The latest panel discussion hosted by HTN explored the question of what good looks like for virtual consultations, from a technology, patient, NHS system and clinical perspective.
To bring a variety of expert insights and viewpoints to the discussion, we were joined by Dr Penny Kechagioglou, chief clinical information officer and deputy chief medical officer at University Hospitals Coventry and Warwickshire; Dr Paul Wright, GP Northenden Group Practice, deputy CD and IT clinical lead Manchester Locality, and chief clinical information officer Manchester and Trafford Local Care Organisation; Umang Patel, chief clinical information officer for Microsoft, and John Kosobucki. founder and CEO of OX.DH.
Umang: I’m a paediatrician in the NHS and work in Frimley. I also work at Microsoft as the chief clinical information officer – this centres around trying to translate what people need on the frontline and translate it backwards into a tech organisation. Equally, from the other side, it’s about understanding what the big tech organisation has that might be helpful but isn’t necessarily getting into the hands of the users quickly enough.
John: I’m the CEO and founder of Oxford Digital Health (OX.DH). We provide cloud-native solutions leveraging Microsoft’s outstanding infrastructure, along with the NHS who have also made a big commitment in that space. OX.DH works closely with clinicians and patient-facing staff to remove friction from their day-to-day lives, using the technology that we have developed at OX.DH on top of familiar Microsoft tools.
Paul: I’m a GP in Manchester where I’ve been for the past 17 years. I split my time between that and working three days a week with our locality team as deputy clinical director in IT, and working for our local care organisation as the chief clinical information officer. That means I’ve got the privilege of working across the system in Manchester and supporting implementation whilst also providing a clinical and strategic voice over the direction of travel in our locality. From a virtual consultation perspective, we’re looking at implementation in primary care, but there are also conversations happening within the locality around crisis response and hospital-at-home, as well as within the trust around virtual wards.
Penny: I’m a consultant oncologist and chief clinical information officer for University Hospitals Coventry and Warwickshire, so I’m involved in a mix of clinical practice and digital transformation. At the moment we are implementing our electronic patient record, due to go live in autumn. We’re also looking at implementing a patient portal and revamping our digital strategy. Obviously virtual consultations play a huge role in this. We have seen a great uptake of virtual consultation over the pandemic which we are wanting to leverage and learn from.
Setting the scene
Penny: First of all, we need to describe what we mean by virtual consultations – we mean an interaction between clinicians and their patients around the patient’s care, which could take place through digital means such as video conferencing or telephone. It’s about having open access for patients, so they can choose if they want this, and having the device capability and infrastructure to be able to deliver.
We have seen a great uptake of virtual consultations over the pandemic which we are wanting to leverage and learn from. It has benefits and we are measuring and evaluating those. It’s convenient, we saw a lot of joint consultations with patients and carers which can be difficult to achieve with face-to-face appointments, and we also saw financial benefits. We’re seeing improvements in patient experience and we are seeing a lot of satisfaction from staff as well. It’s about building on that and creating the right technical infrastructure to support the scaling up of virtual consultations moving forward, the continuous refinement of approach and process.
As we move beyond the pandemic, we’re seeing a lot of patients coming back into clinic seeking the face-to-face element and reaching out to the clinicians, and it’s important to bear this in mind. That’s where the challenge comes in terms of working out who the virtual approach appeals to. We need to be respectful of the fact that there may be various reasons why someone might want a face-to-face appointment; it might be a cultural need, for example, or it may be that the face-to-face interaction is what they value the most.
Paul: From a practice perspective, I think that the different dynamics and structures of general practice compared to hospital trusts means that the challenge of the virtual consultation is somewhat different. We’ve got different estates, different infrastructure and we’ve seen consultations happening through other means, which I’ve heard referred to as ‘another lane on the motorway’. As Penny said, it’s important to specify what we mean by virtual consultation, because of these other means. As a GP, my mind tends to go to the online interactions that are happening through online consult platforms, like asynchronous messaging and digital exchange of photographs. There are lots of different types of interaction and that breadth of scope of virtual consultation means that they be considered with a wider focus than just video and telephone.
We’re seeing an increased level of activity in this area across the city of Manchester. We have 83 practices, they don’t all have the same systems; a colleague of mine referred to this approach as ‘letting 100 flowers bloom and seeing which succeed’. As ever, general practice is so busy, so that is a key challenge in terms of exploring new opportunities.
We did some work around winter pressures with an external provider and video consultations, alongside the primary care model. That’s been really valuable learning and has posed some interesting, challenging and beneficial questions. They provided large numbers of video consultations as a support alongside practice.
A reflection on that from from my perspective is that, if the right estates and systems are there to provide that video consultation, it’s clearly a medium by which consultation can be transacted at scale. But it’s key that we have the infrastructure in place to support that to happen and to succeed. We also learnt a lot about the need for inclusion, as Penny raised, and the importance of thinking of it from the start. We’re rightly challenged by some of our clinicians and leading voices to address issues in terms of things like interpretation, for example; what are the challenges for someone using these virtual platforms if their first language isn’t English? There are also considerations for the longer term, in terms of infrastructure and investing in sustainable services.
John: From a supplier perspective, we’re observing similar patterns across the organisations that we’re engaging with; when COVID first started, there was that initial ‘make do and mend’ attitude and a need to have some kind of virtual consultation mechanism just to connect clinicians and patients. Now that’s evolving into an entire patient engagement model. How do you engage with patients virtually, through SMS messaging, through the NHS App, all with different capabilities for sharing voice, video, documents, files, and images? It needs to be seamless whilst you’re talking with them, rather than having to log in to separate systems to bring it all together.
When we look at one of our most recent implementations at Barnsley NHS Foundation Trust, it’s a great case study about what is possible when you’re using modern technology in a 100 percent cloud-native environment. We installed one of our components for patient engagement in the NHS national tenant and within an hour Richard Billam, deputy director of ICT, was able to install that in his local Teams channels and start test driving that capability. Within a week, we enabled an endpoint to listen to their HL7 messages, to integrate with their existing systems. We’ve continued to roll out new enhancements to use direct phone calling and file sharing with some of Microsoft’s latest technology using Azure communications services. Richard is a great reference point for discussions on how that worked practically for them, and how it drives improvement.
Umang: As a paediatrician I always thought that we’re lucky; by definition our patients are younger and their parents tend to be too, so we’re less likely to have challenges around whether they own mobile phones for reasons around lack of understanding of technology. In my clinical life, the shift towards virtual care seems very clear. However, as Paul said, we do need to think beyond where we are today in terms of what is coming next.
One of our things at Microsoft is that we build Lego bricks – we build stuff for other people to take and then put into things that are then more useful than the sum of their parts. I love seeing what’s coming out from that; being able to connect care up, from pharmacies into GP practices into hospitals, and seeing patients being able to connect with clinicians in this new hybrid way.
When I think about the question ‘what does good look like?’, it’s amazing how that has shifted. We can get WiFi on a plane now, for example – if that goes down, we all complain, but when you think about it, you’re in the air and you’re connected. That is good. There’s something to be said about expectation and how we can keep up with it.
As Penny said, we’ve got to make sure we do the evaluations along the way. It’s one thing to say ‘I want it’, it’s another to make sure that we do it in a safe and supported way. We can’t just let everyone have all the data digitally and then feel afraid or perhaps have the wrong information.
My final point here is that medicine is a very human-based practice. We’re always going to want that physical, human touch. We’ve got to somehow work out a hybrid way that takes this into account and works for everybody. I’m really encouraged by the work that everyone’s been doing, especially with the NHS leading the way in many respects.
John: Picking up on the point around access and translations for those who don’t have English as a first language; previously in consultations third-party translators were required to facilitate those sessions. Right now we’re seeing a pilot focusing on being able to publish the dynamic translation directly to the patient and vice versa, to assist in those consultations. That’s not to say that technology will completely replace the need for a translator to be there, but it takes a big step in showing the art of what’s possible.
Penny: Those are really important messages around sharing files and records and using them during virtual consultations. We need to move into a data-driven culture; we need to review it, we need to make decisions based on it. I think the culture is shifting for patients as well in this area – they are more aware of this data and their rights around it. Virtual consultations should go to the next level, I agree.
John: When we think about modern 21st century systems, we all know that there has been an incredibly high bar set by retail, banking and travel experience. People are asking why this experience isn’t consistent in all aspects of life, including health. They’re right to expect the same, if not better, in healthcare as they do when they use internet banking.
What does good look like?
Penny: I think virtual consultations can be – should be – available for the majority of patients. But if we take a specific, such as patients with long-term conditions, there is a huge role for technology and virtual consultations to play moving forward. I’d also reiterate the need to link this up to data and remote monitoring. Through demand-led virtual consultations, we can more proactively monitor those patients with long-term conditions and get the benefits of preventing admissions and readmissions, reducing costs and enabling clinicians to spend more time with patients who really need it.
Paul: I’d agree. A local trust has implemented a new EPR with a patient-facing app, to make progress on things like patient-initiated follow-ups and hospital-at-home, optimising outpatients and helping with inpatient pressures, and there are ambitions in this area which tie in as well.
In general practice, the reality is that it becomes almost a population-based virtual ward. That is the job; you have an EPR that covers your local population and you’re responsible for providing them with care. Essentially the tech is just a rising tide of tools and functionality to help us enact these transaction.
I would hope and expect that over the next five years, what we’re doing is focusing our energy to solve the biggest problems.
What good would look like is for those people who are receiving that care to not really perceive that change; to just see it as care improvement and not see it as receiving a new piece of tech. I don’t particularly like the ‘virtual ward’ phrase because for someone who is not tech savvy, it could sound like the tech is being provided without the input of clinicians, like there’s an AI bot in the background dealing with you rather than a person. And that’s not that it is; the whole ethos is around personalised care plans and engagement and communication. I think the name almost does it a disservice.
But ultimately, I hope we see that we are using tech to solve the big problems and that it feels good for the people who are receiving that care.
Umang: That’s how you’ll know when you are successful – when it’s not called a virtual ward. It’s just an extension of the ward, another discharge pathway. I can’t think of a pathway that couldn’t be supplemented if done correctly, by using some form of additional technology.
The other thing to add to what Paul was saying is the point around staff. When we start making this stuff difficult, it becomes another thing the staff have to think about. Instead, seeing it become part of the norm would be great.
John: It’s about using technology in support of sound judgement. There is so much opportunity to automate things that are manual today. That’s not to say that everything can be automated, but whatever you do automate, you free up more time to deal with the exceptions. You’ve then got more time to focus on patients, and also on the areas of practice or business that really need attention, looking at how they can be improved.
Penny: The opportunity in this area is huge. Each individual organisation may have their own technology to deliver virtual consultations but if we look at it from a larger scale, the benefits can be maximised if we are able to standardise and connect. Implementation evaluation is key – sometimes we run pilots as an organisation but we are not very good at scaling up. It’s important that we are learning systems and that we use the refine, redevelop and scale approach to use technologies across the board that work. How do we share that knowledge, how do we share those outcomes? The benefit that one organisation gets needs to be magnified.
There’s also a big opportunity around societal benefits, coming back to long-term conditions; the demand is really high across the ICS and we need to work collaboratively to manage that demand. Virtual care is a catalyst for managing that demand and providing more responsive, effective and safe care.
Paul: The ICS sets the scene in terms of the provider partnership conversation, to think about how we bridge the gap in terms of data flow and care provision between primary, secondary and community care. There are great examples of virtual care in all of those places and the ICS needs to bridge that divide when it comes to challenges around continuation of care. If we’ve got our community team working on something, we need the secondary care team to be able to translate what they receive into activity so we don’t have two different teams working on something without clarity around who is doing what.
We’re making good progress in Greater Manchester with integrated care records and care pathways in areas like heart failure, frailty and end-of-life care. I think those are places where integration of information and personalised care plans are going to be key. But we’ve got to have the conversations at system-level so that across providers we are agreeing on what we are doing, solving those big problems and working as one NHS.
John: I’d say something that we are seeing come out of the ICBs is the approach of ‘how do we solve something once at scale?’ That’s where a lot of our focus lies. We want to have scalable solutions that will help simplify the IT landscape and deliver the best care possible. That’s part of the mission brief; there are many different ways to solve a problem at individual trusts or in different settings, but can we take that up a level and do it consistently across a geographic region? Then let’s go from origination to replication, to do it in multiple places. We’ve very much on board with that approach.
As I mentioned, OX.DH works with Microsoft, and it’s worth pointing out that it’s so important to start with the right foundation and architecture. Once that’s there, you have the underlying technology stack, and as I like to call it, the plumbing, to connect up and build on quickly and easily.
Umang: I’m really excited about ICSs. We’ve talked about them forever. It’s a truism isn’t it, that working together is better than working alone, and yet we’ve worked alone in healthcare for so long for no particularly good reason. I think that implementing ICSs is a bit like trying to change the engine whilst you’re still flying the plane, but I’ve no doubt that we’ll find a way.
Bringing it back to the earlier point around the standard that people expect, I think that’s really key. When someone sees Paul in his GP practice, they expect him to be able to see a result from the hospital instantly. That puts extra stress and anxiety on the clinical workforce as well as the patient, in terms of not knowing where to go or how long things will take. So if I’m looking at what I expect to see in three or five years, I hope we’ll have that seamless, connected system to support us with this. We’ve got EPRs, we’ve got primary care tech that is actually leading the way in some regards. I don’t think it will be a single system, I think we’ll have a way, as John said, of seamlessly being able to pull everything together in front of a patient to allow them to see that a) their care is being looked after by the right people in the right place and b) we can help them get to the care that they need next. It’s optimistic – I say that without underestimating the challenge that everyone is facing.
The recipe for success
Penny: The most important part is why we are doing this. What’s the problem we are trying to solve? The answer lies in how we empower our patients; how do we engage with our citizens; how do we evolve and give power to patients with regards to their own health? That starts with giving them a choice. It’s about giving them the tools and building their trust in those tools. Patient trust in digital technology is as important as clinician trust.
We need to start with the problem and technology can be the enabler, and we need to let patients and clinicians go and create and build that technology. It’s very important that end users are involved in the design of these tools so that they meet their needs and the system gets the benefits.
There’s a lot happening around applications – we need to make them simple and accessible for patients to use. At the same time, we need to respect that some patients will not be able or want to use them, and have other means available so we don’t widen the digital divide.
Umang: I’m in a privileged position with Microsoft because we travel up and down the country talking to people and we get to see lots of things that are happening. I’d say: always lean on colleagues. I’ve not come across a single person or organisation who hasn’t wanted to share their journey, warts and all. It’s great to do things like this panel, to talk to people and hear perspectives. Don’t be afraid to ask other people for their experiences if you see that they’ve implemented something that you’re interested in or they’ve tackled a challenge that you’re facing. We don’t need to start from scratch every time. The lovely thing about the NHS is the fact that we are all one massive team. We’re all driving towards the same outcomes.
Along the same lines, I’d encourage people to talk to other people outside the NHS too. If you come to tech providers or suppliers like Microsoft or OX.DH, you can ask ‘what can you do to help me get started?’ All too often people say they wish they had known something at the beginning, but we’re more than happy to come and share what we know or offer our opinions. Ask people, send that email, post something on Twitter or LinkedIn. We’re all desperate to share best practice and move the NHS forward one step at a time.
John: Similarly, some of my best days are when we go out and talk to people and listen to them sharing the challenges that they face. We translate that into what the technology can do to help them in their day-to-day life. It’s always focused on having the patient at the centre, improving that outcome and making it possible to provide the best care that can be achieved.
Sometimes there are isolated bits of work that have been kicked off and then people have to make course corrections and adjustments based on learning, but as long as there is a mechanism that can feed those learnings back into the process and turn them into improvements, I think it’s great. As Umang said, we’ve found that people in healthcare are keen to share their good experience and their learnings, and that really helps people like us do more with technology.
Paul: On that note, I think NHS Futures gives us a great platform for sharing.
One of my most important learnings would be to make sure that inclusion is baked in from the start. We have an opportunity to remove barriers and I’ve seen great examples where digital technology has made it easier for people to access care. But I’ve also seen examples where we’ve inadvertently added barriers to the system. We need to make sure that we are considering the potential risks and unintended harms of implementing digital solutions. What haven’t you thought about?
From a clinical perspective, there are additional elements to consider around the use of multiple systems. On Monday, I was working on a best-of-breed solution at general practice and I had four different workflows on four different solutions. It’s really quite tiring and it’s a very different way of working to how this looked and felt 15 years ago. So I think we need to be thinking about digital literacy, the fatigue that can sit around the work that people are doing and the intensity that comes with it. I’m looking forward to doing more face-to-face work; hopefully something we learned from COVID is the need to make sure we don’t digitalise our whole lives.
John: That reminds me of some of the conversations we’ve had with people at OX.DH. It’s been really effective to get people together and talk about the desired future state that we want to be moving ourselves towards. We know we can’t go there in one big jump; instead there are incremental steps we can take to get us closer to it. There is a lot of common ground and shared vision, and it is really encouraging to work with a whole generation of people inside the NHS who come under the banner of digital transformation. It’s nice to know that we all wake up every day thinking about how we can achieve that desired future state.
Many thanks to Penny, Umang, Paul and John for joining us.