Proactive Monitoring, Intelligent Recall

Never miss a patient.

Integrated with SystmOne and EMIS

Surface anyone overdue a test, review or vaccination
Recall them automatically
Save time, optimise resources and maximise revenue

Book a demo How it works

600+live practices

7.5M+patients monitored

300+PCNs

36/36ICBs

Proactive Monitoring

Searches last ran: today

Medication Condition Complete 12 Opportunistic 5 Overdue 27

NHS number	Age	Status	Days overdue	Most overdue task
••• ••• 446	45	Overdue	52	Renal Profile · ACE-I/ARBs
••• ••• 948	13	Opportunistic	25	HPV Vaccine · HPV Vaccination
••• ••• 776	41	Overdue	38	COPD review · COPD
••• ••• 668	53	Complete	0	Full Blood Count · Heart Failure
••• ••• 556	88	Opportunistic	25	Lipid profile
••• ••• 968	28	Overdue	27	LFT · Azathioprine

Patient · ••• ••• 44645 · Type 2 diabetes, CKD stage 3

3 overdue5 due soon

Blood pressureOverdue

Pulse rhythmDue soon

Body mass indexComplete

WeightComplete

Renal profileOverdue

HbA1cOverdue

Full blood countDue soon

Thyroid function testDue soon

Lipid / cholesterolComplete

Breast cancer screeningDeclined

CAT · COPD assessmentDue soon

Alcohol intake (mental health)Due soon

Smoking statusComplete

EthnicityComplete

All registers Suggestions 14 Corrected 12

NHS number	Suggested correction	Action
••• ••• 446	Missing asthma register entry
••• ••• 219	Historical BP reading not coded
••• ••• 882	Possible undiagnosed diabetes
••• ••• 134	QOF: BP target not coded
••• ••• 770	CKD stage not recorded
••• ••• 503	Smoking status not recorded

Quick & easy

recall & self-book

Personalised care at Population Scale

Manual recall does not scale with multimorbidity.

People are living longer with more conditions, and spreadsheet-driven recall leaves gaps. The cost of missed monitoring shows up in both lives and lost income.

~30%

// of patients on high-risk drugs are overdue their monitoring

£40k

// QOF, IIF and case-finding income at risk each year

300+

// medication & monitoring actions overdue at any one time

* Illustrative estimates for a typical 9,000-patient practice. Your figures will vary.

How it works

System of record action.

Your clinical system records what happens. Abtrace acts on it, lifting complex, repetitive clinical work off people and handing it to clinical-grade, regulated software that runs safely against the live record every day. One tool the whole team can use, doing the work automatically.

Doctors

Manage chronic disease in one sitting

See everything a patient is due and action it in the same visit, whatever they came in for.

Administrators

A global overview of patient care

Pull prioritised lists, automate recall and send self-booking links, protecting QOF revenue well before year end.

Pharmacists

Repeat prescriptions in one panel

Manage repeat prescriptions in one panel and keep drug monitoring safe and up to date.

Nurses & HCAs

Act without waiting on a GP

See what each patient needs and message them directly, no GP sign-off required.

Reads

Analysing the full patient record

Sits on top of EMIS and SystmOne, reading the live record and writing back in real time.

Acts

Does the work for you

Finds who needs care and recalls, books and monitors them automatically, turning manual work into software.

Scales

From one practice to a whole ICB

The same tool that helps a single site now runs across 300+ PCNs and all 36 ICBs.

Explore the product →

Proven in primary care

Results GP practices can measure.

Outcomes reported by practices and PCNs running Abtrace Proactive Monitoring across long-term conditions, medication monitoring and recall.

80%

of recalled patients had their blood pressure updated within 4 weeks

// Hypertension case study →

37%

reduction in healthcare assistant (HCA) appointment use whilst maintaining monitoring levels

// SBRI Healthcare evaluation

+75%

CKD005 QOF revenue, year on year

// QOF register case study →

84 of 90

patients messaged and coded the next day

// Medication-safety case study →

From the front line

What practice teams tell us.

HCAs, pharmacists, practice managers and GPs use Abtrace every day. Here is what they say it changes.

“Staff are raving about Abtrace, just a fantastic addition. Our HCAs and pharmacists are making a huge difference to patient care with it. A massive game changer, thanks to the visual presentation, data recording and the population tool for our LTC manager.”

GP Partner

“It has saved my practice over 15 hours a week in admin time. The recall process essentially runs itself now, and nothing slips through.”

Practice Manager

Video

Proactive monitoring for smarter primary care

See how practice teams find, recall and monitor patients with long-term conditions, without leaving EMIS or SystmOne.

Play video

The bigger picture

A $10 trillion market, still run on disconnected records.

Your practice isn't the only place this breaks. Across the whole system, payors, providers and patients each sit on separate, legacy systems of record that store data but never act on it. Abtrace is building the system of action for care operations, and primary care is where it starts.

$10Trn

// global care market still run on legacy, disconnected systems of record

~70%

// of health costs come from chronic disease, the care that needs constant monitoring

5 hrs

// a day clinicians lose inside the EHR instead of with patients

FAQ

Common questions

What is Abtrace?

Abtrace is a Proactive Monitoring and Intelligent Recall tool for NHS primary care. It reads your clinical record every day, finds the patients who are due or overdue a test, review or vaccination, recalls them automatically with self-booking, and helps your team keep monitoring, coding and QOF up to date, all inside EMIS or SystmOne.

Who is it for?

The whole practice, really. Abtrace is built for everyone involved in patient care: GPs managing chronic disease in a single visit, administrators running recall and protecting QOF, receptionists acting on what a patient is due the moment they call or come to the desk, pharmacists handling repeat prescriptions and drug monitoring, and nurses and HCAs who can see what each patient needs and act without waiting on a GP. It works for a single practice or across a whole PCN or ICB.

Which clinical systems does Abtrace work with?

Abtrace integrates directly with EMIS Web and TPP SystmOne, the clinical systems used by almost every GP practice in England. It reads and writes back to the record in real time, so there is no new system to learn and no data migration.

What does Abtrace help with?

Case-finding, automated recall with self-booking, live monitoring dashboards, one-click SNOMED coding correction, automated blood-test forms, a patient portal and performance analytics. Daily smart searches keep your QOF and IIF registers, CQC evidence and local enhanced services (LCS) continuously up to date, and long-term condition and high-risk drug monitoring on track.

Is Abtrace clinically validated and regulated?

Yes. Abtrace is a UKCA-marked medical device, NHS Digital approved, and independently certified to ISO 27001 (information security) and ISO 13485 (medical device quality management).

Is our patient data secure?

Yes. Abtrace is UK GDPR compliant, completes the NHS Data Security and Protection Toolkit and holds Cyber Essentials Plus. Your data stays within your practice's own governance under a data-sharing agreement and DPA, is stored in the UK, and is never shared with third parties.

How is Abtrace bought and funded?

Abtrace is available through NHS-friendly procurement, including the Crown Commercial Service G-Cloud framework, and can be adopted by a single practice or funded at PCN or ICB level. We will help you find the right route during your demo.

How do we get started?

Book a 30-minute demo and we will show you how Abtrace fits your clinical system and your team, and what it could mean for your practice, PCN or ICB. Because it runs on your existing record, there is no data migration and onboarding is quick.