For HTN Digital Primary Care, we were joined by a team from Generated Health to discuss the benefits and challenges of remote monitoring, with focus on behavioural health, intelligent messaging systems in healthcare, how this can be implemented into clinical practice and what the future may hold.
Generated Health run the Florence platform, an evidence-based intelligent health messaging platform aimed at driving self-management, particularly for people with long-term conditions. Described as a “persona-based smart messaging tool”, Florence works on basic mobile phones without need for smart devices owned by the patients, and communicates with patients through text messaging. The company works with their customers to identify the problem that Florence needs to solve and then design the algorithm together, providing support in a range of areas such as with medicine management, pre-operation preparation, anxiety, depression and more.
The session was led by Dr Jonathan Serjeant, GP and Chief Medical Officer, along with Gemma Donavan, Head of Digital Therapeutics Development for Florence, and Mohammed Rahman, Generated Health customer and Principle Pharmacist for Foundry Primary Care Network (PCN) and Foundry Health Care, where Florence is being implemented.
Jonathan began by sharing a patient story to illustrate Florence in action. “I saw this patient a few months ago,” he explained. He described how the patient came to see him for the first time since lockdown restrictions ended, feeling isolated and struggling with weight issues. The patient had stopped exercising and taking medication for his Type 2 diabetes, hypertension and hyperlipidemia. Jonathan noted that it raised an important question to consider: “How could we have stayed connected with this individual and caught up with him before he reached this point? He happened to come and visit in person – if he hadn’t, he could still be out there.” Florence’s year-long monitoring protocol would have helped in this instance; there is more information on that below.
Jonathan highlighted how the COVID-19 pandemic caused a surge in remote monitoring, which can bring challenges as well as benefits. “I think a lot of this is landing at primary care’s front door,” he said. “It’s causing a huge amount of backlog, information is coming in via technology and via paper and clinical teams are having to try to respond to everything.”
He emphasised that remote monitoring needs to evolve to be designed to change behaviour.” Remote monitoring drives data and work into the clinical teams and helps clinical teams manage risk. It gathers data so that we can get a really good picture of what is happening with the patient’s condition, but it often has quite a low level of patient involvement. The difference with a platform like Florence is that we take that data and empower patients with information to help them manage themselves. They can act upon the messaging and metrics they are given, to see how they can better look after themselves. We provide education for them.
“I think a lot of remote monitoring can often be designed for providers,” Jonathan continued. “Virtual wards, for example, are focused on getting people out of hospital quickly to free up capacity and help with patient flow. Remote monitoring is about understanding risk – who do we need to see quickly? But if you have a messaging system led by the aim of changing behaviours, you get two-way communication with patients. It’s more personalised for their circumstances. The intelligence built into the system means it responds to how the individual communicates with it. It gives people structure and empowerment.”
Remote monitoring can give clinical teams a perception of safety, Jonathan observed. “But it is often reactive,” he pointed out. “With intelligent messaging tools, you can take that remote monitoring and you can help the patient choose what they want to do, what is the most important to them. It helps them understand their disease or condition, it helps them make lifestyle choices that can make a difference. It strengthens autonomy and it supports people to manage their own care and therefore they feel more connected, and potentially safer.”
Jonathan shared how Generated Health have been working to implement Florence with Foundry Health Care in Sussex. “They’ve got three practices which operate together in one primary care network,” he explained, “covering about 28,000 patients.” Here, Jonathan brought Mohammed into the conversation to share some of his experiences as a customer using Florence.
“Can you outline the problem that you are trying to solve, by using Florence?” Jonathan asked. “You’re the head of medicines management and also the head of long-term conditions, particularly around hypertension. Can you share a bit about that and the population that we are trying to make a difference to?”
“Let’s pick up on that one specific area, hypertension,” said Mohammed. “Foundry has got 3400 patients on the hypertension register. If we try to analyse this cohort, we will find that 38 percent of those patients have blood pressure that is actually out of range. They need clinical intervention. How can we address this?”
The current pathway involves the Foundry team inviting patients for a hypertension review and patients attending clinics for blood pressure checks and tests. The patient then takes a blood pressure diary home to monitor their readings over seven days and returns it to the one of Foundry’s sites, where printed copies are collected and sent to the coding team to be processed. The readings are scanned, sent to the clinical pharmacy team, and the intervention process is initiated, with patients channelled through to hypertension clinics following review.
Mohammed noted that the current pathway, which involves four teams and six processes, has barriers and limited factors. “It’s extremely time-consuming and presents some missed opportunities,” he said. “When the patient takes the blood pressure diary, we cannot guarantee that they will follow the process we need and bring the results to us. That means that they are missed in the system. There is also a capacity constraint with the clinical team workload.”
Jonathan shared how Florence has helped to improve this pathway. “We’ve taken that pathway and reduced it to about two steps, because the intelligent algorithms can manage a lot of the process steps,” he said.
On how this benefits Foundry, Jonathan said: “Let’s try to estimate some timings for the original pathway: you’re looking at about 25 minutes of administrative time spent on each patient, plus approximately ten minutes of healthcare assistant’s time to manage the remote monitoring section. If you multiply that by the number of patients you’ve got in your hypertension pathway, you’re looking at around 42 days of work for an administrator, and about 634 hours of the healthcare assistant’s time. So you’re looking at a lot of savings there, just from putting in a process that has some intelligent messaging in it.”
Examining how Generated Health are supporting Foundry in more detail, Jonathan shared information about their BP@Home Pathway, which includes three separate protocols to support patients with the most appropriate monitoring schedule for them.
Stage one, diagnosis, involves remote blood pressure monitoring over seven days, identification and maintenance, intelligent messaging to support patients to manage themselves and assessment of blood pressure against population standards. People can be uploaded to the protocol individually or in bulk to help provide an overview of blood pressure health among a population for clinical teams.
Stage two sees patient medication being safely titrated in partnership with a clinician and blood pressure measurements collected and checked for side effects. “The clinician on the other end of the process can see that Florence has been talking to patient, that they’ve reported no side effects, and that means the clinician can message the patient to say that they can titrate their medicine safely,” said Jonathan. “This saves patients from coming in, saves clinical consultation, and you can see who is tracking towards their target and who is moving away.”
The third protocol, long-term monitoring, can be put in place for a whole year. This involves the management of annual blood pressure check for whole populations, monitored against NICE guidance. Citizens receive bite-size education about blood pressure, helping them to make behavioural changes to support a healthy lifestyle. “This enables you to make efficiencies year after year, using this platform.”
Jonathan shared some of Florence’s evidence base; BJGP, for example, published that “mean systolic BP fell by 6.6 mmHg in telemonitoring participants, vs 3.5 mmHg in non-participants”.
Commenting on this, Jonathan added, “Remember that 10mm of mercury reduction leads to a 20 percent reduction in heart attack and stroke – so it can really make a difference.”
Gemma entered the discussion at this point to talk about behavioural change and self-management.
“The behaviours that people perform day-to-day are going to be really important in determining how well or unwell they are,” said Gemma. “There’s a whole range of behaviours that potentially influence that. We know, for example, that how many fruit and vegetables we eat, how much salt we eat, how much physical activity we undertake and so on has an impact on cardiovascular disorders. And of those factors are behaviours that are really important to our health and wellbeing.”
“The problem with behaviours is that they don’t exist in a vacuum. Behaviours are interlinked. The factors that affect whether we perform those behaviours, whether we don’t, the frequency… behaviours are all subject to very complex influences.
“With Florence, we’re thinking about these behaviours and how to understand them when we are designing these clinical pathways. We’re making sure that we are targeting the right behaviours to make sure that we’re getting the most beneficial outcomes for patients. For example, in hypertension monitoring, remote monitoring can be a very powerful behavioural tool for patients to help them understand what’s going on with their health. It can help them reflect on the things that they have done – or maybe haven’t done – that could impact their health. Then if they change their behaviours in light of this and they see the impact on their blood pressure, that embeds that behavioural change.
“So self monitoring, as a behaviour in itself, has the potential to be a really powerful tool to help people change a range of other behaviours that can then affect their health, such as medication adherence. We know that one of the key drivers for improvements in blood pressure from the studies that we’ve seen with Florence have been driven by clinicians and patients making better decisions about medication, such as changing the drug used or changing the dose taken. Those changes are informed by the clinician and the patient both receiving information about the patient’s blood pressure control, so that they can come together to make better decisions about the next steps.”
Gemma shared how she is working to integrate within Florence using features like the behaviour change wheel by Susan Micky to develop understanding of the behaviours that impact people’s health, and the behaviours that Florence can potentially influence.
“Because Florence is intelligent, two-way and automated, she’s very quick to respond to patients and that gives us a lot of behavioural tools to play with when we are designing protocols with our customers in order to achieve the outcomes that they want and solve the problems that they are experiencing,” said Gemma.
On how Generated Health plans to move forward, building on their evidence base, Gemma explained, “There are all sorts of things that make a Florence protocol quite a powerful behavioural tool. One of those things is the behavioural change techniques that we include. Going forwards I’ll be working on what those techniques are and which behaviours are we targeting.
“I’ll also be using the behavioural monitoring aspect, which embeds itself nicely within Florence protocols, to understand what patient behaviour looks like when they receive our protocols. That can then feed back into a continuous loop of improvement, so we know how to make our protocols more effective.”
The other element to all digital health technologies, Gemma said, is that they are only as good as the patients engaging with them. “With Florence, we used persona-based communication and we know that that really supports patient engagement,” she said. “Tracking their engagement is also really important to make sure that we are delivering the behavioural content that we want Florence to achieve.”
Jonathan highlighted that behavioural change within practices is also something that must be considered, and asked Mo for his thoughts on the barriers to implementing this change.
“It’s not only the patient that needs to be convinced that something is good for them,” commented Mo. “Staff also need to be convinced that we need to change our processes. For our patients, the initial onboarding will start from the nurses’ clinic, where patients are coming to have their blood pressure checks. We are trying to enrol them in Florence at the point where they would receive their home blood pressure diary. All the clinics face time constraints, so allocating more time to having a good conversation with the patient about this can be challenging.
“Patients’ comfort with using technology can be another challenge. Patients tend to only be convinced when staff demonstrate the system with confidence. So there is a necessary level of training and education required for the internal team, which needs to also fit into their busy schedules.”
“When you are implementing technology, supporting the team is very important,” agreed Jonathan. He shared how Generated Health work with customers for a ten week period when implementing Florence, which includes pathway planning, administrator training, protocol testing, the development of materials to support the protocol, and final sign-off.
“With Florence, we have a capability and maturity model because we find that as we work with customers over three or four years, they become more and more sophisticated with how they use the tool,” Jonathan commented. “In some ICSs they actually have dedicated people to use the Florence platform, because they can use it across the whole system in multiple different areas.
Jonathan concluded the session by sharing some of Generated Health’s innovative work with Florence.
“We’re supporting work looking into who is not engaging. One of the good things about Florence is that you can see who is not engaging, and Foundry is paying attention to this. They have invested in some team time to use that knowledge to develop their understanding of who is not being reached. Are they particular groups, do they need to do something different?
“We’re also working on bringing in artificial intelligence, in partnership with Florence, to how we can identify people at risk.”
Many thanks to Jonathan, Mohammed and Gemma for their time; you can watch the full session below.
