TABLE OF CONTENTS


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Introduction


Following the great new SystmOne feature release, we are excited to announce the arrival of the new Ardens Auto-Review Results resources. 


This new functionality on SystmOne has great potential to increase your efficiency and save you considerable time when reviewing results. It is essential however that clinical safety always come first for you, your practice and your patients.


Ardens has developed its new Auto-Review Results resources with clinical safety at the forefront to avoid automatically reviewing results if clinical input is required.


Process


Once a result is received it is automatically filed into the patient record (which allows the result to be viewed in the patient record and included in reports, protocols and other resources) but it still needs reviewing. The auto review system allows certain results to be marked as auto-reviewed if they pass certain rules. If the result does not pass these rules they will remain in the pathology inbox to be reviewed manually.  


Variation in clinical practice when results are actioned:

For auto-reviewing results to be implemented safely and efficiently there has to be an understanding at point of requesting the test what you would like the follow up action needs to be:

 

  • Do you still want to follow-up the patient up?
  • If so, book them in now, or
  • Mark as ‘not for auto-review’ to ensure results will remain to be manually reviewed where follow-up can be decided
  • What safety netting advice +/or advice about drug treatment/dosing should you give to the patient? Ideally, this should be explained when the test is ordered


Reports, Batteries & Results

  • A report is a grouping of one or more batteries requested at the same time
  • A battery is a grouping of one or more results, such as a Full blood count. 
  • A result is a single result, such as haemoglobin concentration. 



Reports with a single battery

If the results pass the rules, then the review status is set to ‘not applicable’ and removed from the pathology inbox


Reports with multiple batteries 

If one battery passes rules but the others do not, the report will remain in the pathology inbox until the last battery has been manually reviewed but any passed batteries will no longer show in the report.



Result Types

  • Blood Tests
    • FBC
    • UE
    • LFT
    • Bone
    • ESR
    • Vitamin B12 and D
    • and more
  • Urine Tests
    • ACR
    • Bence Jones
    • and more
  • Stool Tests
    • FIT Tests 
    • Faecal Calproctectin
    • and more
  • Microbiology Tests
    • Urine
    • Stool
    • Chlamydia
    • Wound
    • TB culture
    • and more
  • Radiology Imaging
    • USS
    • X-Ray
    • CT
    • and more
  • Cancer Screening
    • Bowel cancer
    • Cervical screening
    • and more


Safety


Abnormal Values

If a result is outside of a normal range then the result will not be auto-reviewed. Due to the number of different pathology laboratories across the country, there are differences in reference ranges so the normal/abnormal thresholds vary. There are also some laboratory differences in Units Of Measure (UOM) so conversion errors can occur. 


As a result of this, the normal ranges chosen by Ardens have been created from multiple laboratory sources and national guidance resources, but the user must always check these against their own laboratory results before activating.


Significant Thresholds

A seemingly normal value might not necessarily be normal if there has been a consistent or rapid drop/rise in this value. Ardens takes significant trends into consideration and results in the following circumstances will not be auto-reviewed.


  • A haemoglobin drop of 15 (9-11%) in the last 2 years despite being in the normal range

  • On DMARDS & trend in last 1 year
    • FBC - Drop in WCC/neutrophils/platelets or rise in eosinophils/MCV 
    • U&E - Rise in Creatinine 
    • LFT  - Rise in ALT (excluding AST), drop in albumin


Specific Circumstances

There are also specific circumstances where you may wish to always manually review a patient's results. 

  • FBC + haemoglobinopathy (including sickle cell) - As may have different ranges or targets
  • HbA1c + haemoglobinopathy (including sickle cell) - As may have different ranges or targets
  • HbA1c + severe anaemia (latest Hb <8g/dL) - As may have different ranges or targets
  • ESR + polymyalgia rheumatica, temporal arteritis/GCA - As any rise may be significant
  • TSH + thyroid cancer or hypopituitarism - As may have different ranges or targets
  • Clotting/INR + on anticoagulant - As anticoagulant affects result
  • Folic acid & iron + on oral supplementation - May consider stopping supplements
  • HbA1c + medical history as per the table below

 

HbA1c mmol/mol

Considered normal or abnormal but expected if:

21-41

No pre-diabetes or diabetes type 1 or type 2

42-47

Pre-diabetes

48-57

Diabetes Type 2 and diet only or on 1 drug with low hypoglycaemic risk

53-57

Diabetes Type 2 and on 2 or more drugs or on 1 drug with high hypoglycaemic risk


        HbA1c trends are not taken into consideration as they are very patient specific. 

        If changing medication, either make follow-up or mark as not for auto-review. 

        DM Type 1 patients are never auto-reviewed.


General Cohort

Aged <18 years or pregnant patients are not for auto-review on Ardens as these patients often have different normal reference ranges and thresholds for intervention. Do remember the importance of always recording pregnancy on the patient record though.


Laboratory Interpretation

If a report is received that has been interpreted by the lab as abnormal, these will be excluded from the Ardens auto-review rules.


Clinical Override 

By adding the code 'Results for this patient are not to be auto reviewed (Y408b)', this will remove the patiet from being auto-reviewed. This can be added from the 'Results - Review & Auto-review' template that can be accessed by searching for this in the bottom left of SystmOne or by adding it to your F12 Favourites. This dropdown is also on the phlebotomy test templates too.



There are also some reports in the location below to help highlight potential patients you may wish to record this on proactively record this code on their record on a case-by-case basis.



Enable

To enable auto-review results on SystmOne, go to 'Setup > User & Policies > Organisational Preferences', under 'Pathology >Auto-Reviewing' tick the 'Use auto-review pathology rules' option and add appropriate staff from the left-hand list to the right to give them permission to manage the pathology rules.

Create

Knowing who should create the rules is a challenge due to the following factors:

  • Number of laboratories
  • Laboratory changing codes, text or ranges
  • Laboratory misses one result from normal battery
  • Newly published guidance
  • Different clinician tolerance thresholds
  • Updating rules + communicating to practices


Practices will need to discuss this within their practice, PCN and ICB to see what works best for them. Ardens will happily support as needed, so please just contact us at [email protected] if you would like further information.



If you wish to create your own rules, go to Setup > Workflow Support > Pathology / Radiology Results Auto-Review Rules Engine.


To save you time, you can go to the 'Arden's Ltd' scope and then click 'Export' to export on the rules.

 

You can then import the rule set to your own site and amend the rules as you wish.


Activate


To activate an individual rule, go to 'Setup > Workflow Support > Pathology / Radiology Results Auto-Review Rules Engine'. On the 'Scope' picklist, select Arden's Ltd and click 'Subscribe'.


You can only subscribe to rules published by one organisation group e.g. Ardens. This is to prevent any conflict between two rule sets acting on the same investigation You can change who you are subscribed to at any point though. Then just tick/select the specific rule set you wish to activate.


NB: If your organisation has any rules already set up and subscribed to, you will no longer be subscribed to that set of rules. The rules will not be deleted but just become inactive and you will just need to click 'Yes' on this next popup



Apply

Apply Rules - Single patient


In the Pathology inbox, right click the patient and then select Apply Auto-Review Rules
Apply Rules -Bulk apply


In the pathology inbox, select ‘Apply Auto-Review Roles’ button to run all active rules against new reports, which have not yet been run through the engine. The auto-review rules run across the whole inbox, regardless of recipient. If you filter to registered practice, then only runs for these patients if you doing shared administration. 


Audit

To view an audit of which rules were applied and passed or failed, in in the pathology inbox, right click the patient and then select 'View Auto-Review Audit'You can expand the rules to view a breakdown of why the result failed to be auto-reviewed.