Running Guideline Evaluations
A guideline evaluation runs a set of clinical rules against a population of patients in your business unit. You can run evaluations in Report mode to analyze results without creating tasks, or in Active mode to trigger real prior-authorization workflows.
GoldCard configs are different: they do not use Play / Run Guideline from the list or detail page. Matching and proactive prior authorization for GoldCard run automatically on a schedule for enabled configs. Use Guideline Configuration to create or edit the GoldCard; then rely on the scheduled run rather than a manual evaluation dialog.
Triggering an Evaluation
You can trigger an evaluation from the guideline’s detail page or from a patient’s chart (wherever the Run Guideline button appears). Standard guidelines, exclusions (where applicable), and Therapeutic Interchange configs support this path; GoldCard configs do not show Play / Run on the Guidelines list.
- Open the guideline you want to evaluate.
- Click Run Guideline. A dialog opens.
Evaluation Mode
Select one of:
- Active — the evaluation runs live. For standard guidelines, patients who meet the criteria generate prior-authorization tasks, and contact with prescribers, patients, and pharmacies occurs according to the guideline’s contact settings. For Therapeutic Interchange guidelines, matching patients receive conversion outreach letters (member, prescriber, and optionally pharmacy) instead of PA tasks.
- Report — the evaluation runs in analysis mode only. No tasks are created and no outreach is sent. Use this to preview which patients would be affected before committing to an Active run.
Evaluation Type
Evaluation Type applies to standard guidelines only. Therapeutic Interchange runs do not show this control — interchange matching is based on the source drug and conversion rules, not PA initiation or continuation routing.
For standard guidelines, select one of:
- Auto — the system detects from each patient’s claim evidence whether initiation or continuation rules apply. Use this for population-wide runs. Patients already on current therapy may be skipped for initiation (rules not run); see Not Evaluated on the evaluation results page.
- Initiation — evaluates only the initiation rules. Suitable for patients who are starting therapy.
- Continuation — evaluates only the continuation rules. Suitable for patients who are already on the medication and approaching a renewal.
When Auto is selected, patients on current therapy are typically skipped for initiation unless you switch to Initiation and enable Force evaluation (ignore PA and therapy requirements). Force evaluation is also hidden for Therapeutic Interchange runs.
Contact Settings (Active mode only)
When you select Active mode, additional dropdowns appear for Prescriber Contact, Patient Contact, and Pharmacy Contact. These override the guideline’s default contact settings for this run only.
For Therapeutic Interchange guidelines, a Send conversion outreach to pharmacy checkbox appears above the contact dropdowns. Leave it unchecked (the default) unless pharmacy NPIs are reliably available for this population. When you check it, the Pharmacy Contact dropdown becomes available so you can choose automatic or manual pharmacy outreach. Pharmacy letters are sent only when a dispensing pharmacy NPI is available from the matched source-medication claims; if no claim for the source drug carries a pharmacy NPI, the pharmacy letter is skipped automatically for that patient.
Also evaluate other indications
If the guideline targets a drug with multiple indications, you can check Also evaluate other indications for the same drug to include all related guidelines in a single multi-guideline evaluation.
Click Run to start the evaluation.
Viewing Batch Evaluations
All evaluations — past and in progress — are visible at Settings → Guideline Evaluations.
The table shows:
| Column | What it tells you |
|---|---|
| Status | Pending / Running / Completed / Failed |
| Guideline | The guideline that was evaluated (links to the guideline detail) |
| Mode | Report or Live |
| Created | When the evaluation was triggered |
| Completed | When it finished |
Click any row to open the evaluation’s detail page.
Monitoring Evaluation Progress
A running evaluation shows a progress bar in the Status column. The bar fills as the system processes patients. For large populations this may take several minutes.
Refresh the page or wait — the table updates automatically when the evaluation completes.
Reviewing Patient Results
Open a completed evaluation to see the full results.
Standard guidelines
Summary cards show totals including Not Evaluated (patients whose rules were skipped, e.g. on current therapy in Auto mode), Initiation Matches, Initiation Rejections, Continue Therapy, Discontinue Therapy, Current Therapy, Data Requests, and Tasks Created.
The Patient Results tabs list patients by outcome:
| Tab | What it shows |
|---|---|
| Initiation Matches | Patients who passed initiation rules |
| Continuation Matches | Patients who should continue therapy |
| Data Requests | Patients missing required data |
| Rejections | Patients who failed initiation with PA rejections |
| Not Evaluated | Patients skipped — initiation rules were not run (common when on current therapy) |
Each row shows the patient’s name (links to their chart), Current Therapy, Initiation Match, PA Rejections, and skip reason where applicable. Click a patient row to jump to their chart.
Therapeutic Interchange
Interchange results use conversion vocabulary instead of prior-authorization labels:
| Summary card | What it means |
|---|---|
| Evaluated | Sub-label: On source drug (conversion rules run) — the count of patients who were on the source drug and had conversion rules applied to them. This is the actively-evaluated population. |
| Not Evaluated | Sub-label: Not on the source drug — patients in the population who are not on the source drug. Conversion rules are not run for them. They appear in the Not Evaluated tab with the reason “Not on the source drug.” |
| Conversion Candidates | Patients who were on the source drug and passed all conversion rules |
| Not Eligible | Patients who were on the source drug but failed the conversion rules |
| On Source Drug | Members currently on the source drug (equals Evaluated + Not Eligible + Conversion Candidates combined) |
| Tasks Created | Conversion parent tasks created in Active mode (zero in Report mode) |
Continuation and Data Requests cards do not appear — interchange does not evaluate continuation therapy and does not create data-request tasks.
Configuration cards also differ: Evaluation Type and Force Initiation are hidden. Pharmacy Outreach shows whether pharmacy conversion letters were enabled for the run (Not enabled / no letters sent when the pharmacy checkbox was left unchecked).
The Patient Results tabs are:
| Tab | What it shows |
|---|---|
| Conversion Candidates | Patients who qualify for conversion (on source drug, rules passed) |
| Not Eligible | Patients who did not qualify (on source drug, rules failed) |
| Not Evaluated | Patients not on the source drug — conversion rules were not run for them |
Each row in the Not Evaluated tab displays the reason “Not on the source drug” (not a skip due to PA or therapy requirements). Each row in the Conversion Candidates and Not Eligible tabs shows On Source Drug and Candidate instead of Current Therapy / Initiation Match. The PA Rejections column is not shown. Click a patient row to jump to their chart.