The digital cardiac network transcending care providers in the capital: how teams have united in London to empower and keep patients safe through technology-enabled support.
Delivered in partnership with the AHSN Network.
A shared digital vision between clinical and non-clinical professionals across two cardiac networks and seven hospitals in London has helped transform the pre and post operative experience for hundreds of patients.
Teams from multiple organisations have united as part of a single programme aimed at using technology and data to monitor the health condition of people awaiting elective cardiac surgery.
Led from inception by a clinical council, the pilot project is allowing cardiac teams to quickly spot and respond to early signs of deterioration within a large and potentially vulnerable cohort, while empowering and improving patient experience through digital tools.
People
In London, around 1,500 people are waiting for elective cardiac surgery, with surgeons across the city’s hospitals undertaking a collective total of 150 to 250 procedures every month.
Since the pandemic and similar to other regions, the city has seen an increase in both the number of patients waiting for elective procedures and in the length of time between referral and surgery.
Clinicians including Martin Yates, Consultant Cardiac Surgeon and Remote Monitoring Clinical Lead at Barts Health NHS Trust, were concerned about the risk of deterioration among patients waiting for their procedure.
Martin said: “We needed to prioritise patients on the waiting list by clinical need, not just by time they've been waiting. Previously, this was done by patients contacting the hospital, either by telephone or e-mail, if they were concerned about themselves. But we needed more equitable access across the region for all patients to have a way to be monitored for changes in their symptoms.
“We wanted to find a solution to be able to give patients a way to take control and to inform us if their symptoms were getting worse while they were waiting at home, by being able to contact us directly rather than going via their GP or local hospital.”
Collaboration between professionals within London’s two cardiac networks was key to finding a potential solution to the issue.
Alice Ward, Network Manager at South London Cardiovascular Network, worked with colleagues from both networks to explore the potential value of digitising the patient pathway and offering technology-enabled remote monitoring to everyone waiting for elective surgery across all seven hospital sites.
She explained how early and continuous involvement of clinicians through a clinical council model laid the foundations for the pan-organisational pilot project, which began to take shape after the team made a successful funding bid to NHS England.
Alice said: “Even before our bid went in, we had letters of support including endorsements from cardiac surgery clinical leads and chief technology officers in London.
“It's really important that clinicians lead the process, and the clinical council model is a good way of ensuring they're all involved. It pulls clinical expertise around a subject and allows decisions to be free from organisational bias because the council is made up of representatives from all the different sites.
“It’s also essential to ensure patient views are incorporated at an early stage and patient experience is central to the tender design and procurement. We were lucky to work with one of the sites that had used a previous system and had collected quite extensive patient feedback. We were able to incorporate that into our procurement requirements to ensure we met patient expectations.”
Process
Experience and knowledge of people who had previously used technology-enabled remote monitoring, underpinned by the clinical council model, was central to developing the funding bid and subsequent tender criteria.
Alice said: “Previously our procurement projects used the clinical council model for stents and devices in South London and saw real benefit, so when we were successful with our remote monitoring funding bid we suggested that we adopt a similar model for the procurement process.”
Consultants involved in the bid were asked to become members of the clinical council to help inform the tender specification, decision-making process and ensure needs were met across all sites.
Members reviewed documentation and were represented on the shortlisting panel, with successful suppliers invited to present to the full council.
Clinical council meetings continued after the supplier was selected, providing a clear clinical governance structure to report progress and escalate challenges from different sites.
Alice said: “This enabled us to share experiences as we went through implementation and to understand where things worked well, where things have been difficult and to learn from each other.
“It can take quite a lot of commitment to roll out this kind of project and we've been careful to ensure that when we ask for time, things are organised and clear. We've used virtual methods where possible, so people aren't travelling, and tried to meet at convenient times for clinical teams.”
Together, the team created a tailored criteria endorsed by the clinical council and all seven sites. The specification included system capability around recording and gathering information like patient questionnaires, uploading documents like discharge summaries or images, and hosting educational materials for patients.
Nathan Roberts, Network Manager for North London Cardiac Operational Delivery Network (ODN), worked closely with Alice and colleagues to create and shape key documentation.
He explained the team has a shared focus on ensuring their system could support effective, secure communication between clinicians and patients, such as two-way messaging and video calls, while adhering to information governance requirements.
Nathan said: “Secure communication was central to the design specification along within the ability to safety net, availability of different languages, options to customise the system and ease of use.
“In addition to user acceptance testing, we all got logins and used the system ourselves to make sure we were happy with it. We looked at data capacity and things like exports reminders, analytics and surveys alongside the ability to interface with existing systems, which was absolutely essential.”
From the outset, the team thought about the potential future of the service, embedding steps to allow for effective assessment, development and potential diversification.
Alice said: “A significant part of our bid when we first approached this project was a good amount of funding for a really robust evaluation. We knew remote monitoring was becoming increasingly used across the NHS and that having a strong evidence base about what works is going to be valuable.
“Our evaluation partners, UCL Partners, were brought on board very early. They attend our weekly project meetings, so are really embedded within the team and have a good understanding of the project.
“We also designed our tender to give us flexibility beyond the pilot stage. If our evaluation is able to evidence benefit to the system, we will be able to expand into future years and other specialties without having to retender.”
Tools and technology
The technical solution, supplied by Ortus iHealth, includes remote monitoring dashboards and prioritisation, assessment and discharge tools. It also allows the team to see any trends across the region, including different pockets of performance.
Patients onboarded to the system are asked to use their digital device like a tablet or smart phone to regularly fill in a digital questionnaire, designed with expert guidance from the clinical council. Answers are assessed via an algorithm and made available in real time to clinicians via a dashboard, which flags a deteriorating patient by marking their data in red.
Dr Debashish Das is a Consultant Cardiologist at Barts Health NHS Trust and Chief Executive of Ortus iHealth.
Speaking from a clinical perspective he explained how the system allows cardiac teams to “pick out a deteriorating patient from a crowd”.
Debashish said: “To put this into context, consider you have a list of 50 patients you would normally telephone, but instead they fill in the digital questionnaire. If 45 show grey on the dashboard it means they're doing fine, so in one glance you've managed to keep an eye on 45 patients.
“For the five flagged up as red, you can gather more information by calling or messaging them through the system. That’s a perfect example of how we've used technology to be able to manage a large cohort of patients with the same workforce.”
Patients also have access to digital educational tools, helping them along the entire pre-operative to post-operative journey, and can make virtual contact with their clinician, including messaging and video consultation.
Martin said: “A patient interaction may not be about a deterioration in their health. They may have a question that they want to ask us about medications that we're able to talk to them about, something that was very difficult beforehand.
“The waiting list pathway allows us to provide the patients with digital data about what to expect during their time in hospital and during the recovery. Previously this was printed on paper and posted to the patients by mail, but they can now receive it electronically.”
Culture
The project and emerging service is built on a culture of unifying expertise to ensure patients across all of London’s hospital sites benefit equally.
It is typified by clinical and non-clinical experts working as one to ensure the system is effective, safe and interoperable with existing systems.
Crucially, there is consensus and cohesion of underpinning site structures and processes such as standard operating procedures, information governance frameworks and staffing models.
Nathan said: “Engaging with sites early, getting them on board and creating a shared vision, a unified need and passion was fundamental to the effective delivery of this project.”
The team were united in a determination not just to enhance patient experience, but to ensure an inclusive approach that would meet the varying needs and wants of individual patients.
Debashish said: “Technology is not always the solution, but what it allows you to do is save time with the larger cohort and free up time for those in need of a personal approach. Pathways must be tailored to the patient and whatever it is you deliver, technology-enabled or not, you must make resource for those patients who potentially aren't using or don’t want to use it and not leave them behind.”
Martin said: “One of our concerns when we started this project was that some patients wouldn't be able to interact with the program. But what we've seen at our hospital is that even patients who are older are keen to be involved in this and the majority of patients are able to interact with such technology. The technology also allows patients’ families to assist them if they're not so familiar with it, in the same way that patients would come to clinic with their family for support.
“With the technology that's now available, I think it's essential that all patients have the ability to interact directly with their surgical teams and convey any change in their symptoms that they're having. This allows surgical teams to prioritise in real time the patients that need their operations performed most.”
Benefits and Impact
Nathan said: “This project has allowed us to effectively manage a large cohort of patients in a really effective way. That efficiency, whilst keeping people safe and giving them a positive experience, is really vital and has to be the future of how we deliver our services.
“So far, the system has flagged several hundred patients through symptoms and questionnaires as potentially deteriorating. We have had around 60 patients who have had their treatment quicker as a result of using this platform, which means that they don’t present as emergency cases.
Martin said: “In the first four months of doing this we had over 2,000 patients pass through the pathway across London. At my hospital, that's more than 500 patients who are being remote monitored waiting for surgery. We've seen a number people of who have deteriorated while waiting and had their cardiac surgery expedited via this pathway and they've had their operation and gone home well.
Alice said: “We've seen a lot of benefit already. The activation rate has been really high, so patients are really engaging with it, and we've already had a significant number whose care timeline has been brought forward or their care has been escalated.”
An evaluation report due in autumn 2023 will include patient experience, clinical experience and economic impact components.
Alice said: “We will ask patients how they found using the remote monitoring system and how it compares to any previous systems they might have used. We will also speak to patients who've opted not to use the system to understand why that might be. Another important component will be feedback from the clinical teams about how much time it's taken them to engage with patients on the system, how it's benefited them professionally and how that compares to previous systems they might have used. There's also an economic aspect to the evaluation looking at the financial impact for trusts on using this kind of system.”
Patient testimonials include:
"It helped me manage how I was feeling from week to week and keep it in check."
"It gave me the opportunity to monitor my health without having to see or schedule an appointment with the doctor. I would recommend the program to anyone who has health concerns."
"It helped me get referred for a procedure, which was much better than waiting for an appointment."
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