Chronic Condition Hub

Manual Recalls Are Broken

Most practices manage chronic condition recalls through a patchwork of EMIS searches, spreadsheets, and manual processes. The result? Patients fall through the gaps, staff burn hours on admin, and blood tests are ordered multiple times for the same patient.

• Fragmented Tracking — Each condition managed through separate lists and spreadsheets with no unified view
• Patients Missed — Without systematic recall, patients with multiple conditions slip through the gaps
• Redundant Blood Tests — The same patient gets called in multiple times for tests that overlap across conditions
• Inconsistent Cycles — No standard approach to when patients are recalled or how often
• No Multi-Condition Awareness — Systems treat each condition in isolation, not the whole patient
• Admin Burden — Staff spend hours searching, texting, following up, and manually tracking responses

A Smarter Way to Manage Recalls

Birth Month Recall Scheduling

Every patient is assigned their recall month based on their birth month. This distributes your workload evenly across the year — no more end-of-quarter rushes or forgotten cohorts.

Invitations are sent 7 days before a patient's birth month to give them time to book their blood test or appointment within the correct window.

3-Stage Recall Funnel — The 35-Day Cycle

Every patient progresses through a structured 35-day recall cycle tied to their birth month. The system manages the entire timeline automatically.

Intelligent Message Routing

The CCH determines exactly which message each patient receives based on their conditions, medications, and what clinical actions are needed. Patients with multiple conditions receive one message — the one matching their highest intervention need.

Automatic Completion Triggers

When a patient completes their blood test, has their BP recorded, or attends their review, the system detects this automatically via EMIS Web and marks the recall as complete. No manual ticking off required.

• Blood test results landing in EMIS
• BP and physical observations recorded
• Review SNOMED codes applied by clinicians
• Structured medication review completion
• ECG results for relevant medications

20 Chronic Conditions. One Unified System.

Every major QOF condition covered, with condition-specific recall frequencies and completion triggers.

Average 2.9 conditions per patient. Up to 12 conditions managed simultaneously for complex patients.

22 Monitored Medications

High-risk and long-term medications tracked with clinically defined monitoring frequencies.

When a patient takes multiple monitored medications, the highest frequency wins — ensuring they're never under-monitored.

26,000+ Redundant Blood Tests Eliminated Per Year

When a patient has multiple conditions — say Diabetes, CKD, and Hypertension — each condition may require overlapping blood tests. Without deduplication, the same patient gets called in three separate times for tests that could be done in one visit.

Deduplication Examples

ICE Clinical Detail Templates

Each ICE order includes pre-populated clinical details in the text box to guide the reviewing clinician:

Smart Scheduling for Every Patient

While most patients follow annual birth-month cycles, some high-risk patients or specific medications require more frequent monitoring. The CCH handles both seamlessly.

• Annual Recalls — Standard birth-month scheduling for routine chronic condition reviews
• 6-Monthly Cycles — Diabetes interim reviews, Diuretics, Aldosterone antagonists, ADHD medications, DOACs (moderate renal impairment)
• 3-Monthly Cycles — CKD Stage 5, Lithium, Methotrexate/DMARDs, Carbimazole, DOACs (severe renal impairment)
• Multi-Condition Merging — When a patient is due for multiple reviews, they're combined into one recall event
• Highest Frequency Wins — A patient on both annual and 3-monthly cycles gets the 3-monthly schedule
• Workload Balancing — Even distribution across the year prevents bottlenecks and Q4 rushes

Uses the Systems You Already Have

The CCH is designed to work with the tools your practice already uses — no new software to install, no new logins for your team.

Safety & Compliance

DCB 0129 Compliant

The Chronic Condition Hub has a formal Clinical Safety Case Report (CSCR) and Hazard Log maintained under the DCB 0129 standard — the NHS standard for clinical risk management of health IT systems.

Conservative by Design

• Human-in-the-Loop — Stage 3 of the recall funnel always involves a human making the final contact. The system never replaces clinical judgement.
• No Clinical Decisions — The CCH manages scheduling and communication. All clinical decisions remain with the GP or clinician.
• Manual Review Safety Nets — Any patient the system cannot safely process is escalated to a manual review list for practice staff.
• Full Audit Trail — Every recall action, SMS sent, blood test ordered, and completion trigger is logged for clinical governance.
• Partial Observation Detection — If a condition requires multiple observations and only some are recorded, the patient is flagged rather than auto-completed.
• Age-Based Routing — Under-16 patients with complex conditions are removed from automated messaging and flagged for age-appropriate contact.

Bespoke Pricing for Your Practice