For our latest panel discussion on projects involving remote models of care, we were joined by Bruno Botelho, deputy chief operating officer and director of digital operations at Chelsea and Westminster Hospital NHS Foundation Trust; Becky Taylor, director for transformation and quality improvement at University Hospitals of Northamptonshire NHS Group; and Pete Hansell, co-founder and CEO of Isla.
Pete introduced the session by sharing some context around remote care at scale.
“I thought that a good place to start would be with the question of why we believe that remote care is the right thing to do for patients and for the NHS. We believe that the NHS is right at the start of its journey with clinical data and how we can use that to inform care. If we can move to a model where we’re able to capture much more continuous information from patients, so that we understand what’s happening to the patient and their condition when they’re not with us in hospital, that helps us build a more responsive way to treat patients. Getting that right will unlock a much more scalable and proactive way to treat patients across every specialty in the NHS.”
The concept of continuous information is one of the “fundamental capabilities that we think are important to delivering remote care”, Pete added. “It’s about moving away from collecting information from patients predominantly when they are sitting down with us in a consulting room, and moving towards the remote and ongoing collection of information from anyone involved in that patient’s circle of care. In doing so, we have the opportunity to begin to use the sorts of media files and content that we use so comfortably in our everyday conversations, but which are underused in the health setting, like sound recordings, images and videos.”
At Isla, Pete explained, the flow of continuous information is supported by design, with focus on minimising the “friction points” where people would normally drop off from submitting data.
“We send a link to patients by text or email, and they can click that link and follow the instructions within 60 seconds with no need to download or install anything. As the data from patients flows in, the second step is allowing clinicians to interrogate that flow of data, to understand what is changing, and whether those changes in the patient’s condition are something that needs to trigger a decision or an action. By setting thresholds for a wide range of things that might be observed in the data – for example, whether an affected area of skin has changed by more than a certain percentage over a certain time period – we can begin to allow clinicians to automate the way that they’re assessing and viewing that information.”
He noted that Isla “is used end-to-end in all sorts of different use cases”, including triage, diagnosis, treatment, recovery and monitoring, and handover/discharge. For triage and diagnosis, Isla can support early screening and risk assessment; remote monitoring of patient conditions to support treatment; patient-initiated follow-up to keep on top of recovery and monitoring; and virtual wards to support handover/discharge.
Using triage as an example, he said: “Perhaps we receive a referral from the GP – what we need is images that the patient can supply in order to understand their condition with clarity. It has a huge impact getting patients onto the right pathway as quickly as possible; rather than bringing them in for a long series of follow-up appointments, you can set up a pathway which empowers the patient to monitor their condition, and which tracks through their recovery and post-discharge.”
Pete said that shifting to this caseload model of care, where patients are specifically segmented and filtered to allow clinicians to take collective action by honing in on patients at similar points in the pathway or exhibiting a certain change in condition, “unlocks a much more scalable way to monitor large numbers of patients”, along with supporting clinical teams to intervene as quickly as possible to avoid deterioration.
On how to achieve this at scale, Pete highlighted a number of factors that Isla believe are key. “The first is to build a very low-friction data flow, for clinicians and for patients. We’ve found that building a platform that doesn’t require downloads of log-in information from patients is really important for that. Often, the people we need information from will be submitting it irregularly – it’s a bit of an ask to expect them to download a particular app and remember a username and password. Keeping the solution web-based and accessible from any device, with no need for log-in credentials, has enabled us to get a high response rate from patients.
“We also spend a lot of time with our clinical teams trying to iterate on and improve the user interface of the platform. That enables us to understand the breadth of the application and start to build functionality into the platform which can open up new areas of usability, and it also enables us to gain a detailed understanding of the configuration needed to make our platform suitable for specific pathway needs across specialties.”
The third factor Pete raised was that of automation and integration into the existing flow. “We’re driving this as an end-to-end pathway where we take a referral or an appointment and there’s a code associated with that, and then we can drive a series of events off the back of that code. We don’t want to have to ask an administrator to trigger an event every time – these automated workflows really enable us to deliver this intervention at huge scale.”
Work happening in north-west London is “a real testament to that”, Pete noted. Describing how the region has successfully rolled out teledermatology, he said: “We’ve seen month-on-month growth in submissions from patients in that region, and we’re expecting to see 100,000 submissions by June – that’s very exciting because we didn’t start the project too long ago. It’s great to see the impact.”
Chelsea and Westminster
Pete handed over to Bruno Botelho, deputy COO and director of digital operations at Chelsea and Westminster Hospital NHS Foundation Trust, to talk about his experience.
Bruno said: “As a director for digital operations and innovation I try to align our agenda to the trust or sector’s overall objectives and priorities, and try to ensure we maximise resources, reduce variation, and attempt to create a local ownership by empowering users to drive change or transformation.
“Our approach to creating a shift towards more scalable healthcare delivery has a few key principles, including establishing and agreeing the problem statement, empowering users to locally own and drive the solution forward, and using learning to improve. Ultimately, the work we do is guided by the operational clinical quality and financial objectives of the trust, which are aimed at providing better care for our patients, retaining and recruiting talent and staff, and creating more sustainable healthcare.”
Through Isla’s solution, Bruno explained how the trust now sees a number of specialties submitting questions, pictures and videos, “which are significantly enhancing our ability for managing patients, specifically around teledermatology. 75 percent of that patient population is now submitting questionnaires with photos, reducing time spent on processing these patients by about 50 percent. Pete mentioned how Isla can support with preoperative assessments – what that means on the ground is that 180 slots for face-to-face appointments are now dedicated for patients that actually need the slots, enabling us to reduce our waiting list.”
Bruno noted that integration of data and access to trustworthy information can remain a challenge. “However, the ability to integrate Isla with our data platform tools that are supporting patient management has been a huge benefit. Things that are normally done in months are being done in days or weeks, and that has created that seamless experience for the users.
“Like anything you adopt, the cultural change that is required for the transformation remains a priority; we’re continuing to work with our colleagues on embedding and adopting these tools. All of that is done at Chelsea with a collaborative approach. We are very keen to continue to put users at the forefront of what we do, and that collaboration extends to our suppliers like Isla – that can often accelerate and support the delivery of our objectives.”
On patient feedback, Bruno commented that patients “often tell us that this is the way forward and they want more.” He added: “We expect a continuation of this type of project as we strive to further improve our ability to keep patients outside the hospital, but retain the ability to remote monitor and support their care needs. We’re just at the beginning of that journey, so actually innovation can easily be scalable if we have the right tools, and the right teams working together to unlock its full potential.”
What advice would Bruno give to somebody looking to begin this kind of journey? “Identify the problem, and focus on the collaboration,” Bruno said. “Actually, it is about the team effort and putting the users at the front of helping you to come up with a solution. Use the data to drive the approach, build a cross functional team and maintain a user-centred design. It’s about having resilience and it’s about creating that ability to continue to push through the number of challenges that you’re going to face.”
Bruno also commented that he wanted to take the opportunity to thank Pete and the Isla team for their support during the pandemic, stating that they “played a key role in supporting us to maintain care for some of our patients”.
University Hospitals of Northamptonshire
Next, Becky Taylor, director of transformation and quality improvement at University Hospitals of Northamptonshire NHS Group, led the discussion.
On her team’s experience with scaling remote models of care, Becky said: “It’s about creating an organisational culture and approach to change and improvement. It can be really challenging – I think those of us who work in hospitals know that people don’t have a great deal of brain space to think innovatively about things that could be done differently. They also don’t necessarily have all of the tools in place to be able to make things work better.
“Similarly to Bruno, our improvement and transformation plans have got patients at the heart of what we do, and one of our strategic priorities is about improving our communication with patients. In terms of really focusing on how can we make changes to that, it can be quite tricky to engage some of our very busy clinical and operational teams around how you practically make a difference to something like that. Digital tools are just coming to the point now where they can really help with that, instead of hinder it. It’s really important to have that low-friction mechanism for people to engage with, having that simple interface, and having that encouragement to think differently.”
Becky explained that one of the first services her trust looked at with regards to remote models of care was the pain management team. “We’ve got a really innovative clinician, who was super passionate about improving pain questionnaires that we sent to patients. We had a relatively low response rate from patients coming into clinic – it would take eight days from when the patient was sent the questionnaire to when it then got entered into the system, and obviously there’s an admin team member typing up all of those responses into the system. But when we implemented remote monitoring, we had really positive engagement driven by this individual. I think one of the big lessons around driving change and innovation is finding those people who are the natural changemakers, because that spark helps get through some of that initial scepticism. It’s made a massive difference for that service.”
Becky talked about how the initial success of this service led to better engagement with the idea, saying: “It resulted in everything from saving administrative time to getting better response rates, and quicker return times for patients, as well as a cost savings. We’ve then got that clinician to come to our medical leadership groups and share that and talk really enthusiastically about the difference that that’s made to the patients, which has helped people to start thinking differently.
“The other thing that has been really useful about working with a platform like Isla is bringing Isla’s experience in from other trusts, being able to share and spread the ideas around. The second service that we looked at was in ophthalmology, doing triage for eye casualty, because Isla had experience with that. It really helped to spark conversations, like how we can make this pathway work better? What are the pain points that you simply can’t do if you’re not thinking digitally and at scale? How can we get videos of seizures in front of neurologists in such a way that helps them actually see what is happening rather than relying on a description after the event?”
What does the trust’s transformation programme look like, going forwards? “I think it’s a difficult time for change and transformation in the NHS, because there’s a seemingly impossible set of asks at the moment, that don’t quite square up,” Becky acknowledged. “But at the same time, it does provide a real opportunity to completely rethink the way that we deliver services, because it’s the only way to achieve the things that we need to.” Big programmes of work in place in the community mental health primary care space, she noted, “are very focused on outpatients and how we can support people from the point of being referred. We want to make the best use of joining up different systems, of creating innovative pathways, of sharing information and communicating with patients.”
Becky added: “Bruno and I are in national pilots for joining up bits of data from NHSE, as well in terms of the improving elective care coordination pilot. I think there’s a real exciting opportunity here to join up in a coordinated way, a number of different systems in a way that makes better sense for our clinicians and makes better sense for our patients.”
So what brings an organisation to use the Isla platform?
Pete said: “I think the most compelling thing about Isla for senior decision makers – who often don’t have too much time to go into the detail of all the different clinical requirements – is that breadth of application. We have designed the solution with focus on tackling the wider challenge of moving towards remote care, rather than designing it with a specific pathway in mind. That has enabled us to build technology which is very configurable to a massive range of different pathways. For decision makers who are often having to weigh up different systems or different strategic approaches to the IT, it’s important that we are able to offer something that flexes and consumers can build as they as they go on that journey. That’s key – being able to start wherever the pain point is, and then bring in a system with the features that you need.”
Many thanks to Pete, Bruno and Becky for joining us.