The transfer of clinical data in and out of primary care information and communications technology (ICT) systems is referred to as ‘clinical messaging’. The main service that facilitates this within health and social care is called MESH (Message Exchange for Social care and Health). This uses the Spine infrastructure to transfer electronic messages from one application to another, thereby allowing different organisations to communicate securely with each other.
The term ‘clinical messaging’ may also be used to refer to the transfer of information between clinicians and patients. Here it is mainly used to communicate test results or share patient information leaflets and resources.
Further information on the more detailed interactions between clinicians and patients can be found in the related articles on remote consultations tools and video consultation tools.
Clinical messaging standards
The NHS has adopted three standards to ensure that IT systems can communicate, and that data can be linked and shared clearly and safely:
- SNOMED CT | a national information standard of coding for the unambiguous identification of clinical concepts such as disease, findings and procedures
- Fast Healthcare Interoperability Resources (FHIR) | which allows systems from different manufacturers to exchange messages and data, no matter which setting care is delivered in
- an individual’s NHS number | which can also be used as a unique patient identifier to ensure records are not duplicated or matched in error
In addition, the DAPB4017: Pathology Test and Results Standard is a useful resource designed to support generic pathology test requests and test report cycle processes.
The NHS Interoperability Toolkit (NHS ITK) sets standards for web services, which can also allow systems to transmit data securely between GP and NHS trust clinical systems.
Where paper flows are still being received, practices should liaise with GP IT delivery partners or Integrated Care Board (ICB) contacts to explore digitising the process with senders.
Clinical messages received by GP practices
Approximately 50 million reports are sent through the MESH service every year. These include haematology, biochemistry and microbiology reports, cytology and radiology reports, and results from schemes such as the bowel cancer screening program.
The technology allows primary care IT systems to receive information from other organisations within the NHS, including NHS 111, GP out of hours services, the ambulance service, and different hospital departments such as emergency departments.
This process is often engineered to happen automatically, with a near constant stream of results and letters appearing on primary care systems. The result can be a wealth of clinical information being available for each patient. Whilst this can be useful, in order to simplify the information and make it searchable, practices must ensure adequate coding of these documents. Most messages will be automatically coded into the GP system once they land and are processed in the workflow screens.
Practices are advised to use SNOMED CT when coding, as it provides a structured clinical vocabulary and is built into the majority of electronic patient record (EPR) systems.
Clinical messages sent by GP practices
Digital systems can only be as good as the data they are provided with. In the case of hospital pathology labs, the data being sent by primary care must be accurate and up to date. This includes both the electronic request form and the physical sample, and these must also correlate appropriately.
Requests that are unclear, inaccurate or incorrectly labelled, are often rejected and not processed. This can lead to delayed or missed diagnoses, slower treatment decisions, unnecessary additional costs and inconvenience to both the patient and the healthcare provider.
Risks and responsibilities
Clinical staff, along with the organisations that they work for, have a responsibility to understand the capabilities and limitations of the clinical communication tools they use. Understanding these factors, and staying up to date, may form part of staff mandatory training.
There must be adequate preparation and continuing awareness in dealing with digital faults. Business continuity plans must include:
- arrangements for dealing with full and partial outages of services,
- the ability to detect when requests, messages or digital flows are not working as expected
- training on what steps to take to report and mitigate the risks.
Note: Failures can occur at different parts of the digital chain, e.g. from the sending laboratories, the various applications used to transmit messages, receiving/sending systems, etc. In addition, the physical chain may also be affected which will require management of test samples in transit, samples lost, damaged or spoiled, re-routing of new specimens, engagement with patients, etc. A worst case scenario is the occurrence of undetected systematic faults where messages are not received or delivered-these pose significant patient safety risks and will incur significant costs to remediate.
GPs should ensure that practice staff continue to be failure risk aware and are capable of undertaking manual processing and coding of paper versions of messages to enter into the patient records.
In the case of test requests, there should be a local process which enables the monitoring of requests sent, those received and those outstanding, as and when necessary.
Points to consider
- How much of the information received into a clinical system will automatically become part of the local medical record?
- Is this information searchable as part of the patient record or are additional steps and/or coding required before this is possible?
- Can this information be exported via the GP2GP record transfer system if a patient moves to a new practice?
- Where is data being exported to, how is it being stored and used, and does this conform to NHS guidance on encryption and security?
- What training and support is available for both clinical and non-clinical staff?
It is also vital that practices are aware of the ‘human’ component of these systems, particularly when it comes to filing clinical results or documents.
Most practices will have an internal policy to manage this, however it is prudent to appreciate the potential consequences that could result from missing a vital piece of clinical information. Safeguards should be in place to ensure that laboratory results and other clinical messages are reviewed and actioned when the named or requesting clinician is on leave or absent.
This is vital to prevent adverse patient care outcomes and has been highlighted by the Care Quality Commission (CQC) as a major problem in primary care settings.
Communicating test results with patients
Watson and colleagues, writing in the British Journal of General Practice in 2022 commented that:
‘Current systems of test result communication are complex and confusing, and mostly based on habits and routines rather than clear protocols. This has important implications for patient-centred care and patient safety.’
A standardised approach should, therefore, be used by clinicians when arranging any investigations. This should involve a clear set of instructions advising patients how and when to access the results and this should be agreed at a practice level.
GP systems have the capability to simplify the notification process when patient access to their records, including test results, is enabled.
A suggested checklist is outlined below:
- Document all requested tests within the relevant clinical systems.
- Ensure measures are in place to track test results, including any results that take longer to process and any specialist tests that are sent to different labs for analysis.
- Ensure that results are reviewed promptly and that systems are in place to action any abnormal results.
- Where samples need to be retaken, this should be communicated to the patient along with an explanation of why this is the case.
- Procedures should be in place to manage staff absences, whether these are planned or unplanned. Buddy systems are a popular way of managing this within practices.
- Business continuity plans should exist for use in the event of technological failure. These may include the use of paper forms to request tests or results being sent through to be manually uploaded. Importantly, training and materials should be kept up to date so that patient care can be maintained regardless of the system status.
- Patients should be informed if the practice policy is only to contact patients when results are abnormal, and a clear process should exist for patients requiring follow up or additional investigations.
- Abnormal results should ideally be shared with patients before these are filed, as filed results are visible for patients that use the NHS App (or any other app) should they have suitable online access provisioned.
Related GPG content
- GP2GP – transferred in records – processing
- Clinical coding – SNOMED CT
- NHS number
- Remote consulting tools – procurement, regulations, governance and transformation
- Video consultation tools – to follow
- Cyber security
- GP connect
- NHS App
- Shared care records
- Data and clinical record sharing
Other helpful resources
Journal of General Internal Medicine, Failure to follow up test results for ambulatory patients: a systematic review.