New Feature - Using PatientChase to conduct chronic disease reviews via email - A customer case study

4th Nov 2020

We thought we’d share how one of our practices is using PatientChase’s existing functionally to conduct partial reviews using 2-way emailing of patients.

With this in mind, we’ve made this process even slicker in our newest version, details of which can be found at the end of this blog.



Alka Sethi, PM, Park Road Surgery, Surrey.

In the new world we are in we are facing new ways of managing our QOF patients.

As with all practices, we have to adapt to new ways of working, so we’ve modified the order in which we contact QOF patients:

Email -> Telephone -> Face to Face

Naturally, we have to also be mindful of the patient’s ability to manage technology and go down the hierarchy accordingly based on this flow.

So we’ve started to use PatientChase’s built in functionality to email patients where we can. Using this method we’re sending condition specific questionnaires for our patients to complete which the patient can then return via email. At the very least this means some or all of their reviews are being conducted remotely and easily.

The software has always personalised the letters to patients based on the condition/s the patient has and also for each outstanding target, so we’ve found it easy to adapt this to emails. In essence we’re contacting the patient the fewest times necessary (even if they are a co-morbidity patient), supplying them with condition/s specific information and web links and collecting information from them by reply (such as blood pressure and peak flow readings).

The idea is that one email goes out to the patient with all their relevant conditions, questions and information listed and their reply delegated accordingly within the surgery.

This is an example of how PatientChase generates personalised emails to patients with entries specific to the conditions they have.  Notice it mentions blood pressure readings and advice as the patient has hypertension and also refers to asthma forms as they have asthma.


Workflow and Outlook

With all this information coming into the surgery we developed a workflow to help delegate and reply to emails accordingly.

Outlook is perfect for storing replies from patients and delegating emails to staff members.

We created folders depending on how we manage staff in our surgery. Each folder represents a worklist for the staff to work on.

Modifying the PatientChase email template.

We created just one email per patient by merging together items which shared similarities across clinical domains but at the same time added text which we wanted to know about based on the patient’s conditions (such as in the example email above). For example text around MRC for COPD and Asthma Control and Action Plan should only be included in the email for patients who have these conditions. This is where we found PatientChase exceled. Some minor modifications to merge fields in the email template meant the algorithms of PatientChase populated each email with specific questions and information.

Actioning replies.

The clinician actions the email from the patient and has a conversation with them about their condition explaining via for example web links to show them inhaler techniques or how to take their blood pressure properly. Once the clinician is happy with the review, they can record this in EMIS themselves via EMIS Templates or move the message to the ForCoding folder to be actioned by admin.

Its early days, but the data we’re collecting from patients thus far has been excellent. While it is true that QOF patients tend to be more elderly, but you’d be surprised how many tech savvy ones are out there!

Alka Sethi, Oct 2020


Update from the PatientChase Team

Preparing PatientChase.

To make it easier for other practices to implement this, we’ve automatically created pre-prepared settings for you. Go to Advanced->Options and click on the check box which activates our email feature. Should you wish to revert to your original settings for letters, click Swap Media File again.

In creating the email we are looking to create just one email per patient by merging together items which share similarities across clinical domains but at the same time add text which we’d like to know about (based on the patient’s conditions). For example, text around MRC for COPD and Asthma Control and Action Plan should only be included for only patients who have these conditions. This is where PatientChase excels.

The concept of modifying your email template is the same as sending letters. PatientChase’s algorithms will personalise information to each patient depending on the conditions they have.

However with this virtual QOF review approach, you’re asking patients to supply specific information. So make the merge fields request this information.


The email template.

In the latest version of PatientChase we’ve included a sample email template for you to use. Go to Admin>Edit >Letters and open the file called AnnualReviewViaEmail.html. This is what was used by Alka’s surgery (see above).

It’s preferable to deal in html when creating the letter rather than docx. There are several free html editors which you can use to modify the template.

The concept is there are several basic bits of information which we need for all patients for example smoking status but we also need to include text specific to their condition.

Don’t use images if you can. They can also make your email appear as spam as it is pulling data from a separate source.

Modifying the merge fields.

In the Prose section (Admin>Edit>Prose) change all the text for the register searches just to the name of the condition. For example, change You have a history of a heart related condition to Coronary Heart Disease.

The conditions merge field on the email template should be [ConditionsInOneLine] which will list the conditions the patients has on one line (see email example above).

For the targets merge field [Text] only include text specific to the condition, for example asking a patient for their MRC score if they have COPD or give them web links for the Asthma Action Plan to fill in if they have Asthma (see email example above). All the other fields you can put the word [null] to ensure that any text representing this target will not be displayed. These suggestions have already been implemented via the 'Swap Media' function. Edit how you wish.


In the Investigations section (Admin>Edit>Investigations) include text around the patient needing to record the Blood Pressure if required and also which blood tests are required for which condition. We tend to use the same text to keep it simple and if you do this PatientChase will merge the sentence so it just appears once. These suggestions have already been implemented via the 'Swap Media' function. Edit how you wish.

Non virtual items.

There are a few potential non virtual items which need to be managed.

Blood tests

In some areas patients can go directly to the hospital without the need for a physical form so long as they include their NHS number and a form of photo ID. Check if your local area offers this and while sending the email out create the blood form. If this is not the case this can be picked up from the surgery prior to the email review with urine if required.

Blood pressures

Patients who need their blood pressure done should be encouraged to obtain a blood pressure machine and take it at home with the correct instructions. Please refer to this excellent guide

Peak flows

Again please encourage patients with Asthma to use their own peak flow meters and they will need it to know how to manage their Asthma within their Action Plans.

The most useful and user friendly software that I have encountered in over 30 years of working with management systems.

Cheryl Barton, Data Manager – Bramblys Grange Medical Practice, Hampshire

I am so glad that we as a practice have purchased PatientChase – it has completely revamped our recall system, has been invaluable during flu recall season and more importantly shows us where the ‘holes’ are when we get to near the end of the QoF year. Many thanks!

Jackie Hogg, Clinical Data Manager – The Baffins Surgery, Portsmouth

PatientChase is an excellent product of which I think as soon as you purchase it you will ask yourself ‘how ever did I cope without it?!

Rachel Mardlin, Health Informatics Facilitator – Sheffield University Health

This product will make my QOF staff member’s job so much simpler and is a quarter of a QOF point for me

GP, Newcastle

This is exactly what we’ve been looking for

PM, Cambridge

PatientChase is extremely user friendly and the support provided by PatientChase has been excellent

Practice Administrator, Otley

By using PatientChase, what would normally have taken half a day has just taken 10 minutes!

GP QOF Lead, North Wales

We use PatientChase and find it invaluable, it saves a lot of time and helps us organise our work effectively

Sue Careswell, Leckhampton Surgery

As a practice we have relied upon PatientChase to streamline our patient recall system for several years now. I consider this an essential tool

Karen Walsh, Chilcote Surgery

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Dr. Raza Toosy

Dr. Raza Toosy

Raza is a current partner of a GP practice in Wallington, Surrey. He has had a passion for IT for all of his life and obtained an MScIT in Kingston University with Distinction in 2008 whilst still working as a GP. With his knowledge of both medicine and information technology his focus and vision is to create a line of business applications for GP surgeries and has been actively involved in the development of PatientChase and now PatientLeaf since 2005 using the .Net Framework. He's always wanted to improve the way clinicians access and view data to make their lives easier.

Dr. Raza Toosy

Richard Chmielowski

With qualifications in business and marketing and having previously held managerial roles in both primary and secondary care, Richard Chmielowski is co-founder of GPSS. Passionate about helping primary care staff manage their patients in the best way possible, Richard is involved in many of the customer facing aspects of delivering IT solutions.