1. Incorporating: Manchester Royal Eye Hospital Manchester Royal Infirmary Royal Manchester Children’s Hospital Saint Mary’s Hospital University Dental Hospital of Manchester Community Services Trafford Hospitals
Share a management of change experience undertaken in Gr Manchester over the last six years.
Whereby we wanted to tackle a problem encountered by labs across the UK.

2. Development of the National Pathology Exchange system in Manchester
Robin Lythe

3. Immunology CMFT (MRI)
Major referral centre – performing almost 400,000 tests per annum.
The largest Immunology department in the North West of England.
Offer a comprehensive test repertoire for GPs and hospitals in Greater Manchester and across the North West.
Currently around 80% of all Immunology requests now made electronically.

4. User Requirements
According to a recent survey the key requirements for all of our users are;
Transport links
Turnaround time
Cost
Quality
Another survey showed that service users, remote from the Trust, rate electronic transmission of results as very high.
Electronic communication functionality is a stipulation of recent Tender requests.
Being such a large referral center we need to respond to user needs.
All of this shows that electronic communications form a vital part of customer needs.

5. Background
In 2008 the Review of NHS Pathology Services in England, chaired by Lord Carter of Coles, called for greater connectivity and consolidation of non-urgent work.
Key to this is the transfer of pathology specimens and delivery of swift, accurate results between hospital sites - “send aways”.
Historically hampered by the lack of a national electronic network.

6. Problem
Currently there is a requirement for the manual input of patient and test details into the receiving laboratory information management system (LIMS).
Even though this has already been done at the referring site.

7. Problem
Once processed, a hard copy result is returned to the referring laboratory, which again needs to be manually inputted.
Both of these processes are highly error prone and time consuming, and could be made redundant with the introduction of an electronic system.

8. Solution
The NHS Health Informatics Service (THIS) provides a solution in the form of an electronic network.
Based on software developed by X-Lab Ltd, a company formed by students and staff at the University of Leeds.
In collaboration X-Lab and THIS - National Pathology Exchange (NPEx) launched 2009

9. NPEx Two of their products are used to run the network:
The NPEx system – Web-based software featuring a dashboard that allows laboratory staff to control test routes and track the location and status of specimens.
The NPEx SNOMED CT-browser – List of available pathology test codes.

10. About NPEx NPEx is a national service for NHS pathology labs.
It works like a telephone exchange by connecting pathology LIMS to a national network.
Enabling test referrals and results to be sent between laboratories electronically in a few seconds.
Supported by THIS, including support desk, infrastructure hosting and account management.

11. NPEx in Gr. Mcr
Funding for the implementation of NPEx in Manchester was provided by The Greater Manchester Pathology Network.
Chlamydia test results were first sent between Virology at Central Manchester and Micro at Stockport NHS Foundation Trust in 2009, with the project signed off in 2010.
Since then, Greater Manchester has led the way in implementing NPEx.

12. NPEx in Gr. Mcr
Currently the majority of Trusts in Greater Manchester are signed up to the network. Including Central Manchester including Trafford, Pennine Acute Trust, Tameside, Stepping Hill at Stockport, Salford including Wigan, Wythenshawe at South Manchester, and Bolton.

13. Process Change Specimen Arrives Specimen Barcoded
Locate External Lab Details
Book into local LIMS
Paper Based Results Returned
Paper Based Results Returned
Re-Enter Specimen Details
Re-Enter Specimen Details
Package & Send to External Lab
Package & Send to External Lab
This flow chart shows the current process with the boxes in red highlighting steps either altered or made redundant with NPEx.
Results Reported
Results Manually Re-Entered
Results Manually Re-Entered

14. NPEx Process Referring Lab Users
Batch specimens into shipments based on type – done in LIMS.
Print specimen pick list for daily shipment.
Collect and assemble shipment.
Print shipping manifest with barcodes.
Receiving Lab Users
Scan shipment barcode.
Assign new identifiers to specimens.
Book in specimens and report problems via NPEx (damaged/missing etc.).
Report results electronically (PMIP).
So what is the NPEx process? It is quite similar for the referring lab initially.
Process far easier for receiving lab. Once booked in, requests arrive in the LIMS within seconds.

15. Pre-NPEx Request From
Example of current hand written request from – patient data removed. Hand written, hard to decipher clinical details and test requests, easy to make mistakes and miss requests and will take a long time to book this in.

16. New NPEx Form
Example of NPEx form – using a test patient. Easy on the eye, clean, well formatted.

17. Benefits to Referring Lab
Reduced time spent preparing send away lists.
Original request forms may not be required.
Full audit trail.
Elimination of result transcription errors.
Large reduction in turnaround time.
Cost savings – result entry.
Time taken to enter results per day
Time saved yearly
Staff grade entering results
Cost Saving – based on midpoint of £16,210/£30, pay scale.
1 hour
261 hours
Band 6
£4,022
2 hours
522 hours
£8,044

18. Benefits to Performing Lab
No transcription errors of patient, location, clinical details or tests.
Clinical details arrive in electronic message (if entered).
Reduced clinical and management time spent dealing with errors and ad hoc enquiries.
Reduction in training time and request entry time (based on approx. 45 seconds saving per request).
No of requests sent daily
Time saved daily
Time saved per year
Cost saving – based on midpoint of Band 2, £16, pay scale. 20
15 min
62.5 hrs
£519 50
37.5 min
156 hrs
£1296
100
75 min
312 hrs
£2592
200
150 min
624 hrs
£5185

19. NPEx Network
There are currently 47 trusts in the UK either live or in deployment to send or receive specimens through the system.
NPEx has been a success for CMFT and we currently account for around 60% of all national test traffic.
Thus enhancing pre-existing specimen and result transfers with users.

20. Weekly volume across all sites on NPEx (Feb 2015 top 20 tests)
Total weekly volume
Antibody to tissue transglutaminase for coeliac disease
654
Antinuclear antibody
588
Vitamin D measurement
268
Total IgE
226
PCR for Chlamydia trachomatis
221
Anti DNA antibodies
167
Autoantibody screen
150
Cytoplasmic ANCA screen
125
ACCP
121
Extractable nuclear antigens
115
Drugs of abuse urine screening 99
Aspergillus IgE specific allergen 92
ANCA pattern 80
Aspergillus IgG specific allergen
CD4 cell numbers 78
Anti cardiolipin antibodies 66
Thyroid peroxidase antibodies 61
House dust mite IgE specific allergen
Serum free light chain measurement 58
Rheumatoid factor 50
The table illustrates that the specimens currently being sent over NPEx are all specialist tests.

21. Turn Around Times
The biggest benefits of the system are dramatically improved turn around times (TAT) and reduced error rates and incidents.
When Trafford Hospital became partners with the MRI, they re-directed work to Immunology that was previously sent to three other sites.

22. Turn Around Times
B2 microglobulin – Wythenshawe TAT 168hrs, MRI Immunology TAT 43 hours.
Thyroid peroxidase antibodies – SRFT TAT 221 hours, MRI Immunology TAT 66 hours.
Vitamin D – Paper requests 346 hours, NPEx 182 hours (both figures MRI Biochemistry).
Three examples of which are shown with their TAT data.
Samples still sent by transport between trusts. May be differences in how often tests are performed, but the third point clearly demonstrates the difference between getting a result electronically or on paper,

23. Testimony
“One of the biggest areas of improvement has been the amount of time it takes staff to deal with problems. We can see immediately where there is an issue by logging on to the system, the reference labs send back an immediate notification regarding problem specimens. Missing results can be tracked down far quicker (we have the reference lab number), and the best bit is we have a full audit trail.”
Scott Bowden (Senior BMS at Biochemistry Trafford).

24. Testimony
Respiratory Consultant who deals with the asthma cases at Royal Bolton - "this is extremely useful and will make our lives much easier ! "  She previously used to give a 6 week follow up appointment to make sure the results were back – this has now been reduced.
The Haematologists are pleased  that they no longer have to trail through paper reports when following through the Light Chain results.
Information provided by Tina Tennent (Senior BMS at Royal Bolton Hospital).

25. Success in Gr. Manchester
Current workload figures for September 2015:
SHH have performed 1,179 tests so far.
Biochemistry at MRI currently receive over 200 and send out over 150 specimens a week.
Biochemistry at Wythenshawe perform over 500 tests via NPEx weekly.
Tameside Microbiology carry out nearly 350 tests a week.
Salford Royal Biochemistry have carried out 809 tests this month.
Immunology MRI = 13,217 in September. September NPEx total = 25,638.

26. Disadvantages
Reliance on system and internet connection – alerting mechanism required when issues arise.
Not suitable for all disciplines in current format e.g. Micro results are text.
Problems reporting qualitative results between LIMS.
Cost – support fee and staff resource for config – essential.
Change management – need to inform users of report changes and amended reports.
Servers down recently at MRI – went back to paper requesting using Shipping Manifest with no detrimental effect to the service.

27. Advantages Improved overall quality – full audit trail.
Utilities unique PID, improved data quality.
Reduced transcription errors.
Decreased TAT.
Reduced staff time for booking-in and resulting specimens – no duplication.
Paperless real-time electronic reporting.
NPEx software easy to use and set up.
Seamless process within LIMS.

28. What Next?
The question is why NPEx has not been implemented more widely across the UK?
Was funding from Greater Manchester Pathology Network key to achieving this locally?
Resource issues within labs?
Fear of change?

29. Future Developments
National Laboratory Medical Catalogue and ISO compliance.
NEQAS – Birmingham intend to proceed.
Ensuring a robust and stable system as users grow.
Improved usability; more interactive and improved stats.
Development of Microbiology.

30. Conclusions
The NPEx service is available to all NHS pathology labs in the UK at no cost other than a support fee.
Biggest success in reducing TATs, errors and costs.
Has instigated a successful change in process in labs across Greater Manchester.
More suited to specialist labs/tests.

31. Thank You
Neil McAuley – Acting Service Manager, Biochemistry, Pennine Acute Trust.
George Fielding – Operational Manager, Blood Sciences, Stepping Hill Hospital.
Joy McHugh – Senior BMS, Haematology, University Hospital South Manchester.
Tina Tennant – Senior BMS, Biochemistry, Royal Bolton Hospital.
Scott Bowden – Senior BMS, Biochemistry, Trafford General Hospital.
Sandra Cunliffe – Senior BMS, Immunology, Salford Royal Foundation Trust.

32. Questions Questions? Useful links: www.x-labsystems.co.uk