For our November edition of HTN Now, we were joined by Jamie Innes, Product Director for Inhealthcare, for a discussion on virtual wards and how ICSs can keep them as simple as possible.
Jamie began the session by providing some brief background on Inhealthcare, explaining that their digital health solutions have supported more than two million patients. They support 50 NHS trusts in England, five health social care trusts in Northern Ireland and now have an agreement with NHS Scotland to deliver their solutions across the 14 healthcare health boards.
Inhealthcare currently have over 100 digital services that support patients with a range of long and short-term conditions, and develop these solutions to be “bespoke to their local populations and requirements.”
The challenges facing healthcare
“There’s a perfect storm of issues being faced with increasing demand across the spectrum,” Jamie said. He highlighted “challenges in recruiting staff for health and social care, and patients with more complex multiple long-term conditions who require additional support.”
He further detailed challenges around patient discharge, referencing data from one trust where it was reported that 30 percent of their bed capacity was taken up by patients awaiting discharge. Another trust experienced similar issues, with 300 beds taken up.
“It’s preventing many providers from working through their backlog of appointments from COVID,” Jamie noted, “causing the backlog to then grow in size.” This demand affects transfer of care, with ambulance services impacted as a result and response times to category one and two calls exceeding expectations for the services.
To address these challenges and their wider impact, Jamie explained that it “requires a redesigned approach to how we deliver care to patients.” He added that the NHS now needs to alter their models and support their patients in different settings using new technologies and digital solutions.
The digital transformation of healthcare
“Like in all industries over the past decade, the way we consume healthcare services has dramatically changed,” he said, “and with the COVID-19 pandemic, citizens now expect and demand different ways of accessing and receiving treatment.”
Jamie explained that NHS providers now have a better opportunity to “embrace this change” and continue to drive forward the use of new technology to better engage with their patients in new ways.
Giving examples of some of the new digital outcomes, he showed that a new COPD and heart failure service in Norfolk Community Healthcare saw an 88 percent reduction in “bed days” and a reduction in A&E attendances.
Additionally, Jamie showed that Inhealthcare has worked alongside the Surrey Heartland Health and Care Partnership to develop a blood pressure remote monitoring service (BP@Home). When evaluated, Jamie said this “showed fantastic outcomes for patients” with 53 percent of patients who used the new technology moving from high to normal blood pressure. This service is now being used by over 3500 patients, with approximately ten patients added every day.
“For many digital health services, there are cohorts of patients who reside in care homes,” Jamie continued, “and many of those individuals require frequent visits from healthcare professionals.” An example of Inhealthcare’s work in this area comes in the form of SBAR with County Durham and Darlington Foundation Trust. “We worked with that organisation to develop a digitalised solution which allows care home staff to provide a consistent and concise set of information and observations to a single point of access team, who can then review that information and determine the most appropriate resource to go and visit the patient, and the appropriate next course of action.” Outcomes for this service include a 45 percent reduction in specialist nurse visits and an 18 percent reduction in overall unplanned admissions.
Jamie moved on to discuss the development of the respiratory virtual ward pathway. He explained that it began as a COVID Oximetry@home scheme in Wessex, with Sussex Health and Care Partnership, and that “various evaluations demonstrate effectiveness across multiple providers in the region.” He highlighted an important evaluation from the Sussex ICS, noting that “it demonstrated that patients felt more assured in the knowledge that healthcare professionals were routinely reviewing their measurements and able to act in the event of deterioration.”
The evolution of virtual wards
“The Oximetry@Home service has led to many digital health innovations with our customers” Jamie said, “and also paved the way for the delivery of virtual wards within NHS providers.”
He continued: “Virtual wards are, by their definition, designed to support patients who would otherwise be in hospital, and prevent readmission or support early discharge. As winter approaches, NHS providers are ambitiously working to deliver 2,500 virtual ward beds across England. These virtual wards are supporting patients with a wide range of different conditions.”
From Inhealthcare’s experience over the past six months, Jamie commented that it is interesting to note how providers have “expanded from the NHS England targets of respiratory and frailty, into developing virtual wards for other patient cohorts.” This, he said, has had “significant impact” on local bed capacity. “We are witnessing many providers naturally expand virtual wards to deliver services that will benefit their local population.” This leads to physical bed space being ‘unlocked’ within those organisations.
Focusing initially on frailty and respiratory, virtual wards are now expanding to include other conditions such as cardiology, diabetes, and specialist palliative care.
Jamie touched upon the NHS England guidance on virtual wards, which includes the need to use new technologies and to have “clear criteria for the step up and step down of patients within their caseload.”
NHS England has also shared minimum requirements for providers of virtual wards as they develop and drive forward the use of virtual wards. These requirements include the use of NHS numbers as a single identifier, through to the use of SNOMED codes for reporting and integrating data back into clinical systems.
Jamie highlighted the importance of ensuring that your technology can be “adapted and scaled” to meet these requirements, along with ensuring that you can embrace new capabilities “as virtual wards evolve and we enhance them to meet new conditions and challenges facing NHS providers.”
The technology must be able to integrate with different clinical systems and different patient cohorts, he said.
Digital inclusivity
“One element we need to be mindful of when deploying virtual wards is the big digital divide across much of our population,” Jamie said. “The technologies and devices that we can take for granted and use continuously may not be accessible or used by portions of the population.”
Jamie noted that digitally excluded individuals can be “the highest users of NHS services.” He shared stats including Good Things Foundation’s finding that 33 percent of the population are limited users of the internet, and Ofcom’s finding that 6 percent of UK adults do not have access to internet at home. This can lead to individuals feeling “disenfranchised and excluded from digital health services.”
Therefore, Jamie said, it is “vital, when developing digital services, for providers to ensure that their solutions are inclusive.”
Inhealthcare’s approach, when working with NHS providers, “is to identify the different cohorts of patients who access and use the services, and to ensure that we’re not excluding anybody by using a full range of communication channels,” Jamie said. These channels include video conferencing, smartphones, an online portal, a text messaging service and an automated phone call service that only requires landline access.
Having a wide range of communication channels means that more patients can and do take up digital health services. Much of this learning around how to communicate and support patients in this way was taken from the rollout of the Oximetry@Home programme.
Coming back to the webinar’s key point of keeping virtual wards simple, Jamie stressed that it is also important to keep this in mind for patients. He shared that some of the key learnings from Oximetry@Home “were around keeping it simple for patients to provide their information, and providing them with different communication channels for them to do that.”
He then shared data showing that 25 percent of patients still opted for an automated phone call, noting that it indicates that “there is still a large demand for individuals to access these services, who don’t necessarily have access to the latest technologies.”
Integration
“Integration is king, and ensuring that data can be shared between different clinical systems and get into the hands of healthcare professionals without manual entry is vital,” Jamie said. “This type of integration delivers massive efficiencies and ensures that data is available across the health system.”
Without integration, he pointed out, virtual wards would not be able to “deliver real efficiencies for providers, and ensure that regardless of where the patient is treated within the health service, that there is the latest information available for the healthcare professional without the need to access a separate system.”
When Inhealthcare are designing a digital service and the topic of integration comes up, Jamie shared how they “always look to define a set of goals for the integration – what data items are included, what systems are involved, how will it be achieved? This often means that you need service providers to have a number of different integration options at the disposal, including direct integration with NHS systems and with widely-used clinical systems such as EMIS Web and SystmOne.”
To provide an example of integration in use, Jamie highlighted a project with the City Healthcare Partnership and the Yorkshire and Humber Care Record. The project aimed to ensure that whenever there was a patient admission, discharge or transfer within any of the local acute organisations, the community provider has full visibility and can use this information to activate or pause any digital health services that the patient is currently on.” This integration, Jamie explained, is a great example of local systems sharing data to the benefit of the patient and healthcare populations.
Virtual wards: the good news
“The delivery of Oximetry@Home monitoring services during the pandemic has now proven that the technology for virtual wards exists,” Jamie explained.
He noted that COVID-19 had a significant impact on the adoption of digital technologies by necessitating acceleration in the process of digitisation. “Almost overnight, the NHS was faced with the challenges of how to support an existing caseload of patients without face-to-face contact, and digital became the de facto approach.”
Whilst patients with long-term conditions such as COPD and heart failure have traditionally experienced elements of remote monitoring prior to the pandemic, “the success of remote patient monitoring during the pandemic is now supporting the expansion of the technology into new areas.”
As the NHS continues to address the backlog of patients, he noted that there will be a need to introduce more technology that can support remote monitoring so that more patients can be placed into virtual ward programmes for a range of different conditions.
“Continuous monitoring technologies allow for the introduction of virtual wards, which will transform the way in which patients are discharged from hospitals,” Jamie said, “even when they have much more complex care needs. There will be much more emphasis on proactive monitoring and intervention to reduce the number of patients being admitted to hospital, or at least reducing the average length of stay.”
Respiratory virtual ward: how it works
Jamie shared an example of how Inhealthcare is enhancing services to meet new clinical needs in the form of their respiratory virtual ward programme, designed to support people with a history of asthma, COPD or other longstanding respiratory illness.
“This programme is designed to not only spot deterioration and support the remote triaging of patients but also to provide patients with more education and guidance,” Jamie said. He pointed out that the programme has been designed with self-management in mind, providing patients with the tools to take control of their condition and to better self-manage their conditions.
Jamie provided some more high-level information on how the virtual ward respiratory programme works, available to view from 17:59.
“The patient is added and important information such as the patient’s registered GP practice is captured so that it is visible and can be used for integration later,” he explained. “The patient is referred onto the service and information is captured such as any bespoke patient thresholds and the method by which they want to be contacted. They receive onboarding messages from the system and then receive notifications to input information based upon the frequency set in the pathway or against their patient.”
Jamie raised an important point around virtual wards here: “You want to be able to step patients up and down in terms of the frequency of monitoring. It may start with all patients receiving a standardised set of care, but then you may wish to invoke additional monitoring periods based upon deteriorations that you have observed.”
Once the patient has inputted their results and the results have been checked against thresholds and algorithms, any relevant alerts can be raised and displayed in a dashboard for clinical teams to investigate. From that point, patients go on a cycle until they are discharged.
Jamie then showed an example of a virtual ward dashboard; go to 19:19 on the video below to watch.
Tailoring to the needs of patients
“You need more than a dashboard to manage critical patients,” Jamie acknowledged. “That’s why we provide alerts and workflows that are designed around those pathways. It allows for alerts and patients and patients to be risk stratified and filtered into different teams. Workflows can be customised and kick off separate processes such as integration or sending information to patients and other clinical teams.
“You also need to manage exceptions. What if patients don’t respond, what if they don’t provide their results after a number of attempts to communicate? This is key with all virtual ward programmes and something that is really important during the design phase.”
Next, Jamie moved onto devices. “We provide a number of different device options for patients. From experience, you need a range of different options for devices which helps tailor devices to individuals but also helps to reduce the overall cost of delivering the solution.” He advised offering non-Bluetooth options for people who may not be comfortable with technology, along with Bluetooth-enabled devices and continuous monitoring devices. “Not one size fits all,” Jamie stressed. “You need to tailor your devices and pathways to individuals and the level of care that is needed for them.”
Keep it simple
When designing virtual ward systems, “the best advice is to start small,” Jamie said. “Iterate and expand from there.”
He explained that many digital health services fail to deliver the intended care because of overthinking in the design stage; over-expanding the scope for the virtual wards means that they “get too caught up in trying to build the ultimate solution.”
Jamie also highlighted the importance of gathering feedback from service users, noting that it is vital to understand what they need and want from their digital health services so that this can inform the service design.
“Don’t waste lots of time building technology into the process if it’s not needed,” Jamie said. “Start simple, and expand from there.”
Continuous monitoring
Coming back to the topic of continuous monitoring, Jamie commented that it was an area that Inhealthcare have recently discussed in great detail with customers at a recent round table event.
“To support continuous monitoring of patients, we’ve been working with a couple of different manufacturers,” he said, “looking at different approaches such as disposable skin patches that are connected to a mobile device that can capture a variety of vital sign measurements. They capture activities such as steps, and because of the gyroscope, it can also detect falls.
“These monitoring patches provide continuous vital sign measurements over a seven-day period and if necessary, the patient’s monitoring can be extended with additional patches, or they can be stepped down to alternative remote monitoring technologies that don’t need to be continuous.”
The patches include the option for a single lead ECG measurements, which Jamie said “can provide a wealth of data and allow for the identification of atrial fibrillation.”
In addition, there is also a watch that is capable of taking the same measurements. “That can be re-used across as many patients as necessary,” Jamie shared. “The devices are rechargeable and have a battery life of five days.
To finish the session Jamie offered a demonstration of a continuous monitoring view, which can be viewed in the video below beginning at 25:23
Many thanks to Jamie for joining us.
