For HTN Now, we were joined by panellists including Ricardo Pereira, associate director of transformation at Nottingham University Hospitals NHS Trust; Dr Gorana Kovacevic, clinical lead for Hospital at Home at University Hospitals Coventry and Warwickshire; and Chris Taylor, director of partnerships at Isla Health.
Our panel shared their insight and experience on virtual wards and remote monitoring, covering common challenges and how to tackle them, as well as providing an update on current projects.
Ricardo was the first to share some insights from his role and his work on delivering a remote-first model of healthcare with Nottingham University Hospitals. He talked about his responsibilities around quality and service improvement programme management, and the trust’s journey so far with implementing the Isla platform to offer remote care for patients.
Ricardo went on to discuss how his team’s role is not in digital deployment but in managing the “human factors” of the process, such as integration into existing workflows, encouraging adoption, and using those early adopters to then encourage spread and scale.
“Scale is really contingent on the financial impact, or in demonstrating how that time you are releasing to care is being used, and how you reflect that when looking for the investment that scale requires. You need a sound case to start building that story from the outset, and some of that is practicalities around the design process and if you see a release of time for clinicians, administration, operational teams. Co-production really helps – working with patients, starting local, finding out what works for them, because that story tends to unlock the door to do more.”
Gorana joined the discussion to share her experience so far working on the Hospital at Home programme in Coventry, highlighting the importance of a blended approach and step-up, step-down protocols, as well as the challenges of not yet having an EPR in place to help support the care of patients.
She moved on to highlight many challenges, including supporting patients with different language needs, to patient wi-fi coverage and access. On overcoming these challenges, Gorana talked about how she relies on her team of nurses to be her “eyes and ears” when physically visiting patient’s homes, and that whilst labour-wise, this is a “very human resource-intensive delivery of the service”, this is currently a model which seems to have been working well based on positive feedback from patients.
On virtual wards and remote monitoring, Gorana added that “it’s been stuck here for a while, but we do plan as a service to move forward, and we will try again with EPR in June, and hopefully the EPR will bring some sort of improvement.”
Chris gave us some insight from a supplier perspective, talking about how he and his team at Isla have been focusing on removing these kinds of barriers relating to access, ensuring it is accessible from any device with no hardware requirement, and making it simple for patients by not requiring them to download an app and ensuring simplicity with sign-in credentials.
“Because it’s very streamlined, you see really high patient engagement, with an average of 74 percent of patients submitting onto the platform when requested. It’s important to realise that just deploying tech alone doesn’t create sustainable transformation, and so we always keep in mind that the change management piece is so crucial, and not underestimating the cultural change that’s needed to implement the solution. With any of our roll-outs we have a dedicated programme manager that’s responsible for training and clinical mobilisation, all the way through to ongoing support and benefits realisation, and in a partnership we always place co-development at the centre of that.”
Scalability of remote care
We asked our panellists to share with us some of their insights around creating a scalable remote model of healthcare, and for any advice they would give to someone looking to scale their approach in this area.
Ricardo told us that in his view, “scalability is only as good as the infrastructure you have, both technologically and support-wise. I’ve seen remote care scaled to an extent, but I’ve never seen full functionality or benefits realisation happen as a result.” Reflecting on possible reasons for this, he added, “I think some of that is down to whole-pathway-commissioned models, that don’t work well together, because a good remote care model will fundamentally require an excellent interface, shared understanding and purpose between your secondary, your community, your primary care provision, and we often don’t get that balance right”.
“We’ve explored a few things in Nottingham that we haven’t actually taken forward but we looked at inequalities as one of the challenges to scaling, and how you can make it equitable when you’re talking about technology, how you leverage things like library resources or local authority resources to offer access, and that takes quite a lot of brokerage and partnership working to get into that space.”
Ricardo also considered success in Nottingham around going from having nothing in place for things like image sharing and supporting clinical decision-making in 2021, to “expanding to 500 plus clinicians and 17 plus specialties in the current solution across the trust”.
“We’re rolling out a new EPR, we have digital health records, we have multiple solutions like Isla and DrDoctor that work to enable patient access. I think we’re quite blessed in terms of what has been put in place infrastructure-wise over the years, which means we’ve got greater scope to think at scale.
“Getting the right allies on board is important, and those people are going to help you take that journey forward. I actually think a lot of challenges people describe with things like commercialisation and partnerships are barriers that we artificially put in front of ourselves – if it’s the right thing for the patient and will help them get better care, but it doesn’t work for our clinical team’s workflows; surely the answer is we need to pursue it and find ways around that.”
Gorana talked about how when starting out with Hospital at Home, she had visited other trusts to find out what they were doing and what she could learn from their approach. “I went to Oxford, because they were doing what I wanted to do, which is working a bit like a first responder once the triage has been done and they say, ‘this patient has a swollen right leg, is it DVT or cellulitis, can you come and have a look?’. That’s what I would like to do, and we’re getting there, but you need the people, and you need the referrals coming through. Now we can’t accommodate all the referrals we have, but in the beginning we didn’t have enough, and that came from going to my colleagues, finding allies, people with the same vision, to move that forward. It’s amazing what we can do with point of care testing, with AI – we really can deliver a ‘hospital’ at home – and we can do all that.”
On starting with the basics, Gorana shared how at first, she worked on building policy and governance around the programme, adding, “it sometimes requires a lot of sleepless nights to get it through”. In terms of available solutions, she highlighted the variety of solutions out there, the emergence of AI and social care integration, and the possibilities that provides for remote care.
Coming back to Gorana’s point about AI, we asked Chris what opportunities he felt there were for AI in predicting and automating, and how Isla was working toward that. He shared some of the automation being built in specialties like SSI and cardiac surgery, like a computer vision tool which can assess signs of infection from a patient-submitted image.
“A lot of work goes into our AI models, but then it’s also how do we operationalise that and embed that? We see Isla as almost an interface which allows those to work in a seamless way when actually put into practice. Isla is essentially a solution that allows healthcare providers to run highly-automated pathways, and we harness modern media types such as videos, photos, sound recordings, so that patients can regularly update clinical teams on their condition. Clinicians have a more continuous view of that patient’s condition without actually needing an additional touchpoint, because the platform works by leveraging multiple sources of information from patients, family members or clinical teams that support them, and then flowing this data into a healthcare setting to enable faster clinical decision-making.”
Chris also shared how this work was making an impact, with Isla having worked with 30 NHS trusts across acute and community, implemented in over 40 specialties.
“In the case of dermatology, we’re seeing 15 percent of follow-up appointments avoided; in community wound care in one of our trusts, 75 percent of their care home caseload was deescalated from same-day intervention to planned intervention, and a further 10 percent are being managed entirely virtually. In one of our trusts, there’s a six-times reduction in readmission for patients, which from a financial point of view in the case of cardiac surgery, means avoiding the cost of readmission at an average of £15,000 per patient.”
Starting out with remote care
Talking about how his journey started with remote care in Nottingham, Ricardo told us how in the push to recover from COVID, his team set up three transformation programmes, and took a “back to basics” approach to things like clinic templates, structured flows, and ways of communicating effectively with patients.
“That’s where the opportunity is to explore adoption of technologies in line with the push to move more toward remote monitoring. During that acute period of COVID, much of the financial barrier dissipated from historic attempts to do remote stuff, which helped us start off on our journey. Then you need buy-in from leadership, and to get your people on board, and then you start hitting barriers relating to how you navigate the complexity of an ever-evolving integrated care system lens, and not knowing who to connect with.”
Ricardo also shared some of his insights from working for a commercial company around virtual wards prior to his current role, including the benefits of working with trusts which had an EPR in place to capture patient information; clinical transfer coordination on site to facilitate referral, assessment, consent, optimisation and discharge; and “the ability to ultimately review how effective we were”.
“The key challenge to some of that remote scaling is the difference in how trusts want to use that service – do you want it to be something that helps high volume exit-flow; do you want patients staying on the service for one or two nights and then be discharged into local community care; or do you want them to be longer stayers? Those are very different models of support that you need. And then you have to think about having a nurse visit a home when needed, to assure that has been blended with the technology capability, so actually how do you harmonise that? We had a central clinical scheduling function to optimise our roaming clinical workforce of therapists and nurses, so you can book your journey plan, so that every patient contact is mapped appropriately and turn around time between each visit is minimised; but you need to invest in that infrastructure.”
Chris added to this, saying that from a provider point of view it’s really important to recognise these kinds of challenges, and to realise that “an integration, in a lot of ways, can be more impactful than developing a new piece of functionality or a new feature; not just from a clinical safety point of view, but actually in terms of clinical uptake; making that part of the centralised record”.
“We really prioritise that in our product roadmap. At the moment, for example, we have a native and bi-directional integration with SystmOne and EMIS, and a contextual launch and single sign-on with Cerner Oracle Millennium. I do think that the health tech ecosystem would benefit from a centralised requirement, because sometimes as start-ups, there’s only so much we can do, and we’re sometimes limited by how much the EPRs are willing to enable that integration. That becomes a real challenge for us, because we’re actually on the same side – we both want high clinical uptake and data not sitting in silos, but we can only work within the constraints that EPRs allow.”
Challenges
We asked our panellists what challenge they would most like to solve when it comes to providing remote care for patients.
Gorana said that she would most like to solve the challenge around technology, starting with EPR, and building a system to support live updates from home visits, so that as soon as an entry is made, it is visible to all involved in that patients’ care.
Ricardo mentioned the challenge of coordinating and facilitating things like remote care across the ICS, noting how often, “we miss things like our primary care colleagues or the voluntary sector, who can play big roles in this work”. He also highlighted the difficulties in getting support and approval within an ICB, and that building up a group of people to drive the project forward is important as a first step, before moving on to look at things through an “ICB lens”.
Chris shared that collecting data from patients is often part of the challenge, and looking at “how we change the stream of continuous information into a useful dataset that clinicians can embed into their day-to-day workings”. He added, “we see this in two parts: one is providing an at-a-glance view of a patient’s condition, how that’s changed over time, and then flagging the patients who need attention most urgently; and then the second is actually beginning to recognise patterns in patient data and standardise best practice, automating predictable steps against thresholds and triggers.”
Takeaways and main learnings
To round off the discussion, we asked our panellists what main piece of advice they would give to someone looking to start their journey into remote care at scale.
“When I came into this, I didn’t know about the Virtual Ward Alliance, which is an NHS-funded group, or the Hospital at Home society, so I started writing the policies on my own”, Gorana shared.
“Please don’t make the same mistake – join these groups, ask them whether they have a policy to share, shop around and look for different solutions. Drop an email to people, ask around – the people I’ve been in touch with have been really enthusiastic. At the end of the day, you’re behind the drive to make it better and safer for patients in their own homes, and you’re not on your own. Join those societies, join those groups, ask for sharing, ask for advice, and you will get it.”
Chris highlighted the need to ensure that all stakeholders involved in the journey feel like a part of it, adding, “it can be quite common for conversations to happen in one group, and then when it comes to implementing, there’s actually a much wider group that are involved in that, so if you can involve those people earlier on, that’s where you get the buy-in and the trust, because everyone feels that they’ve been heard”.
Ricardo echoed Gorana’s point on looking for existing good practice and advice, saying, “I think there are so many people pursuing this, and there’s a wealth of resources available”.
“I’m going to make a personal plea from an improvement practitioner community – find them in your trust, because if they don’t know, they will know who you can go and speak to. So seek out an improvement quality, improvement team, or transformation team, and go and speak to them. The NHS Futures platform is not well publicised in terms of general access, but once you get on there, there is reams of stuff and forums, so start there. Then go and visit your neighbours, because there are things they’re probably doing that you don’t know about.”
We’d like to thank our panellists for sharing their insights and experiences with us.
