TABLE OF CONTENTS


WATCH WEBINAR RECORDING


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, so they will not automatically review results if clinical input is required.   

The Auto-review suite takes advantage of two functionality elements within SystmOne. 

 

Auto-Filing: This is the logging into the system of any result that is returned from the hospital. They are filed, but not reviewed, so they show in the pathology inbox. However, the results are seen by the clinical reporting engine and thus will trigger an alert protocol, etc. 

 

Auto-Review: This is the engine that allows for the application of a rule set (locally built or published to the unit) to be applied for a single test or the whole of the pathology inbox.  

 

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
    • ABO
    • ANA
    • Blood group
    • Bone 
    • Coagulation
    • Coeliac
    • CRP
    • ESR
    • FBC
    • Folate
    • HbA1c
    • INR
    • LFTs
    • NT-proBNP
    • TSH
    • UE
    • Vit B12 & D
  • Microbiology Tests
    • Blood film
    • Chlamydia
  • Screening
    • Bowel cancer
  • Stool Tests
    • Faecal Calprotectin
    • H.Pylori
  • Urine Tests
    • ACR
    • Bence Jones

 

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, we rely on each lab reporting results with lab ranges, which means we can make rules that work for multiple labs with different ranges, as the rules only ensure the value is in between the provided range.

 

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
  • 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
  • Bone + on calcium supplements - As calcium supplements may alter the calcium components of the bone profile battery, so will need clinician interpretation in the light of supplementation
  • Coeliac + IgA deficiency - As IgA deficiency may cause false negative results
  • Folate + on folic acid - As the result will need clinician interpretation in the light of supplementation, and clinician review on the need for adjustments to folic acid supplementation
  • Vit B12 + on B12 supplements/CHC - Re. B12 supplements, the result will need clinician interpretation in the light of supplementation, and clinician review on the need for adjustments to B12 supplementation. Re CHC,  as this can lower total B12 concentrations without causing a deficiency 
  • Vit D + on Vitamin D - As the result will need clinician interpretation in the light of supplementation, and clinician review on the need for adjustments to Vitamin D supplementation 
  • 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
  • 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.

 

Exclusion Rules 
The following criteria are built into the rule set. This list might not be updated, so for the current, accurate exclusion list, please see the rules within SystmOne. (Clinical Reporting > Arden's Ltd > Tests > Autoreview results)

 

General Exclusion
  • Remove all patients who are under 18 years old
  • Remove all patients who are pregnant 
  • Remove all patients who have been coded as not for auto review.  

 

Battery Specific Exclusion 
ACR: 
  • Filter for Male or Female
  • Remove patients who have shown a significant trend up in the results over the last 2 years, with females looking at a trending range of 0 to 3 and males 0 to 2.5

Bone:

  •  Remove all patients who take calcium supplements
Clotting screening:
  •  Remove all patients who have oral anticoagulants on repeat 
Coeliac screening: 
  •  Remove all patients who have recorded IgA deficiency
ESR:
  •  Remove all patients who have polymyalgia rheumatica
  •  Remove all patients who have giant cell arteritis
FBC:
  • Filter for Male or Female
  • Remove all patients who have a haemoglobinopathy
  • Remove all patients who have been on a DMARD in the last 12 months who also have one of the following:
    • A significant decreasing trend in white blood count over the last 12 months, with a trending range of 4.0-9.6
    • A significant decreasing trend in neutrophil over the last 12 months, with a trending range of 2.0-6.1
    • A significant decreasing trend in platelet count over the last 12 months, with a trending range of 150-400
    • A significant decreasing trend in mean corpuscular volume over the last 12 months, with a trending range of 83-100
    • A significant decreasing trend in eosinophil over the last 12 months, with a trending range of 0.1-0.4
  • Remove patients who have shown a significant trend down in the Haemoglobin concentration results over the last 2 years (C. 9-11%), with females looking at a trending range of 120-150 and males 135-170.
Folate:
  • Remove all patients who have Folic acid on repeat
HbA1c:
Patients with no DM or PDM diagnosis.   
  • Remove all patients who have a haemoglobinopathy
  • Remove all patients who have severe anaemia (latest Hb <8)
Patients with pre diabetic 
  • Remove all patients who have a haemoglobinopathy
  • Remove all patients who have severe anaemia (latest Hb <8)
  • Remove all patients whose latest reading is >=42 with the two prior readings being below 42
  • Remove all patients who have a significant increasing trend over the last 2 years, looking at a trending range of 42-47.9
Patients with DMT2 who are on no diabetic treatment or on  a single low hypoglycaemic risk  drug 
  • Remove all patients who have a haemoglobinopathy
  • Remove all patients who have severe Anaemia (latest Hb <8)
  • Remove all patients who have a significant increasing trend over the last 2 years, looking at a trending range of 48-52.9
Patients with DMT2 patients who are on 2 or more diabetic drugs or 1 or more with a high hypoglycaemic risk drug 
  • Remove all patients who have a haemoglobinopathy  
  • Remove all patients who have severe Anaemia (latest Hb <8) 
  • Remove all patients who have a significant increasing trend over the last 2 years, looking at a trending range of 53-57.9
INR:
  • Remove all patients who have oral anticoagulants on repeat 
LFT:
  • Remove all patients who have been on a DMARD in the last 12 months who also have one or both of the following:
    •  A significant decreasing trend in albumin over the last 12 months, looking at females with a trending range of 35-45 and males 35-45
    • A significant decreasing trend in alanine aminotransferase over the last 12 months, looking at females with a trending range of 0-33 and males 0-39
TSH:
  • Remove all patients with hypopituitarism
  • Remove all patients with a malignant tumour of the thyroid
U&E:
  • Remove all patients who have been on a DMARD in the last 12 months who also have the following:
    • A significant decreasing trend in creatinine over the last 12 months, looking at females with a trending range of 44-80 and males 59-104
Vitamin B12:
  • Remove all patients who have vitamin B12 on repeat 
  • Remove all patients who have combined hormonal contraception on repeat
Vitamin D:
  • Remove all patients who have vitamin D on repeat

 

 

Laboratory Interpretation


We have recently updated the Ardens auto-review rules to include laboratory reports that contain multiple result batteries, even when the laboratory marks the overall report as abnormal.


This change allows the rules to assess individual batteries within a report, enabling normal batteries to be auto-reviewed and cleared even when they are accompanied by a separate abnormal result battery in the same report. Previously, auto-review rules only ran on reports marked as normal or unknown, which meant many normal-result batteries could not be auto-reviewed and cleared when included in a report marked as abnormal.


There is no increased risk that the remaining abnormal results will be filed without review. If a battery component contains an abnormal result, the auto-review rules will fail because the result falls outside the laboratory reference range, ensuring that it remains subject to manual review.

 

 

 

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 support@ardens.org.uk 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 select any of the 'Arden's Ltd' rule sets and then click 'Export' to export 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'. 

 You will then see a list of 'Rule Sets', and which ones are 'Active'. To Activate a rule, simply tick the box next to it.

 

 

 

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.

 

 

 

 

If you wish to review patients that have been auto-reviewed in the last 12 months or within the last month, you can use the reports found in Ardens Ltd → Tests → Autoreview results activity, which will provide a breakdown.