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Digital technology transformation of outpatient services
22 June 2018
#digioutpatients
Welcomefrom
Guy Boersma, Managing Director, Kent Surrey Sussex Academic Health Science Network
&
Nicki Bromwich, Head of Digital, Oxford Academic
Health Science Network
Agenda
10:00 - Introductory presentations
10:20 - Case studies
11:00 - Industry Insights
11:20 - Break
11:35 - Workshop
12:35 - Feedback
13:00 - Next steps
13:05 - Close
13:10 - Lunch and networking
A Digital World. A Shift of Power?
• Where does power lie in 2018?
5
A Digital World….
• Or is it here?
6
A Digital World…People Power?
7
Digital in Healthcare
8
Internet Activities by Year 2007, 2015 and 2016, Great Britain
>50%
9
Nationally, increased from around 1.1m to 1.8m
In the South 1st attendance tele-appointments
almost doubled
Subsequent attendances in the South
increased from around 255,000 to almost
480,000
So… digital outpatient appointments
The proportion of South 1st attendances that
were tele-appointments was around 2%.
For subsequent attendances in the South,
the proportion was 3.2%.
Data source: Hospital Episode Statistics for England: Outpatient statistics (NHS
Digital)
1/2 of tele-appointments in 10 specialties
10
South providers with highest proportion of tele-appointments
11
Berkshire Healthcare NHS
Foundation Trust
Plymouth Hospitals NHS
Trust
Great Western Hospitals NHS
Foundation Trust
Royal United Hospitals Bath
NHS Foundation Trust
Portsmouth Hospitals NHS
Trust
% tele-appointments
8.0% 7.2% 6.4% 5.3% 4.8%
Main specialities (number)
Community medicine;
Nursing episode
Ophthamology;
Paediatrics;
Trauma & Orthopaedics
Trauma & Orthopaedics;
Allied Health Professional
episode;
Nursing Episode
Midwife episode;
Endocrinology;
Clinical haematology
Rheumatology;
Clinical haematology;
Allied Health Professional
episode
Main specialities (proportion)
Palliativemedicine;
cardiology;
GU medicine;
General medicine
Radiology;
Clinical immunology &
allergy;
Nuclear medicine
Clinical pharmacology;
Clinical haematology;
Geriatric medicine
Midwife episode;
Endocrinology;
Clinical haematology
Rheumatology;
Clinical haematology;
Anaesthetics
Variation between providers - Clinical haematology
12
Digital outpatients could also deliver large financial or capacity improvements
13Source: 2012 DH Report
Examples of good practice
Oxford Health – Telepsychiatry in ED
Emergency 24/7 psychiatric service at John Radcliffe Hospital and Horton
General Hospital (25 miles away)
Oxford Health: Telepsychiatry in ED
16
• Quicker response, facilitating
faster discharge from ED
• Convenient appointments
• Care can continue when
patients are on holidays
• 50% of patients seen remotely
• Saving estimated 444 hours of
clinical time annually
• Not dependent on availability of
outpatient rooms
Oxford Health: Telepsychiatry in ED
17
“It really helped me cope with my
emotions better”
“…really just surprised how personal
the experience was”
“I found this extremely useful,
convenient and actually enjoyed my
session”
“It is brilliant that there is no travel or
expense involved”
Surrey and Borders Partnership –IAPT
Surrey and Borders Partnership: IAPT
19
Patient feedback
“I was not entirely sure about Skype Therapy and what it would be like. However I have found the experience of video sessions great as if I am in the room with the therapist.”
“I use Skype regularly to talk to my colleagues and for meetings so
having therapy sessions on Skype has been really convenient.”
“Having skype sessions give me flexibility to attend more sessions as I can have them in the comfort of my own home.”
IAPT E-Consultation Goals
People
Improve quality of care
delivery
User friendly platform
Improved flexibility for
clients
Improved clinician/client
connectivity
Improved flexibility for
clinicians
Improved Value
Surrey and Borders Partnership: IAPT
20
Unexpected benefitsClinician feedback
“A young Surrey man who is at university in another part of the country was able to be supported immediately by Skype which allowed for continuity of care.”
“More clients are choosing SKYPE over face to face when I assess them as they have busy
lives and are used to this platform.”
“With the introduction of Skype for business I was able to be more flexible to client need.”
Live document sharing with clients
Use of whiteboard to support discussion
Clinical benefit of non-verbal communication
• Start somewhere
• Ambition/targets
• Learn from each other
• Join digital outpatient learning network
21
The Challenge
Thank you
Timely care of long-term conditions
Dr Azhar Ansari
Dr Antony Aziz
Dr Patrick Kerr
Mr Jeremy Hyde
22nd June 2018
Normal colon Severe colitis Ileostomy
Blocks
Reliance
on
healthcare
Capacity
vs
demandRescue
vs
prevention
Flar
e
Poor experience
Poor outcomes
Mild/Moderate
Flare
Delay in
advice
and treatment
Assessment
Severe Flare
Delay in
disease-
modifying
treatment
Stable
Pathway map
DELAY
Core elements
Patient
activation
Flare to
care
Disease
modifying
therapy
Flar
e
Poor experience
Poor outcomes
Mild/Moderate
Flare
Delay in
advice
and treatment
Assessment
Severe Flare
Delay in
disease-
modifying
treatment
Stable
Pathway map
DEL
AY
Open access:
telephone, email, PKB
FAST
Mild/Moderate
Flare
Timely advice
and treatment
Severe Flare
Timely
disease-
modifying
treatment
Good
experience
Improved
outcomes
Flar
e
Good
experience
Improved
outcomes
Mild/Moderate
Flare
Timely advice
and treatment
Assessment
Severe Flare
Timely
disease-
modifying
treatment
Stable
Pathway map
FAST
Open access:
telephone, email, PKB
Patient activation
• Non face-to-face service• Web-based patient portal (PKB)
• Self management
• Patient taking responsibility
Flare to care• Strip out complexity
• Simplify communication
• Early identification and treatment
• Clinician skillset mapped to patient need
Disease modifying therapy• Low dose azathioprine with allopurinol (LDAA)
• Well-tolerated, safe and effective
• Reduced use of expensive monoclonal therapy
• 90% reduction in admissions and
80% reduction in operations
Key learning• Conceptual buy in to new model
• Patient activation with PKB
• IBD nurse capacity to match open door
• Training and support for nurses/admin
• GP engagement for shared care prescribing
Change resistance• Improving outcomes reduces trust income
• In 2015 – 80 less admissions, 132 less ED attendances, 440 less OPD attendances
• Clinician fear of open door access
• Lack of commissioning and funding model
• Investment required for IT solutions
Thank you - any questions?
For further discussion
Provider Centred
Patient Has a Flare
between appointments
GP
Referral
IBD Service
12
wks
Treatment failure
and or
Hospitalisation
Treatment success
1-2 wks
LATE INTERVENTION
Report need
for Help
Improved Outcomes
Early
confirmation
of Flare
• Email, Telephone
• Patients Know Best
• IBD Registry
Pathway: patient reported and open access
Report stability
Patient with
IBD
Record
stabilityDefer scheduled hospital
apptEarly Intervention:
Out patient appt,
Medicines,
Operations,
Hospitalisation
Record
instabilityTrigger action
for help
0
10
20
30
40
50
60
70
2009 2012 2015
Crohn's Disease Ulcerative Colitis Pouch Surgery
Ulcerative colitis
Pouch surgeries
Crohn’s Disease
0
100
200
300
400
500
600
700
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Azathioprine+Allopurinol use
Azathioprine
Surgical rates
60%
34%
6%
71%
23%
6%
83%
11%6%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Yes No Not sure
Do you believe that your IBD has been well controlled in the past two weeks?
Prospective 0 months Prospective 4 months Retrospective
60%
29%
11%0%
34%
29%
23%
14%
23%
11%
40%
26%
0%
10%
20%
30%
40%
50%
60%
70%
1 (low) 2 (low) 3 (medium) 4 (high)
PAM level
prospective 0 months prospective 4 months retrospective
PharmaceuticalsPharmaciesSecondary care/
Hospital
Specialist services
Community teams
Employers
RelativesGP
Charities & Patient Advocacy
Groups
Government & Commissioning
bodies
Researchers
Mobile device and
app developers
Patient
Social services
Primary care
services
The current service structure
Patient becomes a stakeholder in their own health
Pharmaceuticals
Pharmacies
Secondary care/
Hospital Specialist services
Community teams
Employers
Relatives
GP
Charities & Patient Advocacy
Groups
Government & Commissioning
bodies Researchers
Mobile device and app
developers
Social services
Primary care
services
Patient
Optimum Architecture for PHRs
Feb 2018
Adrian ByrneCIO at UHS
Chair of CIO networkINTEROPen board member
Occasional sock wearer
@adebyrne
PHR - A new future ?
• Set out our vision for PHR in 2012
• Implemented an “untethered” model
• A patient centred approach
• Work across the UK – various hospitals
• Have led the development for Prostate Cancer UK programme
Digitally Mature Personal Health Records (PHRs)
Open Platform
PHR
Front EndApplications
Open APIs
Specialised
Interactive
Broad
Digital Maturity Model for PHRsbased on KLAS model
Basic
• View information• Newsletters • General Trust
communications• Appointment
reminders
• Gathering patient input e.g.
demographics• General surveys e.g.
PREMS• Provide results
• Condition specific • Targeted surveys
e.g. pre appointment
• Educational Videos • Reminders for tests/
medication checks• Protocol driven
information push• Wearables
• Pre op assessment • Consent
• Post discharge follow up
• Support self management
• Virtual interactions• Customised surveys
and feedback loops (red flag questions)
Enabling patient centred care
Open platform
Open platform
xn
UHS
My medical record
The transactional record
Appointment cancellations, updated demographics, allergies, medications etc.
Journals and surveys, secure messaging
Appointments, documents, Lab results & Radiology result messages, secure messaging
PatientUHSFT
Open Platform PHR
• If every app has it’s own data platform you will have chaos
• If every app has its own user account process you will have chaos
•NEED:•PHR platform like a vendor neutral archive•A federated identity scheme
The OpenPHR
• NHS Brand (Trademark)
• Based on a US product• Connected Health Base
• Hosted in Azure
• Has open connectivity (FHIR)
• Allow federated identity for apps
• Control proxy access
• Provide APIs to apps/developers
• Security
• Test environment
OpenPHR is Light on Function
Supported Self Management (SSM) Workshop
• 3.5 hour workshop
• 8-12 men
• Way of working (Ground rules)
• Introduction to SSM (quiz)
• PSA Tracking & Surveillance
• Health MOT
• Fear of recurrence
• How to contact the clinical team?
Challenges
• Working with the clinical teams – time to develop content
• Patient engagement
• Patient registration / consent
• Technology
• Lack of national standards
Improved care for staff
New roles
Faster
recalls
Safety netMore
effective
Where Next?
• Spread of the existing use cases
• Growth in UHS• Part of GDE programme reduces outpatients 20%
• Growth in STP• Maternity
• Encourage others to connect• University developers
• Other apps
“I was invited to use My health record and asked to
weigh myself using the digital scales once a week.
As I was going through a rough patch it was good
to know that there were people keeping an eye on
how I was doing. If my weight went down too low
then I would automatically get contacted by a
member of the clinical team.
I also used the messaging function in the system. It
is comforting to have a simple way of telling people
you are not feeling well” – IBD patient
Frugal innovation: Videoconferencing in
practiceDarren Woodall
Trust Innovation Lead
Frugal innovations
Frugal innovation responds to limitations in resources, whether financial, material or institutional, and using a range of methods, turns these constraints into an advantage.
Drivers for Change
• New Models of care
• Reduced resources in both financial terms and specialised personnel
• An Ageing population
• Drive towards a single point of care
• Technology savvy consumers
• Geography
Vision of Our Trust
• Be empowered to manage their own health and care needs
• Work in partnership with professionals
• Only tell us their story once
• Access seamless care easily
• Have care in or close to home, whenever appropriate
• Work together as a community to look after health and care needs.
Video conferencing….nothing new!!
Creating the value… The journey
Without a value based network …there is no network!
• Peer to peer
• Clinician to Clinician
• Patient to Clinician
• Education
End user Design
Example of a value based video conferencing solution
The vision of Video conferencing
• Create value based networks in all areas of healthcare delivery
• Create a controlled interactive sign posting service for healthcare providers ( air traffic control analogy )
• Creating a culture change in communication lines
• The right people at the right time making healthcare related decisions in real time
Current Statistics
• Current platform is IOCOM Visimeet
• GP Practices across Torbay and South Devon 18 practices with 75 licences
• Care Homes across Torbay and South Devon 18 care homes with 23 licences
• ICO staff 340 licences across more than 23 teams
• Other For example Rowcroft Hospice, South Devon and Torbay CCG, Devon LMC, SWAHSN, RD&E, DCC, DPT, Torbay Pharmaceuticals
• April 2017- March 2018 over 2000 V/C Meetings
Questions
Industry Insights
The 2 Minute Challenge
Name: Big Hand
Local HQ: London
Website: www.bighand.com
Twitter: @BigHandHealth
Presenter: Daniel Eyre
Email: [email protected]
Name: Cerner
Local HQ: London
Website: www.cerner.com
Twitter: @Cerner
Presenters: Isabel Drake & Wale Lawal
Emails: [email protected] & [email protected]
Name: Cievert
Local HQ: London
Website: www.cievert.co.uk
Twitter: @CievertLtd
Presenter: Alex Blakoe
Email: [email protected]
NHS HSCN
doc@HOME – Out of Hospital Remote Monitoring
CarePortal™
Tablet/Phones
ADT data
ClinicalDatabase
doc@HOME®
Various Patient Interaction Options• Patient Need
• Technical and Cognitive Ability• Video consultation, e-PROMS, Chatbot,
etc
Clinician Access
Hospital EPR/PAS
Patient Portal
Name: Docobo
Local HQ: Surrey
Website: www.docobo.co.uk
Twitter: DocoboUK
Presenter: Adrian Flowerday
Email: [email protected]
Name: DrDoctor
Local HQ: London
Website: www.DrDoctor.co.uk
Twitter: @WeAreDrDoctor
Presenter: Mark Bartlett
Email: [email protected]
Name: Healthcare Communications
Local HQ: London
Website: www.healthcare-communications.com
Twitter: @healthcommuk
Presenter: Mike Cunningham
Email: [email protected]
Name: Health & Care Videos
Local HQ: Torquay
Website: www.healthandcarevideos.com
Twitter: @hcvlibrary
Presenter: Hugh Kelly
Email: [email protected]
Name: Physitrack
Local HQ: London
Website: www.physitrack.com
Twitter: @physitrack
Presenter: Rosalind Heys-Limonard
Email: [email protected]
Name: Synopsis Healthcare
Local HQ: London
Website: www.synopsishealthcare.com
Twitter: @Synopsis_Health
Presenter: Mike Applewhaite
Email: [email protected]
Problem Solving and Analysis Roundtable Workshop
Table themes
• Referrals: from GPs, other referrals
• Appointments: booking, rearranging, cancelling, emergency, last minute
• Wayfinding: tracking, signage, check-in
• Information gathering/ dissemination: pre-appointment questionnaires, e-letters, PROMs
• Remote/ digital consultation: video, phone, chatbots
• Portals: patient portals
Next steps and actions…
Enjoy your lunch and networking!
Contact your local AHSN for support:
www.kssahsn.net
www.oxfordahsn.org
www.swahsn.com
www.oxfordahsn.org
www.weahsn.net
You can access 3 feedback questions by going to:
http://digitaloutpatientsevent.typeform.com/to/XAff7b
….and all resources using this link:
https://www.swahsn.com/event/channel-shift-to-digital-outpatients-event/
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