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Electronic reporting of pathology results to GPs

The Connect Programme is the government initiative to implement various targets from the White Paper 'Information for Health' including the reporting of laboratory test results to GPs via NHSnet in England. This article (from October 2000) by Dr Kevin Feltham, an expert on laboratory computing (www.fal.org.uk), describes the considerable progress that has been made.

Background

English hospital pathology laboratories, on behalf of GPs, undertake over 35 million pathology investigations per year for diagnostic decision support and the on-going management of patient conditions. These investigations are undertaken in England by some 220 hospital laboratories managed by just over 200 Trusts.

Pathology services are provided for GPs by laboratory disciplines including clinical chemistry, haematology, microbiology, cytology and histopathology. The degree of management as well as operational and informatics integration between disciplines varies considerably across Trusts.  Almost all Trusts in England now have a pathology computer system that is used to support specimen processing, although individual disciplines within some laboratories have their own separate systems and hence there are some 260 pathology computer systems currently installed in England.  The majority of these are commercial systems from 12 suppliers.  Just five suppliers account for over 90% of commercial systems installed since 1990 (ACT Medisys, since the acquisition of CDS, now account for over 60%).

Most GP practices in England use their practice computer system for communicating registration, reimbursement and items of service data with their Health Authorities. The introduction of formal Requirements For Accreditation (RFA) for GP computer systems in 1993, underpinned by an independent testing programme, opened the way for electronic communication with hospitals including waiting lists, discharge summaries and pathology test results. RFA99 is the latest specification. This has been essential to provide a stable base to support future directions in NHS computing.

It is estimated that some 1,600 computerised GP practices (20%) already receive the results of pathology investigations electronically.  These implementations have been developed by local agreements between Trusts and GPs, and, despite the absence of centrally imposed information standards, have generated real benefits for patients.  There now exists a considerable amount of well-documented experience about electronic transmission of pathology investigation results (blood tests etc.) between Trust and GP clinical computer systems.

Between 1995 and 1998 national standards for pathology results messaging were developed and piloted in collaboration with professional bodies. GP clinical computer systems, which had been developed by suppliers against these standards, showed an increased potential for delivering healthcare benefits. It is these messaging standards that the NHS Connect Programme and the Pathology Messaging Enabler Project (PMEP) have brought up to date in line with the government’s target of achieving a 95% connection rate of hospitals and GPs to NHSnet by the end of March 2001 and 100% by the end of March 2002.

There is significant political commitment to this, and this means that, for the first time in ten years, there is strong management resolve and 60m of resources to make it happen.

General clinical benefits of EDI reporting:

  • A more complete and accurate clinical record;

  • Results can be found easily making large savings in administrative and GP time;

  • Results are available from any workstation within the practice (including those in branch surgeries) or from a lap top computer when visiting patients;

  • Reduced number of phone calls made to the Trust laboratory to chase information;

  • Reports are less likely to get misfiled if they come in electronically so saving staff time;

  • Electronic results are inherently more secure than paper results.

Direct clinical benefits of EDI reporting:

  • Faster results from the laboratory means that important clinical decisions may be made before deterioration in clinical condition thus improving the outcome for the patient;

  • The practice-wide availability of results means that there is less time for the patient waiting on the telephone when checking to see if results are back;

  • Patients are more comfortable when their information is readily available in the consulting room, rather than practice staff having to search for paper reports;

  • Less time spent waiting in the consultation room while missing results are located.  Two minutes wasted on this is 25% of the average consultation.

Benefits of pathology EDI reporting:

  • Faster results from the laboratory – typically 2 to 3 times quicker electronically;

  • Robust, safe, cost-effective and accurate reporting method;

  • Statistical analysis for audit and research is a lot easier (e.g. identifying those patients who are on Warfarin and also have INR test results).

Trailblazers and pilots

Issues Resolution

The accumulated experience from formal (trailblazer and pilot sites) and informal implementations of electronic pathology results reporting over the last 10 years has provided compelling evidence that the NHS Information Authority should take full control of the process and invest resources to ensure strong quality assurance of EDI activities. This was necessary to ensure both clinical efficiency and clinical effectiveness.

Several Trust and GP implementations that adopted the existing documented national standards have been evaluated. To date the NHSIA has examined some 24,000 test messages transmitted over 42 months by 50 laboratories using these standards.

Formal examinations of implementations using alternative, often tailored, information standards has not been undertaken as such studies would have been difficult and costly. However it is likely that similar findings would be found and that generic solutions apply equally to all EDI implementations.

The main findings of the evaluation raised serious questions of concern in relation to both clinical efficiency and effectiveness:

Clinical efficiency – several examples pointed to efficiency gains which could be made if there were greater harmonisation of the working practices for generation and use of electronic pathology results information between laboratory and GP practice.

Clinical effectiveness - the evaluations have exposed some areas of concern as to the reliability and accuracy of some Trust pathology messaging software implementations. Such systems software issues have potential implications for any form of pathology messaging, be it national standard based or locally developed. These, combined with the identification of some dubious working practices at both sending and receiving sites, were identified as posing potential threats to clinical safety.

To successfully implement pathology messaging a Trust effectively needs three pieces of software: the pathology computer system, message translation/construction software and NHSnet transmission software. With very few exceptions, current implementations of EDI reporting have purchased each piece of software independently. This has led directly to a failure of many of these systems to interact successfully so that information content has been lost, misinterpreted or amended as it has passed between the various components.

 Procedures have been recommended for resolving all of the issues and these have been built into the specifications for laboratory report messaging.  For example, a pathology-specific bounded list of READ codes has been produced (this is not affected by the terminology collaboration between the NHS and College of American Pathologists to combine SNOMED RT and READ Codes version 3); recommendations for error-free mapping have been made; and a number of important changes to the pathology report message profile have been made to improve consistency.

A list of 56 unresolved issues (see Table 1) were identified from the pilot sites’ evaluation and published on the PATHEDI website (www.leeds.ac.uk/acb/pathedi) in 1999 and an Issues Resolution Mechanism (IRM) was set up to deal with them.  An Issues Resolution Forum (IRF) PMEP technical team consisting of representative pathologists, GPs, pathology and GP system suppliers and NHSIA analysts reached a consensus agreement about how each issue should be resolved and these were put out for discussion on the PATHEDI website during mid 2000.

Table 1.  Some of the issues identified

Issues relating to existing message specifications

Are measurement units required for all tests with numeric results?

Should specimen type be coded?

Should there be a pathology report EDI identifier?

Should a standard list of test codes be used?

Should code meanings (expansions) be included?

Should tests be grouped into batteries?

How will patients be identified correctly?

Issues relating to good practice in message implementation

Are test codes mapped correctly to prevent poor or incorrect mapping of READ codes with the resultant transposition of meanings?

Should absolute or relative results for a differential white cell count be reported?

How should an EDI report be cancelled?

How should displays of data on the receiving system that disassociates data elements be improved?

Issues relating to scope of the existing message specifications

What about Microbiology test results?

What about Histology and Cytology test results?

How should non-GP requesters be identified (e.g. nurses, locums)?

Issues relating to good practice use of laboratory systems

Should numeric result formats be standardised?

Should fasting status be indicated?

Laboratory application / EDI application integration issues
Should print images be allowed as the data source for EDI?

*  How should EDI messages be acknowledged?

*  Should test data be distinguished from live data?

*  Should there be an audit trail to track EDI reports?

Other issues

What functionality is needed on systems to handle GP Practices where not all GPs want to use EDI?

How should national organisation and person codes be made available?

How should EDI sender and recipient identifiers be made available?

Approach adopted for success

A complete set of specifications for secure pathology report messaging was completed in August 2000. Trusts, software suppliers and technical implementers can now use these to set up electronic reporting of pathology results to GPs to meet the national standards and business requirements.  These specifications do not include GP requesting standards.

A separate collaboration between the PMEP and the Encryption Programme Board has produced security requirements which have been built into the specifications. The contract for providing cryptographic security to all transactions was awarded in November 2000 to ENTRUST.

The new Pathology Results Implementation Project (PRIP) will support local implementations to ensure government target dates are met.

A full message checking service is being established to provide immediate support for message development and implementation testing as well as future support for ongoing QA of EDI practice.  A recommendation has been made that testing of Trust implementations should fit within the existing laboratory accreditation procedures.

Existing users of commercial laboratory computer systems should now enquire of their supplier when and how their system will be updated to meet the new specifications. Trusts, which are in the process of procuring new or replacement laboratory computer systems, should now ensure the relevant EDI reporting requirements are built into their strategies, specifications, evaluation criteria and contract documentation.

XML versus EDIFACT

Government IT chiefs announced in September 2000 that XML (Extended Markup Language) is to be the standard for developing data integration across the whole public sector. However NHSIA have said that XML is not ready for use in key parts of the health service, particularly pathology messaging. Instead it will rely on 25 year old EDI technology: "At present XML was uncoordinated and EDIFACT remained a more reliable methodology."

 This article was published in Biomedical Gazette October 2000 pp.946/7

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Last updated 27 May 2008