity; Development of services unconstrained by traditional organisational, departmental or professional boundaries; Development of an ICT infrastructure to support collaborative working between Trusts. As part of this strategy, IHC, on behalf of the WAG Programme Management Unit is in the process of implementing an All Wales radiology management system, a PACS integration system together and a diagnostic imaging requesting system. These systems will: Allow investigations to be requested electronically by primary care and hospital based clinicians, the including requests to more than one imaging department. Allow the sharing of images and reports between clinicians in separate NHS Wales organisations and between the hospitals in newly merged Trusts Allow sharing of images and reports with Trusts in England Without a standard terminology and coding structure to support the description of diagnostic procedures none of the benefits of the facilities above can be safely realised. Without a standard terminology and coding structure there will be no opportunity to collect detailed national statistics on demand for and capacity to deliver diagnostic imaging procedures. NHS England has already established a national set of codes and descriptions. According to the Information Standards Board (ISB) Advance Notification Document - August 2008 (See Section 23), these are due to be mandated by the ISB in November 2008 for implementation across England by 1 st December 2009. These dates allow commercial suppliers 1 year to implement the codes within systems they supply. 10. Scope Imaging Procedures The scope currently includes the imaging undertaken in departments providing the following types of imaging (or using the following modalities): Breast imaging Interventional radiology Dental radiography Clinical photography Computed tomography (CT) including: o CT angiography o CT arthrography o CT radiotherapy planning Fluoroscopy o Angiography o Venography Magnetic resonance imaging (MRI) o Magnetic resonance angiography (MRA) o Magnetic resonance venography (MRV) Page: 5 of 15
Nuclear medicine o Non-imaging therapeutic procedures o Non-imaging measurement procedures o Positron emission tomography (PET) o Single photon emission computed tomography (SPECT) Ultrasound (US) o Obstetric US Plain film imaging o Dual energy X-ray photon absorptiometry (DEXA) NHS Organisations and Information Systems The scope is currently restricted to the implementation of national procedure codes within radiology information systems within secondary care. This will also require their implementation a number of closely integrated systems: Picture archiving and communication systems (PACS) Radiology test requesting and result reporting systems Result repositories in the Trust. It is not intended at this stage to extend the use of national procedure codes into primary care systems. This is likely to be addressed at a future date when the Read codes used in primary care and the national procedure codes to be used in radiology departments both migrate to SNOMED CT. It is not intended at this stage to implement national procedure codes in other departments such as Cardiology, Medical Illustration or specialist dental radiography. These systems will be addressed as separate projects in the future. It is not intended at this stage to implement national procedure codes in Breast Screening Services. This will be addressed as part of the Breast Screening Modernisation Programme. SNOMED CT It is not intended at this stage to make use of the SNOMED CT mapping within the national procedure code dataset. This will depend upon a future Welsh Assembly policy decision and the ability of information systems to support SNOMED CT 11. Funding No capital funding is required. The RIS and PACS in place are capable of supporting the national procedure codes. IHC resources will be available to ensure that the RIS being implemented across Wales (RadIS2) is populated with the codes and that it provides good support for staff that are exposed to the new codes. IHC will also ensure that a service is put in place to inform local system managers of future changes to the codes. Implementation will be resourced and funded locally. Experience at two pilot sites confirms that the majority of the implementation work can be carried out by local RIS/PACS managers though some support might be necessary from PACS suppliers. 12. Support Implementation project management will be provided by existing IHC funded, Trust based project support offices. Page: 6 of 15
Implementation support will be provided by Health Solutions Wales (the supplier of RadIS2) as part of their service level agreement with Informing Healthcare for the development and continued support of RadIS2 across NHS Wales. Ongoing service delivery and support with be provided by HSW under the same arrangements Maintenance of the codes following implementation is described in Section 7. Page: 7 of 15
SECTION 3: HEALTH INFORMATION STRATEGIC AND OPERATIONAL FIT 13. Strategic Fit When RadIS was originally implemented across Wales in the early 1990s a standard set of codes based on the Korner datasets was used, but these codes were not maintained centrally and local codes sets evolved independently to meet clinical and operational needs. A similar situation pertained in NHS England. The resulting diversity of procedure codes has become an obstacle to wider system integration and interoperability, and limits the ability to collate data across healthcare providers Connecting for Health s longer term strategic aim is that SNOMED CT be adopted within all clinical systems, but most legacy radiology systems can not currently support SNOMED CT. So an interim approach was taken in which a new national set of procedure codes was developed which could in turn be mapped directly onto SNOMED CT to provide a migration path To this end, Connecting for Health took a fairly well established set of codes developed in conjunction with the Royal College of Radiologists (CRS Radiology Catalogue v2.0 (Examination Code Set)) and, working with a number of stakeholders (See Section 17) developed this set into a the National Interim Standard Descriptions for Clinical Imaging Procedures. These procedures have now all been mapped onto SNOMED CT terms. (a single procedure code may resolve into three SNOMED codes e.g. the procedure, a laterality qualifier and the laterality.) CfH is also working on mapping the codes to OPCS4. This will allow greater compatibility with corporate datasets (Such as PEDW in Wales). Again, a single procedure code my resolve into several OPCS codes. Within NHS Wales, national codes are a prerequisite for a number of strategic developments including: Informing Healthcare Clinical portal radiology requesting and result reporting across organisational boundaries Diagnostic Imaging Modernisation Strategy removal of organisational barriers to sharing of diagnostic images and reports Corporate Health Information Programme All Wales management information views of diagnostic imaging workload, performance etc. Currently, no detailed All Wales view of activity in radiology departments is possible. Adoption of national datasets opens the way for a nationally agreed, patient based diagnostic imaging dataset. 14. Operational Fit The Connecting for Health national standard SNOMED CT subset comprises simply modality (or imaging method), the body site and where necessary the laterality (by post-coordination). In the National SNOMED subset it was agreed that the descriptions should be clear and unambiguous both within and outside the diagnostic imaging business domain and that the descriptions should represent only clinical activity and not administrative functions. For this reason, the National procedure codes differ from currently used local codes in the following respects They do not encode any information about the location of the examination. So the fact that an examination was undertaken on the ward (portable) or in theatre has to be recorded elsewhere in RadIS2 Page: 8 of 15
They do not encode any information about the nature of the patient. So the fact that a patient was uncooperative needs to be recorded elsewhere in RadIS2 They do not encode any information about other local administrative processes or procedures that may be required The national procedure codes also incorporate laterality into the code itself rather than being held as in independent qualifier. This results in up to three national codes for a single local procedure code + laterality (right,left or bilateral). Nevertheless, national procedure codes have already been successfully introduced into the RadIS2 and PACS system in Velindre and Wrexham Maelor Hospitals. Feedback from these sites confirms that these limitations can easily be circumvented using other features of the RadIS2. Searching for the new codes has proved to be more difficult than for the previously used locally designed codes. This is partly a matter of familiarity but there are also many more national codes because the incorporation of laterality. Additional search facilities will be added to the RadIS2 system to ease this problem, but experience at Velindre and Wrexham Maelor within these additional facilities shows that staff rapidly acclimatise to the commonly used codes and procedure descriptions.. The national code as currently defined do not meet the future needs for obstetric ultrasound reporting as they do not adequately reflect the reason for the scan. The Wales Antenatal Screening Programme is working with its English counterparts to address this shortcoming. The details of these limitations are explained in the CfH guidance document - Implementation Guidance for the Interim National Clinical Imaging Procedure Code Set and National Interim Standard Descriptions for Clinical Imaging Procedures to support PACS/RIS implementations - Editorial Principles (See Section 23). 15. Known standards in use nationally and internationally The National procedure code set has been mapped to SNOMED CT. It is not intended that NHS Wales make use of this mapping as part of the initial implementation. The code set does however represent a step towards the adoption of SNOMED in diagnostic imaging. Connecting for Health s SNOMED CT Clinical Imaging Procedures Subset Management Group have also commissioned a project to mapping the codes onto OPCS4 in order to provide compatibility with other corporate datasets (Eg PEDW in Wales). A mapping table has been developed and is currently under evaluation. In Scotland, national codes are being implemented as part of a the implementation of the new national RIS and PACs system (Carestream). Page: 9 of 15
SECTION 4: THE PROPOSAL 16. Proposed Solution It is proposed that from April 2009 all diagnostic imaging departments make use of the national codes and national procedure descriptions within their radiology information systems: When receiving electronic requests for services When inputting paper requests When managing patient appointments Within the PACS system for identifying acquired images Within the radiology reporting process When transmitting electronic results or printing paper reports. For those sites already using RadIS2.This will involve the following: Site to decide which codes need to be made active to support the procedures offered locally; HSW to load the new procedure codes into the RadIS2 system Site to input additional local RadIS2 metadata to each procedure code( room, length of appointment slot, local exam group etc); Site or PACS supplier to add the new codes to the PACS system and ensure that the correct metadata is attached to each code (modality, work-list, image display parameters etc). These vary according to the PACS system in place and must be determined locally.; Site or IHC to add the new codes to radiology test requesting systems if they exist; Site to train all staff in the use of the new descriptions and the new codes. HSW to modify The RadIS2 system to make finding unfamiliar codes easier. Site to retire existing local codes so they they can not be used for new data input. Site to activate new procedure codes if that procedure is offered locally Site to re-code appointments made before the change-over date. Site to publicise the change and train staff; Site to support staff during the first week of use of the new codes. The change in codes will make it difficult to compare the statistics collected before the date of change with those following the change. For this reason, it is recommended that Trusts adopt the new codes close to the time of implementing RadIS2 so that the additional data fields captured by RadIS2 are collected using the new codes. However, most Trusts are expected to limit the risks of RadIS2 implementation by delaying the new codes implementation until RadIS2 implementation has been successfully completed. 17. Fitness for Purpose On 26 January 2007 a set of procedure codes and descriptions for use in the representation of Clinical Imaging Procedures was released by NHS Connecting for Health. This effort was the result of several years of informal development and a further 2 years under the direct management of NHS Connecting for Health Data Standards and Products Service. The work has been overseen and endorsed by a management group consisting of key stakeholders including the following: Royal College of Radiologists o including numerous RCR special interest groups British Nuclear Medicine Society British Medical Association Royal College of General Practitioners Society of Radiographers Page: 10 of 15
Department of Health NHS Connecting for Health o Regional NHS representatives o System suppliers Representatives of home countries 18. Testing / Pilot Connecting for Health is currently undertaking a final Fitness for Purpose assessment in England, prior to mandating the use of these codes. NHS Wales has already successfully implemented the codes at two sites- Velindre in February 2008 and Wrexham Maelor June 2008. Both pilots have been successful. Neither has reported any significant problem resulting from use of the new codes. 19. Information Governance The new procedure codes do not result in any new flow of patient information or any new sharing of patient information. The Connecting for Health Clinical Imaging Procedures Management Group (CIMG) takes responsibility for the design and assurance of the standard including the editorial principles and implementation guidance and consequent potential safety implications. The NHS terminology service undertakes the day to day management of the standard on their behalf and is subject to the governance of NHS Connecting for Health. The CIMG reports into the Department of Health National Imaging Board via the National Clinical Lead for Imaging. The designated lead for this standard in NHS Connecting for Health is: Ian Arrowsmith, Chief Terminologist, UK Terminology Centre, NHS Connecting for Health, 2nd Floor, Princes Exchange, Princes Square, Leeds LS1 4HY Email: Ian.arrowsmith@nhs.net Telephone: 07775 687931 20. Commercial Considerations None Page: 11 of 15
SECTION 5: IMPACT ASSESSMENT 21. Impact Assessment The decision to adopt national codes was made by the Diagnostic Imaging Clinical Strategy Group in 2007 and supported by IHC s National Architecture Design Board (14/11/07). It was originally hoped that Trusts would implement the national codes at the same times as RadIS2 but this decision was left to local project boards and in most cases they have opted to delay the introduction of the codes in order to reduce the risk RadIS2 implementation. Implementation timescales may also be affected by projects to introduce new PACS systems (ABMU (E), PAS and test requesting systems (Gwent and N Wales Central). If these projects are delayed the new codes implementation may also be delayed. Formal support & Approval: From the minutes of Diagnostic Services Strategy Diagnostic Imaging Modernisation Project Board Held on Friday, 29 th February, 2008: National Coding This was highlighted as a key requirement to facilitate safe information sharing. From the Minutes of the Clinical Strategy Group held on 22nd April 2008: National Procedure Codes NE provided an outline of the national procedure codes project brief and highlighted concerns raised by Velindre as to how to code multiple plain films. NE described in detail the proposed process of requesting the development of new codes through MB through his role on the Clinical Imaging Procedures Management Group The national procedure codes brief was agreed by the group. Page: 12 of 15
SECTION 6: IMPLEMENTATION PLAN 22. Implementation plan Implementation will be managed as a series of local projects, coordinated by Informing Healthcare. (See IHC Project Brief and CFH implementation guidance documents embedded in section 23) Lessons learned in each implementation will be collated and fed back to future implementation projects via the RIS/PACS managers group. Local project management and support will be through IHC funded project offices in each Trust. 23. Official Documentation CfH Implementation Guidance Attached, see also http://www.connectingforhealth.nhs.uk/syst emsandservices/data/terminology/imaging CfH Editoral Principles Attached, see also http://www.connectingforhealth.nhs.uk/syst emsandservices/data/terminology/imaging Information Standards Board Advance Notice Attached, see also http://www.connectingforhealth.nhs.uk/syst emsandservices/data/terminology/imaging IHC Project Brief for local implementation of codes National Interim Standard Descriptions for Clinical Imaging Procedures (NB the version with SNOMED coding is not available via the Web-site) Attached Attached, see also http://www.connectingforhealth.nhs.uk/syst emsandservices/data/terminology/imaging Page: 13 of 15
SECTION 7: MAINTENANCE AND REVIEW 24. Maintenance Process The standard will be maintained by NHS England Clinical Imaging Procedures Management Group (CIMG) as described on the website: http://www.connectingforhealth.nhs.uk/systemsandservices/data/terminology/imaging. The code list itself, first released in January 2007 is documented in Excel format and can be downloaded from the CfH website: http://www.connectingforhealth.nhs.uk/systemsandservices/data/terminology/imaging New releases are made available every 6 months and are supported by release notes published on the same website. Implementation of the new codes (and retiring of old codes) on individual systems will be the responsibility of local RIS/PACS managers but will be overseen at a national level as part of the IHC service management arrangements for diagnostic imaging to ensure that a consistent approach is taken in all departments across all NHS Wales. An All Wales Diagnostic Imaging Service Management Board will be established to ensure that new National Services for diagnostic imaging (currently only RadIS2) are delivered and service managed according to best practice (set of process an procedures known as ITIL). Any requests for change to this service (including changes to the national codes) will be considered by this board. Changes which impact upon other national services (for example the Welsh Clinical Portal) will be referred up to a National Informatics Community Change Advisory board (NIC CAB) for a wider assessment. See diagram IHC Implementation Board Programme Management Session Service Management Session CfH Clinical Imaging Procedure Management Group National Informatics Community (NIC) Change Advisory Board (CAB) National Codes National Service Board (RMS) Service User Group (RIS/PACS Managers) Requests for changes to national procedure codes agreed by these boards will be passed to NHS Connecting for Health Data Standards helpdesk datastandards@nhs.net for consideration by the NHS Page: 14 of 15
Connecting For Health SNOMED CT Clinical Imaging Procedures Subset Management Group. NHS Wales will be represented on that board by a member of the All Wales Diagnostic Imaging Service Management Board (Currently Dr Mike Bourne). The All Wales Diagnostic Imaging Service Management Board has yet to be established but its role in managing national codes is currently being undertaken by the Diagnostic Imaging Clinical Strategy Group for the duration of the RadIS2 implementation project. 25. Planned review dates Review of the national codes implementation by the Diagnostic Imaging IT Project will be undertaken in September 2009 and again on 31 st March 2010 Page: 15 of 15