Transformation Directorate

Remote monitoring of healthcare in the North East

What was the aim?

Delivering care through remote monitoring, where technology and apps enable patients and clinicians to receive and deliver care within the home, is more important in the current climate. Reducing the need for a face to face contact and thus the risk of COVID-19 infection.

To better support people with long term conditions to receive more timely care, the four Integrated Care Systems across the North East and Yorkshire are keen to further develop the remote monitoring operating models in place across the region.

What was the solution?

Health Call, a company owned by seven NHS Foundation Trusts within North East, and North Cumbria. Health Call introduced a range of digital services which are designed, built and deployed by clinicians and then made available for adoption in other areas to reduce operational delivery costs. The solutions allow real-time data transfer enabling clinical teams to monitor and triage patient information. Patients can rest assured the information is delivered to the right person in the right place at the right time to allow the right treatment, sometimes, without entering a clinical setting, therefore reducing the risk of infections such as COVID-19. 

Solution one: INR (international normalised ratio) digital monitoring

The remote testing of INR (international normalised ratio) service was set up at Durham and Darlington NHS Foundation Trust in 2014 and has supported over 2,500 patients taking warfarin and other anticoagulants. 

For patients required to take warfarin, the digital solutions enable their INR levels to be remotely monitored. Reducing the requirement to attend their GP practice or hospital in person for face to face appointments; decreasing the risk of infections but also providing patients with the assurances that their health care professionals are monitoring their health and providing the correct treatment. 

Allowing patients to continue with their commitments with no need to take time off work, find childcare, travel to their appointment whilst providing health care professionals with the information they require to remotely monitor their well-managed patients' while allowing more time for patients who need to be seen. 

One patient the service has supported is Derek Jones. For many years Derek was prescribed the blood thinning drug warfarin. To ensure patients are prescribed the dose of warfarin they need, many patients have fortnightly blood tests to measure their INR- the time it takes for their blood to clot, which can help their health professional to assess their risk of a future blood clot or bleeding. The use of remote monitoring means that Derek is able to test his INR levels at home using a simple kit. He then updates his clinical team by text message. 

Being able to complete this simple task at home means that Derek is saved the cost and inconvenience of regularly travelling to hospital to have this test performed.

Derek Jones says: “Now, more than ever, the ability to use this fantastic automated system is of huge benefit to me and my family”

Solution two: digital care home service

Many care homes have no direct access to NHS IT systems therefore the phone is predominantly used to contact the wider health system. This can waste hours of staff time and there is no ability for clinical staff to remotely monitor residents in care homes. More than one hundred care homes are using the digital care home service to refer patients' details to clinical teams using a secure portal, such as a website or app. Using the SBAR (situation, background, assessment and recommendation) Tool, staff are able to provide clinical observations such as blood pressure, oxygen saturation and temperature, whilst also providing details of their concerns. The system calculates the National Early Warning Score 2 (NEWS2) based on the information provided.

This information can be pulled through to the patient’s electronic record on widely used systems such as EMIS and SystmOne, making it available to all appropriate clinical staff. Allowing clinical teams with the information they require so they have the ability to triage their lists ensuring patients who need to be seen can be seen sooner.

A number of services can be added to the digital care home solution including videoconferencing, undernutrition, wound management. 

Lind Fitzgerald, Bowburn Care Home Manager, says: "We are able to use baseline data to identify 'normal' levels, making it easier to identify poorly residents, the care home staff feel like they are doing that bit extra for their residents. We now able to make referrals at our fingertips to digitally informing the right person who then provides advice sooner"​.

Solution three: digital blood pressure monitoring (hypertension)

The home monitoring hypertension service enables patients to record and relay readings to a clinician remotely, without the need for regular appointments. If readings fall outside of NICE guidelines, an alert is automatically generated which notifies the clinician for the need to follow up with the patient. Patients can choose to use SMS text messaging, an automated telephone call, an online portal or an app to submit their readings, meaning the service is widely accessible to suit patients of all technical abilities. 

The hypertension service calculates the 7-day average blood pressure reading, negating the need to do this manually. All information can then be pulled directly through to the patient’s medical record, reducing staff time and duplication of work.

Catherine McShane, Project Manager, County Darlington and Durham Foundation Trust, says: “The hypertension service was built jointly with GP's to support the management of patients diagnosed with hypertension. It will help patients to manage their hypertension, improve the self-recording of blood pressures and reduce the duplication of work of manually entering BP's into clinical records and having to calculate the 7 day average.”

What were the challenges? 

Ensuring the solutions are integrated into core electronic records for seamless care.

While the tests are simple to complete, education and support is needed so people understand the importance of taking their medication and the need for regular testing.

Patients have to feel confident that they can contact their clinician to discuss the results or about other worries they might have, that can help reduce any anxieties they might have about physically seeing someone once a fortnight.

One of the main challenges is the shift in culture, the technology will do whatever it needs to do but people need to embrace it.

Pathways need to be adapted to support the inclusion of digital rather than trying to get the digital solution to fit in with existing pathways.

Ensuring all stakeholders are involved in the planning and implementation for example the single point of access with the care homes were vital to the successful implementation but not an obvious stakeholder from the outset.

What were the results?

Generic

  • Reduced need for outpatient appointments with associated benefits for patients - 569 patients are using the INR service, these patients now have on average one face to face appointment per year, rather than 18 face to face appointments, saving over 9,000 appointments per year.
  • Increased clinical capacity for other patients.
  • Improved access to health care when it is needed.
  • Improved individuals’ quality of life through a range of intuitive digital applications using the device of their choice.
  • The digital care solutions are driven by Digital Health specialists (a collective of healthcare professionals and digital experts) to help people manage your health, your way.
  • Real-time data transfer means clinical teams can monitor and triage patient information, whilst patients can rest assured the information is delivered to the right person in the right place at the right time allowing the right treatment. 

INR Service

  • An audit by Durham and Darlington demonstrated that 100% of those on the home INR self-testing service said they’d recommend the service to others (77 patients took part in the audit)
  • Patients who monitor their own blood levels in this way have better levels of control and spend much longer in the therapeutic range, significantly reducing their chance of a stroke.
  • 70% of patients in the service experienced sustainable clinically significant improvements in their INR management.

Digital care home service 

  • Care home residents feeling better cared for and more involved in their own care with an output being a reduction in face-to-face appointments.
  • Reduced hospital admissions by an average of two per care home per month (pre-covid and based upon the care homes using the solution).
  • Better informed clinicians enabling improved caseload management.
  • Digital blood pressure monitoring.

Hypertension service

  • Using the service can lead to earlier identification of significant changes in blood pressure, resulting in quicker treatment of conditions and better outcomes for the patient.
  • The service also improves the efficiency of producing documentation, automating certain sections and preventing duplication of work.
  • Monitoring of blood pressure in patients' own homes reducing “white coat syndrome”, which is where patients exhibit a blood pressure level above the normal range, in a clinical setting, although they do not exhibit this at home or other settings.

What were the learning points?

  • Many patients want this and can understand the benefits, we now need to share learning across the country to enable greater spread and adoption of remote monitoring solutions.
  • We need to enable better use of resources within the region while improving outcomes for patients as this can potentially lead to a reduction in unnecessary hospital visits (outpatient and as emergencies). 

Next steps

This model fits into plans across all four ICSs in the region to strengthen the delivery of the virtual ward concept and enable the spread of digital solutions across the region to:

  • allow more patients to be cared for in their own home, whilst the monitoring of vital signs will ensure that patients who need to be seen receive medical attention sooner and reduce the number of admissions for patients who can be safely because their conditions are monitored more intelligently 
  • enable prioritisation – knowing who is well and who needs more support and in turn allowing for a more productive workforce 

Join the innovation collaborative

The innovation collaborative is open to all NHS, social care and local authority staff with an interest in remote monitoring. Join in and access support, guidance and tools developed to help clinicians and social care staff as they implement tech-supported remote monitoring solutions and digital innovations. Existing members of the FutureNHS platform can join the Innovation Collaborative Digital Health workspace.

Alternatively, please email innovationcollaborative-manager@future.nhs.uk to request to join.

You can also join in the conversation by tweeting using the hashtag #NHSInnovCollab.