The Pennine Acute Hospitals NHS Trust (PAHT) was established in April 2002. Serving a population of approximately 800,000, the Trust is 1 of the largest in the country. It employs a staff of 10,000 across 4 hospital sites. PAHT covers 4 Primary Care Trusts which have a total of 160 GP practices.

PAHT initially issued a tender in 2008 to allow its GP community to order Pathology tests electronically for Biochemistry, Haematology, Immunology, and Microbiology disciplines (excluding Blood Transfusion). The Trust also procured a results repository to allow its practices to view results and download the results into the relevant practice management system. In 2010 Pennine Acute rolled out another module to cover the Electronic Ordering of Cervical Cytology tests.

The Trust awarded Indigo 4 Systems Limited a contract to provide the Order Communication system and has tQuest and Review implemented for primary care requesting, reporting and the publishing of Clinical Correspondence. Furthermore, the Trust utilises Keystone, Indigo 4's messaging software to disseminate Pathology, Radiology and Clinical Correspondence documentation to its GP community.

The timing of the Order Communications project at PAHT coincided with the opening of the new Pathology laboratory at The Royal Oldham Hospital site. This facility was opened in 2008 and was designed to accommodate increasing workloads across a range of disciplines and also became the central processing facility for all GP requests in the area.

A key factor in the success of the project was the early and continued involvement of all key stakeholders throughout the implementation. Representatives from each of the PCTs in the North West Sector, the pilot GP practices, Trust Pathology and IT staff were all part of the process and attended project meetings.

Cheryl Nice (Customer Services Manager for Indigo 4 and the Project Manager for the implementation at PAHT) stated:

"I have managed many implementations for order communications within primary care. The enthusiasm and involvement of all key stakeholders was one of the main influencing factors of the project being so successful."

Throughout the project implementation and roll out, PAHT's pioneering approach and decisive decision making has put the Trust in quite a unique position. Early on in the project process, PAHT decided to take a paperless approach to the requesting and reporting workflow. It was agreed with the GP community to use labels as the media to detail the items requested and the patient demographic information. Another element of the Trust's implementation is the use of tQuest's Lab Sample Numbering system. This allows the sample identifier that is printed in bar code form on the tube label, to be the number that identifies the sample. In real terms, this means the sample is identified all the way through the requesting process, from the order being placed to it being booked into the laboratory and processed by the analysers. This represents a significant shift from the process adopted by many laboratories of re-labelling the samples upon receipt in a laboratory.

Gary Walton, Pathology IT Systems & Project Manager, stated

"tQuest provides huge quality benefits, which ensures it is safer for patients, more efficient for our laboratories and GPs alike which in turn reduces turnaround times. The same data quality improvements are also supporting the reduction of paper based results, providing even further efficiency and cost savings for all concerned. It really is a win, win, win for patients, laboratories and GPs, providing huge improvements within Pathology services for the health community as a whole."

Over a two year period the Trust and PCTs have gone on to roll out the system to a total of 160 practices. The system originally was configured to provide electronic requesting of Biochemistry, Haematology, Immunology and Microbiology but in 2010 it was extended to include Cytology. With the introduction of Cytology, the system has also been enhanced with a discipline specific question set that collects all the required supporting information for the staff in the lab, when the samples are analysed. The introduction of Cytology has been a great success, so much so that it has helped the Trust secure a contract to supply Cytology services to GP practices, throughout the whole of the Greater Manchester Area.

Siema Iqbal Lead GP of Wellfield Medical Centre, which was one of the pilot sites, had this to say about the project:

"Everyone involved in the project was enthusiastic and eager to get it started.

We asked to be a pilot surgery as we were already using offline testing and were intrigued to see how online testing would work.

This involved numerous meetings to assess how the system was to be set up, prior to online testing and to see what our needs as GPs who would actually be using the system were. We were given numerous opportunities to show how we did our requesting at the practice and what we would expect from the new system. The project team were attentive and appeared to understand our needs at the GP end and made us feel involved in the whole project from start to finish.

There was a smooth transition from our old system to the online system and training was given to appropriate members of staff who would then cascade the information down into relevant teams. Additional support and training was also offered if necessary. Accessible support was on hand throughout the transition period.

This is a much better system than the old handwritten cards – It allows fewer mismatches which in turn reduces staff time spent trying to sort out results; less time spent in consultations filling in forms allowing more time with patients; The system is easy and straightforward to use; no more writing on fiddly swab bottles or worrying that the ink will rub off the bottle or that the space to fill in the details was too small.

The common orderables screen allows everyday tests to be identified quickly. The format allows more scope for the future and more tests to be added to the system without having to change all the forms. Back up ability to write on the back of the forms during home visits or if system fails allows the system to be used outside of the consulting room, without duplication of multiple forms in the GP room. It is a reliable system, we have had no problems and it has allowed us to turn off paper results as there were no problems with reliability.

The ability to save requests and have the phlebotomists print out the forms and take the bloods at their end, will allow GPs to audit what results are outstanding.

I don't know how we managed before online testing - makes you realise how time consuming filling in the forms was. A brilliant success and pleased to be a part of it!"

The order communications system has now been live for 3 years. Below, are the benefits that PAHT's business case expected to be realised. Against each benefit is the data to support the realisation of these.

1. 1) A reduction in the time between a sample being taken and results being received, which allows the patient to receive the relevant treatment more quickly and reduce the anxiety of waiting.

There has been a reduction in all sample times of at least 2%.

• Samples that arrived in the laboratory but could not be processed were refrigerated overnight to preserve them. This amounted to approximately 1,750 samples or 10% of samples a week. The new system saves on average 20 seconds on each tQuest sample; this is equivalent to 16-17hrs a day, therefore improving capacity making a reduction from 20hrs to less than 4hrs for those samples previously stored overnight.
• The percentage of non-urgent reported samples available within 15 hours, has improved from 93.5% to 96%.
• Urgent reported samples within 1 hour have improved from 94% to 96%.

1. 2) A reduction in the number of samples rejected by the laboratory for illegible or inaccurate labelling, resulting in greater efficiency for doctors and less anxiety for patients through not having to repeat tests.

Laboratory data shows that the rejection rate has dropped from 0.215% to 0.150% (approximately 10 samples a week).

1. 3) A decrease in time to order tests using the tQuest system, allowing clinicians to better utilise their time, allowing patients to receive more focus and an improved level of care.

The users no longer have to input the data into the computer and then complete the paper forms but no empirical data has been collected to support this.

1. 4) A reduction in the number of unnecessary repeat tests ordered, as clinicians will be able to view all of the orders and results for that patient, leading to greater efficiency and fewer repeated tests for patients.

Using Indigo 4's Review system means that patients who have had samples taken at hospital clinics, will not necessarily require a repeat test taken in GP practices.

The system prompts the user that there is a current result in the system (be it taken in hospital or elsewhere within the practice) which the requester may not have seen.

1. 5) Increase in the number of test results from other settings that clinicians can view, allowing them to read test results in context, so that they can better evaluate treatment choices.

Before the introduction of Indigo 4's tQuest, GPs only had access to results that they had ordered. Indigo 4's Review gives GPs access to any test that was requested for their patient, processed though PAHT Pathology Laboratory.

A number of additional benefits, since the project go-live, were also identified that were not originally part of the business case. These are:

• A reduction in the number of sample bottles used – tQuest works out exactly how many of each container is required for the tests requested. This means extra, unnecessary samples are not taken from the patient.
• Enhance access to "test groups" – tQuest has a number of test groups; these test groups are a list of regularly requested tests for a particular condition. The test groups contain standard tests that are used for checking on the progress of that condition. The existence of test groups means that the clinician does not have to choose these tests separately, as they can all be ordered in one click, therefore saving time.

Brenda Hardiman, the Health Care Support Worker at Greenmount Medical Centre said,

"The improvements since the new test ordering system has come in have been really fantastic. It's a much more efficient process and saves me a lot of time. I'm really pleased with the new system and can see it bringing many benefits to patients."

Gill a nurse at Radcliffe Medical Practice said,

"It saves me so much time. I no longer need to write out names, date of births and NHS numbers on all test bottles as these are printed automatically. Some patients have even received test results back the very same day!"

Len Fielding, Pathology Directorate Manager at PAHT Pathology Labs said,

"Pathology at Pennine Acute has worked with its partners in the community to introduce this hugely beneficial service that has improved the quality of requesting diagnostic tests, result reporting and the interpretation of our reports."

The details below show a breakdown of practices in each PCT area covered by PAHT, along with the percentage of these practices which are currently using the system. The figures are exceptionally high and qualify the success of the project.

It is envisaged to achieve 100% across the board within the very near future. Statistics shown represent the roll-out position as at April 2011.

The implementation of Indigo 4's Order Communications system tQuest and Review has, through the help of all key stakeholders and the expertise of Indigo 4 in delivering such projects, delivered many benefits to the patient, the practice and the laboratory. No longer do patients need to be bled unnecessarily, no longer do duplicate requests need to be made when the results already reside in a system and more importantly, a GP can view at a glance a history of results, empowering better treatment management for the patient.

PAHT will soon be extending the Order Communications system to include Radiology.