HTN Now: Generated Health and University Hospitals of North Midlands NHS on using intelligent messaging for heart failure

For HTN Now, we were joined by Generated Health’s chief medical officer Dr Jonathan Serjeant and Sean Davies, directorate manager of cardiology at University Hospitals of North Midlands NHS Trust, for a discussion on the trust’s use of intelligent health messaging for patients diagnosed with heart failure.

In particular, the conversation touched upon the benefits that have been noted for both the clinical teams and patients, and how using a sophisticated algorithm to ask the patient about their wellbeing instead of their vital signs can improve patient awareness and promote self-management.

Smart With Your Heart

To begin, Sean provided some background to the project. He explained how he joined the NHS as an analyst and became involved in a number of projects including the “Smart With Your Heart” project which saw the trust utilise Florence to remotely monitor the health status of heart failure patients.

Sean described how data was taken from two groups comparing the pre-intervention group with the group of patients involved in the Smart With Your Heart project. Outcomes for the two groups were compared “in a lot of different ways – length of stays, readmission rates, A&E access, cost to the health economy and so on. In almost every metric, we saw an improvement between the pre-procedure group and those involved in the project.”

Sean noted that it was difficult to get the project off the ground originally because it was seen as a new and innovative way of working with heart failure, and staff tended to be reluctant to take on remote care of patients. “But now that the evaluation has been done and the results are plain, there has been a very positive reception around the project.”

“The project was a great success for us,” Sean said. “It had a lot of really great metrics associated with it and since then we’ve gone on to use those same principles in a number of other projects. We’ve been using it for patients who are awaiting a transcatheter aortic valve implantation (TAVI) and those that have undergone the procedure, keeping track of them. We’ve also implemented it for all cardiac surgery procedures, both in pre-procedure and post-procedure status.”

On the back of the project, Sean continued, the trust is taking the learnings from Smart With Your Heart and from other cardiac surgery remote monitoring projects and implementing them in an “evolved” Smart With Your Heart project as part of the Managing Heart Failure at Home programme alongside NHS England.

The role of Florence

Florence is an intelligent messaging platform run by Generated Health. It is designed to support people to self-manage their care, and support clinical teams to reduce workload in their normal daily routine.

Using SMS messaging in order to remain as inclusive as possible, Florence creates an ongoing connection between the individual and the clinical team. Patients can send updates to Florence to let their clinicians know how they are getting on, and Florence can also send educational content to help people learn more about their condition and how to care for it, along with prompts, nudges and reminders

Ultimately, Florence is about supporting patients to structure management of their condition and implementing behavioural change towards a healthier lifestyle. More information can be found in our overview of another HTN event in May, where we were joined by Generated Health’s head of behavioural insights Dr Gemma Donavan along with the University of Manchester’s senior lecturer in health informatics Dr Sabine Van Der Veer, for a discussion on digital health and behaviour change.

How are you feeling?

Moving on to look at how University Hospitals of North Midlands NHS Trust went about using Florence, Jonathan pointed out how they “did something quite innovative – instead of just collecting metrics through the text messaging communication, they asked the patient how they were feeling.”

Sean shared that one of the main drivers behind the project a colleague “full of innovative ideas – he’s normally a couple of years ahead of the trend. In this instance, he looked at the documentation that we were already giving to patients highlighting the warning signs to look out for. For people who hadn’t yet had their intervention, they would have to identify a warning sign and then re-access the start of the pathway to flag it, and it just takes time.”

Through Smart With Your Heart and Florence, the process changed so that every couple of days, patients would be asked a very simple question. “It wasn’t around physiological monitoring or anything like that, it was just asking them how they were feeling. We give good education to heart failure patients around what signs to look out for, and I don’t think there’s a better judge of the patient’s health than the patient themselves. We adopted the red/amber/green status, red being ‘I have deteriorating symptoms’, amber being ‘I have some symptoms but they may be related to something else’ and green being ‘I am fine’.

“If a patient responded to say that they were red or amber, then a telehealth worker would contact them. They would track those symptoms, and then the patient would report to the most appropriate pathway. Those workers acted as an advocate for the patients, making sure that they were getting to the right people. We didn’t want to just send everyone saying red or amber to the GP, for instance; it might be suitable for them to skip that step and go straight to the heart failure nurse or community care.”

Once patients were onboarded onto the project, it lasted for three months. For the first two months, Sean explained, the patients received the text message every other day. For the last month, they reduced the contact down to once every four days, with an evaluation at the end.

It puts a lot of trust within the patient, Sean noted, but despite initial concerns that frustrated patients might try to track non-existent symptoms to try and get an appointment more quickly, the team didn’t experience that. Jonathan agreed, acknowledging that whilst clinicians can sometimes worry that increasing communication channels could lead to an overload of patients, he has found that people are largely respectful of these types of tools.

Onboarding patients

“When we first started, we were attending consulting clinics in person so that we could be there in person,” Sean explained. “We learned a valuable lesson there, around the fact that if a patient is told that they are going to have a procedure, sometimes shock sets in. That can mean that they aren’t really interested in what a non-clinician is about to say.”

The team adapted their approach to give the patients a call instead the following day, and sent them a letter with all the necessary documentation including a consent form and a quality of life questionnaire so that they could produce a baseline for each individual.

“Once they’d agreed to take part, we would sign them up over the phone. They would get their first text message through Florence, and we’d proceed from there.”

Very few people decline the opportunity to join the project now, Sean added, and the way that the team onboards patients has evolved with lessons learned.

“It probably would have been best if the clinician onboarded the patient themselves, but the idea of the project was to try and impact the clinical team as little as possible to secure their buy-in,” Sean commented. “If you had clinicians who were wanting to be involved in the onboarding, I think it would be good for them to have that conversation with the patient.”

Patient feedback and stats

“I think one of the great things about using Florence in this instance is almost every age cohort of patients will be familiar with text messages,” said Sean. “We looked into things like apps, but the heart failure demographic is traditionally older and digital exclusion can be a challenge. So from an accessibility point of view, patients were very happy with the process and the technology that we were using.”

Patient assessment indicated that their experiences were positive. “They had a very good experience; they didn’t feel that they were not being seen because of the remote monitoring, and they saw that they could access pathways when they needed them.”

Attendances into A&E and emergency re-admissions for deteriorating patients were “significantly reduced”, with the group involved in the project seeing a 44 percent reduction in risk of attendance to A&E and a 67 percent reduction in emergency readmission risk. As a result of the project, the trust estimates that it has saved around £344,000.

Expanding the project

“In a post-COVID world, we’ve been looking at ways in which we can recover our waiting lists,” said Sean. “The patients undergoing TAVI and cardiac surgery are high-risk patients, and they were waiting longer than we would have liked. The idea behind applying Florence with a similar protocol to the one we used in Smart With Your Heart was that it would help us to re-stratify the patients who are on our waiting lists and have deteriorated symptoms, so we can bring them in earlier if they are clinically urgent and require an intervention.”

Again, patients were texted every other day and could classify themselves as red, amber or green. “In this instance, we also created our own symptom checker. It’s very similar to the way the colour coding scheme is set up, but it’s more related to valve symptoms. Patients were asked whether they were better, worse or the same since their last check. Anyone who said that they were worse would get a call and their symptoms would be highlighted to the surgeon, who could then feed that information into their scheduling.”

To begin, the trust had several hundred patients waiting for a TAVI or cardiac surgery; now, Sean said, they have less than a hundred.

With regards to the Managing Heart Failure at Home programme, the team wants to take the lessons they have learned so far and couple remote monitoring via Florence with an online library of content that patients can access at any time and a patient educator. “We see that engagement increases with education,” Sean said. “But once patients are out from under the clinician’s eye in hospital for example, that education starts to slip. The idea here is to use remote monitoring to engage in safety netting activity for these patients at their most vulnerable times, as well as using a patient educator to speak to them remotely and answer any questions they might have.”

Many thanks to Sean and Jonathan for joining us.