Managing codes on lab reports
Many lab reports come with codes written into the result, but what about the reports which don't have codes, and what about when codes need to change?
What does UC mean next to a code on a report?
UC means that a particular line in a lab report is uncoded, but it could have a code linked to the term written on the line. The UC hyperlink allows a user to add a code to the report, but this can be dangerous if used incorrectly, and only clinicians should use this feature. When a line is linked on a report, the change will be made for every subsequent inbound report, but earlier reports remain in the state they arrived.
We advise against staff using the UC feature unless they fully understand the topics covered in this article.
Adding a code is quite simple; press the UC hyperlink, then press the spyglass and search for a code. Once the code is selected to you do have an opportunity to review and cancel if necessary.
We can see an example of what happens in two (modified) images of results below. These are results for FIT tests which came into the site from the same laboratory approximately 2 years apart.
In the first image from 2020 we can read the result, but we would never be able to search on it. There are some clues which can tell us that this report was uncoded; the test name is in italics and there are some blue UC hyperlinks on the right of certain rows. Sometimes the tests will be shown in CAPITAL LETTERS, which will also be evident when reading a result in the patient's Care History.
The second image from 2022 has some subtle differences, notably the absence of several UC hyperlinks but also the test name has changed from Faecal Immunochemical Test to Quantitv faecal immunochem tst. Notice also that (47K) appears in place of the previous UC hyperlink. The Read code 47K is mapped to 1049361000000101 SNOMED concept ID.
What has happened in the intervening period is that somebody pressed UC and mapped the Quantitive faecal immunochemical test code to the result, or the lab added the code at their end, or both.
Lines such as Comment are completely separate to the result so they wouldn't be initially associated with the result. It is not necessary to add a code to this line.
The same could be said for the test titles in the line above the result, however from the point of view of searches there are certain sets of results where linking a code to the title can be very useful; Full blood count and Urea and electrolytes are probably the most common examples as they are collective terms for a series of results.
Take a look at some other lab reports and notice how many of them will have (4...) on the right hand side plus some UC hyperlinks.
What can I do about previous uncoded reports?
Aside from missing the trendline functionality, it probably doesn't matter much from a clinician's perspective that some results are not coded as it is still possible to search for text within a record. Some QOF, local enhanced services, and the National Contract DES (IIF) contain rules which look for coded results. It is therefore important for these that certain types of test result are correctly coded.
Having identified and matched a code going forward, there isn't a lot you can do automatically code reports retrospectively. A suggested workaround is to view the lab reports archive in Workflow Manager - you do not have to be a global viewer to see everything.
Press the Report column to sort by report name. EMIS may hang for a few moments as it thinks, then use the page navigator in the bottom left hand corner to locate the type of report you want. Each page has 50 reports so start off by making some big jumps of hundreds of pages, then refining by tens of pages until you find the range you want. Aside from being sorted alphabetically by report name they should also be sorted chronologically within each range of reports.
Once the range has been identified it is possible to work through the reports and add a code - if you have already mapped a line with UC for a recent result, you can actually use the UC button on each archived report to link a code - JUST MAKE SURE THE SAME CODE IS USED EVERY TIME!
The alternative approach is to print a list of all the patients you wish to add a code to, then manually add it on the same date as the report. Your Practice can make a decision over how far back to update, but consider that only the current NHS year is likely to be of benefit to achievement metrics. Whilst this second approach will look less tidy in the record, any mistakes made during the coding exercise can be more easily rolled back.
Batch adding is not advisable since timing of reports can be critical to achieving some QOF/ES/IIF indicators.
What reports have had codes linked on the site?
If a code has been linked by somebody at the site, it can be changed in Workflow Config. All users should be able to see the button but only those with the appropriate RBAC code B1700 will be able to manage the Organisation Options.
On the left hand side click on Inbound Code Matches. Do not worry that a lot of entries in this list do not have a code attached to them.
Housekeeping tip: review this list periodically to check what tests have been linked to a code.
You can use the Edit and Delete buttons at the top of the page to make any amendments but remember that this will only affect future incoming reports.
Linking an inappropriate code to the report means that every subsequent incoming lab report for any patient will have the same code. In the Read code era, an appropriate code for a result was one beginning with a 4... while in the SNOMED era the closest thing is an Observable Entity concept. An inappropriate code would be a Disorder (diagnosis) or Procedure concept. Correcting such a mistake might be possible when a few patients are affected, but left untouched a site would need to request assistance from EMIS at a cost.
Ideally all codes relating to test results should come in from the lab, so it is definitely worth approaching the lab to ask them to change the code on their messaging. This will save all other Practices having to do the process themselves. It may be necessary to have your ICS/CCG act as an intermediary to negotiate such updates.
Aside from the faecal immunochemical test in the example above, diagnostic HbA1c and the CKD-epi calculation are two other types of test we are aware of which required code matching before the local lab made some changes. There are undoubtedly more examples.
The unintended implications of matching a code
The UC feature can be useful when used correctly. Unfortunately there have been cases where a clinician has pressed the UC button thinking that they were linking a diagnosis to that particular result. The consequence of matching a code to a result means that every subsequent incoming report with the same line of information has that code attached to it. In the case of a diagnosis, this can mean that hundreds of patients are unintentionally 'diagnosed' with a condition. Depending on the code chosen there may be a negligible effect, but in other cases it may cause those patients to be added to a QOF register or be eligible for a flu jab (greatly including the denominator and the numbers needed to vaccinate to achieve a certain % uptake).
Unfortunately these errors are not so easy to undo, but there are steps which can be taken to identify the scale of the problem.
- Delete the code match in Workflow Config > Inbound Code Matches. Make sure you have made a note of the code before deleting!
- Create a search for the code, plus an aggregate report just looking for the date in order to find 'patient zero'. In order to distinguish between genuine code entries and those added via a report, drag From Pathology Report to the shaded row area.
- Assess the number of affected patients. For small numbers you might consider manually un-filing reports from the record, then reprocessing the transaction to file a new copy. For large numbers contact EMIS to explore chargeable options to remove the codes in bulk.
Digging deeper into lab report messages
Your local laboratory configures what information is sent in a lab report. For those with sufficient RBAC access, the coded message can be seen in Workflow Manager in Interchange History (under the DTS button)
Find a suitable report, either by a date range or interchange number (which can be found at the bottom of any lab report), then select the Interchange Content tab.
Taking the two FIT reports above, it is possible to see how the lab added the Read code [47K] into the message at some point between 2020 and 2022. The test title is free text, while the result has been changed from Faecal Immunochemical Test to Quantitv faecal immunochem tst. EMIS Web then converts this into a recognisable SNOMED term. When comparing the FIT report screenshots with this code, it is also possible to work out that the test title has been mapped by somebody at the site.
Since EMIS applies a code where it reads a defined string of text, the FIT test code would have originally been added to both the title and the result, then the lab's change meant that only the title was being changed by EMIS. Now that the test has been reported, ideally the Inbound code match should be removed to prevent additional codes being added to the record.
Such duplications of codes can also affect searches looking for a latest value unless they are written in a specific way (Include clinical codes....where the value is more than or equal to 0, then ordering by date select the latest....)
Updated 12th May 2022
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