Our philosophy for building AI is: accurate, transparent, and comprehensive.

We've trained our algorithm to understand the following guidelines on investigation frequencies for long-term conditions and high-risk medication monitoring:

• QOF
• CQC
• NICE
• SPS
• NHSE
• BNF
• BSG
• MHRA

Our AI is designed to suggest recall for all investigations a patient is due at any point in time, kept updated as the record evolves. We suggest recall:

• 2 weeks before it's overdue if the investigation frequency is ≤3 months
• 1 month before it's overdue if the investigation frequency is >3 months

This ensures every blood test requested is the most comprehensive and accurate for the patient. It moves us towards full automation of proactive care plans for every patient.

Here are full lists of our logic, in alphabetical order of the indicator we use (medication or condition):

High-Risk Medications Monitoring

• ACE / ARB = Renal Function every 12 months
• ADHD meds (Methylphenidate, Lisdexamfetamine, Dexamfetamine, Atomexitine, Guanfacine) = BMI & BP every 6 months
• Allopurinol = Urate every 12 months
• Aminosalicylates (5-ASA - Mesalazine, Olsalazine, Balsalazide, Sulfasalazine) = Renal Function every 12 months
• Amiodarone = LFT, Magnesium, Renal Function & TFT every 6 months
• Antipsychotics (1st Gen, Risperidone, Paliperidone, Amisulpride, Lurasidone) = Prolactin every 12 months
• Antipsychotics (All) = BMI, FBC, HbA1c, LFT, Lipids & Renal Function every 12 months
• Azathioprine = FBC, LFT & Renal Function every 3 months
• Azithromycin = LFT every 6 months
• Carbimazole = TFT every 3 months
• Ciclosporin = BP, HbA1c, LFT, FBC & Renal Function every 1 month
• Corticosteroids (Oral) = HbA1c every 3 months. BMI, Lipids & Renal Function every 12 months.
• Denosumab = Calcium, Renal Function & Vitamin D every 6 months
• Digoxin = Calcium, Magnesium & Renal Function every 12 months
• Diuretics = Renal Function every 6 months
• DOAC = BMI & BP every 12 months. FBC, LFT & Renal Function at varying frequencies depending on CrCl & frailty*
• Dronedarone = LFT & Renal Function every 6 months
• Febuxostat = Urate every 12 months
• Hydroxycarbamide = FBC, LFT, Renal Function & Urate every 3 months
• Leflumonide = BMI, BP, FBC, LFT & Renal Function every 3 months
• Levothyroxine = TFT every 12 months
• Lithium = Lithium Level at varying frequencies depending on patient age, drug interactions, elevated calcium, latest lithium concentration & pregnancy**
• Lithium = BMI, Calcium, Renal Function & TFT every 6 months
• Mercaptopurine = FBC, LFT & Renal Function every 3 months
• Metformin = Renal Function every 12 months
• Methotrexate = FBC, LFT & Renal Function every 3 months, and every 1 month in the first 6 months of prescription
• Minocycline (6th month onwards) = LFT every 3 months
• Mirabegron = BP every 12 months
• Mycophenolate = FBC, LFT & Renal Function every 3 months
• Penicillamine = FBC, LFT & Renal Function every 3 months
• Phenytoin = Calcium, FBC, LFT, Renal Function & Vitamin D every 5 years
• Propylthiouracil = TFT every 3 months
• Riluzole = FBC & LFT every 12 months
• Roflumilast = BMI every 12 months
• Statins = LFT & Lipids every 12 months, and within 3 months on initiation
• Sulfasalazine (1st year) = FBC, LFT & Renal Function every 3 months
• Sulfasalazine (2nd year onwards) = FBC, LFT & Renal Function every 12 months
• Tacrolimus = BP every 3 months
• Testosterone = FBC, Lipids, LFT & Testosterone Level every 12 months
• Testosterone (male >45 years old) = PSA every 12 months
• Theophylline = Theophylline Level every 12 months
• Valproate = BMI, FBC & LFT every 12 months
• Warfarin = INR at varying frequencies depending on the last INR result***

Long-term conditions

• Anaemia = FBC at variable frequencies.****
• Atrial Fibrillation = BMI every 12 months
• Asthma = ACT & Smoking Status every 12 months
• CHD = BMI, BP, HbA1c, LFT, Lipids, Renal Function & Smoking Status every 12 months
• CKD (All) = BMI, BP & Lipids every 12 months
• CKD 1+ = Renal Function & uACR at varying frequencies depending on their last GFR and ACR results in accordance with NICE NG203 and NICE CKS*****
• CKD 3+ = FBC, LFT & Lipids every 12 months
• Coeliac = B12, Calcium, Coeliac Serology, FBC, Folate, LFT, Renal Function, TFT & Vitamin D every 12 months
• COCP = BMI & BP every 12 months
• COPD = Smoking Status every 12 months
• Diabetes (All) = BP & Smoking Status every 12 months
• Diabetes (Gestational) = HbA1c every 12 months
• Diabetes (T1) = HbA1c every 6 months and Lipids, Renal Function & uACR every 12 months
• Diabetes (T2) = HbA1c, Lipids, Renal Function & uACR every 12 months. HbA1c every 3 months if last result was ≥ 58 mmol/mol (not frail) or ≥ 75 mmol/mol (frail patient)
• Down's Syndrome = TFT every 12 months
• Frailty = BMI every 12 months
• Heart Failure = BMI, BP & Renal Function every 6 months
• Hypertension = BMI, BP & Renal Function every 12 months. BP every 3 months if patient is above target range. Hypertension patients without DM or NHD, but with QDiabetes >=5.5% or Leicester Risk Score >=16 also get HbA1c every 12 months.
• Hyperthyroidism = TFT every 12 months. TFT every 3 months if last result was < 0.38 mU/L or > 5.5 mU/L.
• Hypothyroidism = BMI & TFT every 12 months. TFT every 3 months if last result was < 0.38 mU/L or > 5.5 mU/L.
• NDH = HbA1c every 12 months
• Peripheral Arterial disease = BMI, BP, LFT & Lipids every 12 months
• Prostate cancer primary care coded = PSA every 6 months
• SMI (bipolar, psychotic disorders, schizophrenia) = BMI, BP, FBC, HbA1c, LFT, Lipids & Renal Function every 12 months
• Stroke / TIA = BMI, BP, LFT & Lipids every 12 months

* DOAC variable frequencies

FBC, LFT & UE are due:

• Every 1 month for the first 6 months of prescription
• Every 2 months when CrCl is 15-24
• Every 3 months when CrCl is 25-34
• Every 4 months when CrCl is 35-44 or frail or ≥ 75 years old
• Every 5 months when CrCl is 45-54 & not frail & not ≥ 75 years old
• Every 6 months when CrCl is 55-59 & not frail & not ≥ 75 years old
• Every 12 months when CrCl is 0-14 or 60+ & not frail & not ≥ 75 years old

** Lithium variable frequencies

If any of the following apply, Lithium Level is due every 3 months:

• Age 65+
• Pregnant
• Elevated calcium (> 2.6mmol/L)
• Latest lithium concentration ≥ 0.8 mmol/l
• Drugs (Diuretrics, NSAIDs, Haloperidol, Carbamazepine, Dapagliflozin, Antidepressants or ACE Inhibitors)

If none apply, Lithium Level is due every 6 months.

*** Warfarin variable frequencies

If last INR result is ≥ 5, INR is due every 2 weeks. If last INR result is < 5, INR is due every 3 months. We exclude patients who are coded as being monitored by the hospital.

**** Anaemia variable frequencies

• Latest Hb <70 → 2 weekly (BSH principles)
• Latest Hb 70-threshold → 4 weekly (NICE CKS IDA 2021, NICE NG231 2024; NICE CKS B12/folate 2024)
• Any Anaemia (coded anaemia of any kind; also infer IDA where low Hb and iron prescription as poor national coding)
• • Latest Hb threshold–normal → 3 monthly (NICE CKS IDA 2021)
• Coded IDA
• • Latest Hb normal <12 months since remission → 3-monthly (BSG 2021; NICE CKS IDA 2021)
  • 12–36 months since remission → 6-monthly (BSG 2021)
  • >36 months since remission → none
• Coded Non IDA
• • Latest Hb normal → none (NICE NG231 2024; NICE CKS B12/folate 2024)

"Normal" = Male Hb ≥130 g/L, female non-pregnant ≥120 g/L, female pregnant ≥110 g/L.

"Threshold" = 20 below the normal level

"Remission" = Date of first normal Hb following the most recent abnormal Hb result

***** CKD 1+ variable frequencies

Planner follows this table of frequencies in NICE NG203, which depends on the last GFR and ACR results. If there is no eGFR or no uACR result on record, it is due immediately.

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