Why is an alert showing that my patient is eligible for a vaccination?

Why is an alert showing that my patient is eligible for a vaccination?

We often receive queries about why the red alert box is saying that a patient is eligible for a particular vaccination. This is often flu, pneumo, shingles, or COVID. The Practice has usually already spent time reviewing the record to work out why the patient might be eligible but cannot find the qualifying code. 
Some of these alerts have been produced by EMIS, and others by PCIT.

Understanding why a patient is unexpectedly showing as eligible is sometimes not easy. You need to know what the alert is called, and then know how to test protocols and concepts.
PCIT alerts will always show Powered by Primary Care IT (HPxxx) at the bottom of the tooltip when the mouse hovers over the alert. 

Why are patients being shown as eligible?

EMIS provides a number of code lists to look for patients, many of which are derived from clusters created by PRIMIS. This is usually - but not always - the cause of the confusion.
At this point it is important to explain that EMIS uses different lists of codes between searches and concepts (the components that drive decision making within a protocol). Searches use NHS managed reference sets which are the definitive list in terms of being paid to vaccinate a patient. These have usually been designed to mirror the Green Book, although sometimes offer a slightly broader interpretation. Meanwhile, the code lists that EMIS maintains for use in concepts are not necessarily based on the reference set, and not always on the PRIMIS code list!
Code lists in EMIS Web concepts are fixed in stone. Look carefully at the date in the picker. Once selected, this list will not update for new codes.

A good example of a broader set of codes compared to the Green Book are the immunocompromised conditions and medications for shingles. The Green Book is very specific in terms of co-morbidities or the daily therapeutic dose, but the clinical systems are simply not capable of accurately doing these calculations. Consequently the shingles alert inevitably displays for a number of patients who a human would say are not eligible; to mitigate this, the PCIT and EMIS alerts both suggest that the patient may be eligible to receive a vaccination.
The code lists published by PRIMIS are often much larger than the refsets used in the searches, but they still follow the conditions listed in the Green Book. When alerts appear unexpectedly, most of the time it is down to a PRIMIS originating code list being the cause.

The EMIS flu eligibility concept offers a small amount of help in that it will display the general area of why a patient is eligible (eg: cardiac), but this still leaves users trawling through codes in a record to identify what might be the triggering code.

How to find out what code is triggering the alert

These suggested steps require the user to be able to access Resource Publisher/Template Manager. RBAC B1700 Local System Configuration is needed on the smartcard.
  1. Identify the protocol. As stated above, PCIT alerts will show the HP code when the mouse hovers over the alert.
  2. Go to Resource Publisher/Template Manager
  3. Locate the alert. Look at or sort the 'Type' column as the alert will show Alert Protocol. Depending on the author, look in the following places:
    1. EMIS alerts will be in the EMIS Library
    2. Primary Care IT alerts installed directly on the site will be in the Primary Care IT/Handy Protocols folder.
    3. Primary Care IT alerts shared by resource publishing will be in the Shared Folders section. Locate a Primary Care IT folder, then Handy Protocols sub folder.
  4. With the patient loaded in the precis bar, highlight the protocol and press Test Run on the ribbon
  5. A box showing the outcome of the test will display the flow of the protocol including which concepts passed or failed. One of these concepts will contain the answer, but it does require some detective work to know which one. Make a note of any concepts you think may be relevant. Below are some examples.
    CT01848 Immunocompromised..... is the key concept as the last concept to pass before the alert
  6. Go to the Concepts Manager
  7. Use the Search button to find the concept. The details tab will indicate who authored the concept. Primary Care IT alerts sometimes use EMIS authored concepts. Double click in the Picker to jump to the folder location.
  8. Highlight the concept and press Test Run on the ribbon.
  9. Often the test results will only show whether a concept passed or failed. Look down the evaluation result to understand which parts passed (green) or failed (red). The bottom concept is likely to be the trigger.
    CT01831 Allograft.... may contain the answer?
  10. Pressing the + next to the passing concept will expand the results, and it is possible to find the triggering code within here (usually under a block called Criterion passed with 1 result)
  11. As an alternative to 10, find the concept using the search and press Test Run. If the concept is looking at codes or medication issues, the answer will be shown in the summary.
  12. Once you know the triggering code, a clinician may want to review the notes against the criteria specified in the Green Book. 

This may feel like a long-winded process, but it can help to pin down the answer reasonably quickly, while increasing local understanding of the types of codes that make a patient eligible.. 

Why is an alert is not displaying when we think it should?

This reason is almost certainly down to coding. Perhaps a legacy EMIS code has been used, or the code on the record is simply not part of the cluster.
A similar set of steps can be followed as above, especially testing the protocol and seeing the outcome in a diagram. Unfortunately testing what isn't there is much harder, especially if dates are not part of the test.

It would be best to review the business rules specification and the Green Book to understand who should be eligible. 

Just because the alert isn't showing does not necessarily mean a patient is ineligible. Cross reference with the searches to confirm if they accept eligibility. Searches trump alerts in terms of reporting and payment. 

How to hide the alert

At this point a Practice may question the validity of the alert and will call for the alert to be fixed by EMIS or PCIT. Having considered the source material at the top of this article, sometimes this isn't so easy if the code features in a nationally recognised cluster.
  1. Adding the relevant declined code should certainly hide the alert, but remember for flu this will be an annual occurrence
  2. Editing the care history is rarely an appropriate option
  3. Some concepts fortunately have timeframes on them, so the concept may not trigger the following year because a certain amount of time (usually 12 months) has elapsed since it was added
If the code seems to be in the cluster but this does not match up with published lists of codes, log a support ticket with the concept author.

Things to be aware of

  1. Just because an alert says that a patient is eligible, and the patient is subsequently vaccinated, it does not mean that the Practice will be paid for the activity
  2. It is essential to check eligibility against CQRS criteria, and where appropriate add any qualifying codes such as Needs influenza vaccination / Requires pneumococcal vaccination
  3. Code lists can change depending on the latest MKB version. Some codes will be added to or removed from the cluster - whether intentionally or accidentally - which can have an impact on when the alert shows
October 2023: We are aware of an issue with EMIS' Shingles eligibility alert which is showing that all patients aged exactly 65 are eligible, when it should only be patients born on or after 01/09/1958.

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