HTN’s most recent panel discussion explored the role of digital in supporting self-care and delivering personalised care, looking at how digital can improve patient pathways and experiences, and the data points which should be leveraged to enable health and care organisations to deliver tech enabled care now and in the future.
Panellists included Rachel Binks, nurse consultant and clinical lead for digital and acute care at NHS Airedale Hub; Saif Ahmed, associate medical director, deputy CCIO, and clinical director for frailty at Tameside and Glossop; and James Maynard, product marketing director at Access.
Rachel shared a bit about her background, including her current work at the Airedale Hub in West Yorkshire, and her background in critical care, where she set up an outreach service to try and stop people deteriorating on wards. “At Airedale,” she said, “our services are about trying to intervene to stop people getting sick and needing to come in to hospital, and we’ve been running about ten years in the digital care hub, and since about 2007 with other remote services.”
James also offered an introduction to himself and his role as marketing director for Access, as well as his 25 years of experience “developing different tech from mobile phones through to the first wearable and acoustic monitoring technologies with the likes of Fujitsu and their labs in Japan”. As part of this, he told us, “I’ve spent a long time looking at how technology can understand individuals, and how we can pull the right data, maximise its value, and turn it into meaningful insights that can be utilised in the right way”. With Access, James shared that he and his team’s focus has been “ensuring we meet the needs of individuals and those personalised care journeys, tech-enabled care, and delivering insights for health and social care”.
Saif talked about his background as a GP, and his current work with Health Innovation Manchester, leading on developments within the Greater Manchester Care Record, and “launching things like myGM Care, which is our app for patients”. Recently, his work has also involved “working with industry and academia to develop proof-of-values around certain apps and wearables that patients can use across GM, such as an app to detect falls and deterioration in care homes”. At Tameside and Glossop, Saif has also been part of work on the trust’s own patient portal, alongside responsibilities for virtual wards and remote monitoring services, being “heavily involved in the digital aspects of patients being cared for in their own home”.
Tech in supporting self-care and delivering personalised care
On the role of tech in supporting self-care and delivering personalised care, our panellists shared some insight and experiences from their respective regions, with Rachel talking about the progress made at Airedale from “just using video assessments” to beginning to use the Luscii app to offer patients information and to collect observations. “From our digital hub, we can see a dashboard of people’s observations and we can set personalised thresholds, so we can see immediately if they begin to deteriorate,” she told us.
James observed the “maturing” of these different technologies, “which gives us that greater insight into how we can intervene, how we can support, and a more effective pre-care model”. Acceptance of these technologies is increasing, he continued, thanks to things like Fitbits, “and that certainly helps when we look at monitoring, patients entering information within apps, and so on”, offering “the perfect opportunity to begin to look at how these things are deployed and what that looks like in the future”.
Saif shared his perspective from Greater Manchester, where the myGM Care app is allowing patients to enter information about themselves, what matters to them, and how they’d like to be treated in an emergency. “All of that information feeds into our shared care record,” helping to really personalise care, he told us, “and we launched this in a PCN, where patients record their mood daily on the app, to monitor their reaction to medications and any behavioural changes; so we’ve been able to start to use the app for more self-reported measurements”. A heart failure care plan and a dementia care plan are also viewable on the app, so onboarded patients can view their own care plan and offer input.
Acknowledging the acceleration of tech in this space, Saif also highlighted issues he encounters as a GP, relating to “an overload of information”, adding that “there needs to be a happy medium going forward, where we start to understand what patients want, what we can do as clinicians, and how we bring that together, because as a GP I sometimes can’t see the wood for the trees”.
Rachel and Saif agreed on the need to prioritise those patients who actually need support, with Rachel telling us how from her experience in Airedale, “many carry on fine for months and months, but it’s when they start needing our support that we need to intervene, so it’s about recognising when something changes”. It’s also about using these apps and resources to ensure patients are keeping themselves well, Saif suggested, “and that’s the shift change we need, because we’re overrun at the moment and that’s getting worse by the month, so we have to look at that change, and technology has a massive part in that”.
Funding could be the issue with achieving that, Saif went on, “because I think we need to do this at scale, and if we can see those people we need to prioritise that will make a huge difference, but we need to recognise when that intervention is needed. Technology needs to address that and be able to enable patients to actually look after themselves, because once they’re through the front door of the hospital it’s a different story.”
Measuring impact
Rachel moved the discussion along to focus on how the impact of the use of tech in this space might be measured, talking about the importance of being able to see changes in oxygen saturations or blood pressures immediately, so “we can act very quickly”. People will “only give you what they want to give you”, she continued, “but you have to have some sort of oversight over that, so you can monitor what they’re giving you, and like Saif said, there’s so much data to that”.
On data in Greater Manchester, Saif noted the difficulty when it comes to apps, since “you can collect hard data points, but they’re not massively actionable – we can go on the myGM Care app and see how many people have accessed certain tiles, how many people have put in their blood pressure readings, how many people have logged in, and that gives us an indication as to its use, but for outcomes it’s very difficult”. In terms of “actionable” hard data, he gave the example of blood pressure and sats, which mean “we’re able to actually look for signs of deterioration and therefore predict and use machine learning to look at who is going to become unwell”.
“Engagement is so crucial,” said Rachel, “and we’ve had much more engagement with people that we have already had a contact with and who understand what the app’s all about, who expect our calls, and so on. Patients are often surprised, as well, when we contact them because we’ve detected a change, and they’re surprised we can see that. They can tell us they’re fine, maybe they just ran down the stairs, but having that person they can talk to 24 hours a day if they have worries is what leads to success.”
It’s not only having a voice at the end of the phone when needed, however, as Saif considers “patients are more likely to continue to do something when they can see the results – it needs to change their lives or the way they do something, otherwise they will just drop off”. Safety is also a major factor, he said, “because you want that safety mechanism that says the clinician is going to contact you if something is wrong”.
James touched upon some of his work with Access around education, saying, “it’s about educating people on what these services actually are – when we look at virtual wards, the tech is complementary to the care”. To demonstrate this, he shared findings from research that showed “initial reluctance” to move to a virtual ward stood at around 75 percent pre-education, and “dropped to less than 10 percent post-education”.
Challenges
A comment coming in from our live audience talked about a pilot in Hampshire, and issues discovered with hardware monitoring which impacted on patient experience. James followed on from this by discussing some of the challenges which might be encountered with devices and hardware, saying that like with any new technology, “there’s a plethora of different options out there, and as providers we need to offer support on that”. Recognising the issues with disparate systems and data siloes, he added, “it’s about how we create a level of consistency around that data in a common format – the biggest challenge that we will face by having multiple devices from lots of different groups or suppliers, is that we will create more and more data siloes, so interrogating that data becomes ever more complex, and I think as tech providers that’s where we need to work collaboratively with those trying to deliver these services.”
Saif talked about some of the challenges from his own perspective, sharing that he feels “lucky” to have a digital office team at Health Innovation Manchester who are able to “look at all of these products and vet them against the NHS framework to make sure they pass those standards before we deploy anything”. Compared with this “fairly rigorous process”, however, Saif also highlighted the difficulties as a GP, “because people come knocking on your door asking you to try things, and we don’t actually have formal roles in clinical safety or in technology, so we have to rely on other people to guide us. That’s one of the reasons we’ve formed the digital office in Greater Manchester, so we can vet the tech before it goes in, which is what we did for our virtual wards. So I suggest people start by using the resources they have within their ICBs, whether it’s their digital leads for chief tech officers, because for me it’s not a clinician’s job to do that.”
“I get very frustrated,” said Rachel, “because we always get told these pieces of kit need to be calibrated, there need to be systems in place to make sure things are safe, but people are going out and buying them from somewhere like Boots anyway. If we can support the public by adding that clinical input and that clinical insight, surely that’s better than them doing it on their own and turning up in A&E because they think they’ve got a very high blood pressure when it’s actually the machine that’s not working.”
In Airedale, Rachel highlights the hub’s use of an app that patients can use to record their observations, “and if they’re on our virtual ward we supply the equipment and have an overview, we show them how to use it, and we can watch them doing it via video”. There’s no reason, she continued, that patients couldn’t also add in results from devices like an Apple Watch, with the clinical oversight helping ensure that results are accurate.
James noted some of the interoperability and data challenges arising from the use of devices and apps to collect information from patients, pointing to the need for a common data model “in order for us to consume and use these devices effectively”. Access’s work with North East London NHS Foundation Trust around virtual wards is a good example, he continued, “as it’s very much about how we get data flow from bed management through to provisioning of the right equipment and then supporting the individual within that virtual ward, hospital, or home environment. It’s very much in that instance about getting the data in the right format, and the right way.”
There will always be challenges, James said, “and as things mature the NHS will most likely define exactly what format will be required to fit these things in, and devices like retinal scanners will have to fall in line if they are to be used effectively as part of these pathways. Then, it’s making sure we follow those data standards, and observe the security that sits around that – where the data is stored and how secure it is, which will mean working very closely together. There’s always a push from patients because they’re seeing all of this technology, and it does tend to be a little bit further ahead, but there needs to be a lag period to make sure it’s secure, mature technology being brought in. Improving that interoperability is absolutely critical for us to make the most out of the data and create the most insight from it.”
Saif agreed with James’s point about “a disjoint in terms of what people expect us to be able to do and what we can do within the NHS,” adding that some good progress is being made in moving toward open standards, which “will help in driving those conversations with providers”. It’s still “very difficult”, however, Saif conceded, “and I think that’s one of our biggest issues, and that’s why even conversations with people like Apple with Fitbit in terms of how that integrates into our GDPR or hospital EPR system haven’t got to a point where I can see that happening in the next 6-12 months. So we’re very behind on the interoperability front, but it should be at the start of every conversation, because if we don’t make sure that that data is shared and interoperable, then we’re not going to be doing anyone any justice.”
Approaches to implementation and scaling
“I would just advise people looking to embark on these kind of technological adventures to start small,” Saif said of projects in this space, “and it’s very key to start with a pilot site that looks at outcomes for patients before scaling, because a Big Bang approach is when things can start to go wrong, potentially with quite large clinical safety issues”. Likening this to large scale EPR go-lives, Saif also talked about the “huge amounts of resources” that accompany those kinds of projects, suggesting that “a small pilot that tests the safety issues and then allows you to overcome those barriers” is a better approach. “You’re never going to find something that’s perfect right away,” he considered, “and if you aim for perfection you’re going to fall short, because none of the tech out there is perfect”.
Rachel talked about a pilot her team started in 2018 with 50 patients who were watched over a six-month period, saying the hub “saw a huge difference in terms of how often patients were accessing care” in a cohort of COPD patients who “kept coming in to hospital”. The outcomes of that pilot meant that her team could scale all the way up to “almost five thousand”, she shared, “and we didn’t use lots of tech for that, we just used the app”. For those who struggled with digital literacy, Rachel told us how other options were available, “so they could just write their observations down and call us”.
When it comes to scaling, Saif talked about his Safe Steps project in Greater Manchester, emphasising the need to “start small”. Initially, the project was launched in in one locality, he shared, “which was 35 care homes and 27 GP practices, and the very starting point was fostering a culture of innovation, getting stakeholders on board, and ensuring that everyone was on the same page about our objectives”.
Speaking to stakeholders about what they needed was also important, Saif told us, “and we spoke to GPs to see what they wanted from the dashboard, what they needed to see; then went to carers and asked them the same questions, before we designed the app”. His team then followed up on this once the app was developed, asking for feedback on its ease of use, and for key metrics such as how long assessments were taking. “Education and training was key,” he continued, “and I can’t stress enough the amount of education and training that is needed for digital transformation – we went out there maybe four or five times doing training sessions because of turnover of staff, held webinars on how to use the app, and we have a great communication team who were able to develop patient leaflets, clinician leaflets, webpage resources, and so on”.
Incentives “definitely help”, according to Saif, “which is becoming more difficult as finances become more stressed, as we’re asking people to do this on top of their day job most of the time, and it’s not their day job, this is digital transformation and it requires separate funding to get the outcomes”. Highlighting results achieved in Bury which saw reductions of “up to 50 percent in ambulance callouts”, Saif cited the importance of performing a benefits analysis, then building a business case to go back to the ICB and demonstrate savings or efficiencies. “We’re doing that now,” he shared, “showing that the ROI has been quite significant, and saying we now need investment”.
James also agreed on this need for funding and incentives, adding that “once you have that proof of ROI to take back to the ICB, the challenge is often bringing those stakeholders from disparate services across health and social care together to run the pilot”. Until you can provide those results, James continued, “you’re asking people to do something outside of their day-to-day role, and those first steps towards projects like digital rostering or digital care planning can only be taken through that proof of value”. Once that model is in place, James went on, “you’ve got the ability to scale, because you can use that investment to drive things forward, take the results back to the ICB and demonstrate efficiencies”.
Efficiencies can be things like single sign-on, James told us, “which is hugely valuable, but often overlooked – if it’s saving 5 seconds per login and we put that out across every care worker or member in the NHS, it mounts up, and then you’ve got the time savings from password resets to consider as well”. Rather than looking at those individual pieces in isolation, he said, “it’s how we can look at it from a holistic perspective to truly understand where that return on investment and value comes from”.
Rachel spoke of her team’s passion in Airedale to “take that work away from people and do it ourselves in a very efficient way”, adding that by doing things in this way the hub has the potential to “oversee 40,000 people in residential nursing homes because we have a 24/7 hub available with 3o staff, hopefully reducing the demand on other services”.
We’d like to thank our panellists for their time in sharing their insights with us on this topic.
