A guide to setting up technology-enabled virtual wards

Background and definition

About virtual wards

Virtual wards support patients, who would otherwise be in hospital, to get the acute care, remote monitoring and treatment they need in their own home, including care homes.

There are different models of virtual wards, and their emphasis on technology varies in line with patient needs and preferences. All models provide clinical support to people in their homes. One type of model, however, is predicated on remote monitoring and minimal face-to-face input at home.

Other models provide an additional layer of intensive support through a blend of face-to-face provision provided through a multidisciplinary team and technology-enabled care. This model is often referred to as a Hospital at Home. The concept of a Hospital at Home is well established. As patient needs become more complex, the operating model to meet those complex needs becomes more intensive.

Virtual wards are suitable for a range of conditions which can be safely and effectively managed and monitored at home. Many local areas have developed or are developing virtual wards for a range of people including those with respiratory problems, heart failure or acute exacerbations of a frailty related condition.

Definition of technology-enabled virtual wards

Virtual wards should be technology-enabled to maximise the opportunity they offer for both patients, carers and staff. Technology-enablement means the management of patients via a digital platform. In a technology-enabled model, patients measure agreed vital signs and enter data into an app or website. In some cases, they wear a device that continuously monitors and reports vital signs.

Clinical teams see individual patient measurements for the cohort of patients they are responsible for via a dashboard. The platforms or technology software ensures they are alerted when any patient moves outside agreed parameters, allowing them to take appropriate action. Patients should be considered for a technology-enabled service where one exists, however it is important that alternatives are available to avoid digital exclusion and take account of personal choice. It is also important consideration is given to other opportunities technology may offer such as the use of point of care testing or remote diagnostics to support virtual wards.

Using technology can support organisations to reduce the burden on frontline staff by making the right information available to the right people at the right time to improve patient outcomes. The type of virtual ward model introduced will vary subject to what is locally established and clinically agreed.

Systems may wish to consider phased approaches to implementation, for example establishing an early discharge virtual ward model, then building on this to develop admission alternative models.

The exact virtual ward model and pathway type will differ between and across integrated care systems (ICSs) depending on workforce constraints, existing initiatives and local population needs.

Systems should review and make plans to expand virtual ward capacity, including COVID-19 virtual wards and Hospital at Home services that support more complex patients. This should be done as fast as practical, taking account of local circumstances and building on existing footprint of services.

This guidance is to be used in conjunction with the virtual wards and Hospital at Home supporting guidance. This is intended to enable teams to set up technology-enabled virtual wards. All technology enabled models need to align to the principles for virtual wards outlined in this document. Alongside this, further guidance to support two model virtual ward pathways, such as acute respiratory illness and frailty, is available on the virtual ward website.

Developing a requirement specification

The digital platform chosen to support a virtual ward is dependent on local need and local system digital maturity and strategy. To support this, NHSX has introduced a set of Digital Technology Assessment Criteria (DTAC) for health and social care which all digital platforms are expected to meet. Systems procuring new digital platforms should ensure this is part of their requirement specification. This gives staff, patients, and people confidence that the digital health tools they use meet NHSX’s clinical safety, data protection, technical security, interoperability and usability and accessibility standards. This assessment criteria provides information on designing and assessing digital health services. It describes apps and tools that could be used for patient care, including example procurement frameworks.

Technology is an enabler of a clinical model based on local need and guided by national and locally agreed pathways of care. It is essential to start by considering the clinical and business requirements of the virtual ward service and define a service specification for technology based on those.

Teams should consider the technology partnerships and platforms already in place across their ICS in alignment with their digital strategy to support future scalability. Once the clinical and business needs are determined, a local requirement specification for the use of technology in a virtual ward can be developed. This should ideally be completed at an ICS level even if different technology platforms are in use in the short term to facilitate an ICS level solution longer term. A requirement specification for technology should as a minimum include consideration of the following. This is not an exhaustive list.

Regulatory requirements

Regulatory requirements include information governance (IG), clinical safety, technical security and Medicines and Healthcare products Regulatory Agency (MHRA) level approval required for associated devices. Further information to help with these aspects is available through Digital Technology Assessment Criteria (DTAC) guidance. Further information can be found on the FutureNHS GDE platform in a blueprint that was developed to support the deployment of remote monitoring. To access the whole blueprint you will need to be a member of the GDE Future NHS workspace.

Monitoring

Level of monitoring required, for example continuous monitoring via wearables or spot checks where patients use connected devices to record vital signs at agreed time or enter data from disconnected devices, or a combination of both

Accessibility

Software should meet the accessibility and usability standards set out in DTACs. It is important to consider the range of communication options to include web, apps, video consultation, voice calls and texts to ensure it is appropriate for the broadest range of patients.

Patient support

The level of support patients will require to use the technology should be considered. This may include supporting the use of clinical equipment, accessing a website or using an app via an electronic device. This should include access to patient information leaflets.

Equality Impact Assessment

Completion of an Equality impact assessment ensures the service you are specifying is inclusive and confirms alternative arrangements for patients unable to use technology.

Alongside these considerations it is essential to build a team to enable rapid delivery. Key roles will include:

• clinical leadership
• operational leadership
• programme or project management support
• information governance expertise
• procurement expertise
• digital expertise
• data/reporting expertise
• patients or people with lived experience

Clinical pathway development

The use of technology-enabled virtual wards needs to be supported by robust clinical pathways supported by appropriate local system governance. Guidelines have been developed to support two model virtual ward pathways: acute respiratory illness and frailty [insert links to both when finalised]. More will be completed in due course.

Locally systems are also designing clinical pathways based on local priorities which technology enabled virtual wards can also support as long as appropriate local clinical governance is in place. Clinical pathway guidance should be incorporated into local standard operating procedures (SOP) which support the day to day operation of the virtual ward, clearly explaining how technology will help deliver this. Clinical assessment, referral, onboarding patients onto virtual ward platforms, monitoring and discharge should be covered within any pathways and associated SOPs.

Change management

Clinical leadership

Clinical leadership is important to influence innovation and improvement in both the organisation processes and to engage and support the clinical team. Digital champions are useful to feedback learning from the clinical team and inform enhancements to the clinical pathways.

Standard operating procedures

Standard operating procedures (SOP) should be developed which describe step by step instructions for the clinical team to safely care for patients in a virtual ward setting. The SOP should include:

• define the process for patient assessment and referral to the virtual ward
• onboarding to include support for patients using the technology
• how they will be monitored
• escalation plans
• discharge management

The SOP should also include how the technology equipment will be managed, deployed to the patient, returned and associated infection control procedures. Arrangements for and links to the business continuity plan should be included. Example SOPs are available on the National Innovation Collaborative FutureNHS workspace.

Training

All staff involved in the delivery of the virtual ward should receive training appropriate to their role to ensure they have the knowledge and skills to safely care for their patients. A training plan should be developed at the start of the project to identify the training needs of the staff and the resources needed to deliver this. Training should include all the elements of the SOP, the technology being used and how patients and staff will use it including escalation pathways. Generic training to support registered and non-registered staff working in virtual wards including COVID virtual wards is available on the e-learning for healthcare platform.

Data governance

As virtual wards develop, there will be new partnerships working across different NHS providers, care organisations and technology partners. Good practice guidelines to support the management of data driven healthcare are available as well as information governance (IG) guidance.

In collaboration with your data protection officer, a data protection impact assessment (DPIA) should be completed due to the processing of personal data. The DPIA will help you identify and minimise the data protection risks of your service. It should include:

• a description of the nature, scope, context and purpose of the processing
• an assessment of necessity, proportionality and compliance measures
• identifying and assessing risks to individuals
• identifying and controlling measures to mitigate those risks

NHS organisations should have access to the data being generated in their services In addition to direct patient care, consider what analytics and reporting systems need to deliver which may include population health management. This might include data generated being linked with information from other sources to understand the impact of virtual wards on outcomes and use of other NHS services.

A data sharing agreement (DSA) should be in place which sets out the purpose of the data sharing, covers what happens to the data sharing at each stage, and sets standards for all parties involved in sharing to be clear about their roles and responsibilities.

In respect of data processing, system agreement will be required on data controllers and processors. In all instances the NHS organisation should be the data controller, but it may be necessary to have joint controller and processor arrangements between NHS organisations. These will be set out in the DSA.

There are further tools and templates to support on data governance and information governance on the IG portal.

Clinical safety

Clinical safety is paramount in delivery of any new models of care. Guidance on reviewing tech enabled models is provided on the clinical risk management standards area of the NHS Digital website.

All trusts should have at least one clinical safety officer (CSO) in post, to consider the risk to patients of any new platform, service, pathway or digital solution. CSOs must be registered with a professional body and be a qualified and experienced clinician. Specific clinical safety training can be undertaken by staff and is delivered by NHS Digital. By following a clinical risk management process the potential for design flaws or user error resulting in patient harm is minimised. Standards also recognise the need for organisation commitment and management support.

When a system is implementing a remote monitoring solution to support their Virtual Ward it is essential that any devices comply with the CE or ISO requirements for that group of products. This will be covered as part of any DCB0160 process but is also part of The MHRA device regulations for Software as a Service (SaaS). This may include patients using their own device for example smartphone, laptop or tablet. You will need to ensure that their products also comply with the necessary CE or ISO specifications.

When deploying products that you may want to reuse it is critical that you ensure there is enough time to allow for a deep clean or decontamination of any products. It may be necessary to involve infection control teams in the preparation of an SOP to do this.

There is the requirement to maintain adherence to existing policies and procedures to include DCB0129 and DCB0160. These are NHS Digital’s set of requirements structured to promote and ensure the effective application of clinical risk management by those organisations that are responsible for the development and maintenance of health IT systems for use within the health and care environment. This information standard is published under section 250 of the Health and Social Care Act 2012.

Interoperability

Technical standards to support interoperability are outlined in the DTAC guidance however it is also useful to ensure clarity on the following:

Clinical data capture

Confirm what clinical data items are required. For example vital signs and patient reported outcome measures (PROMs) and how these can be shared across systems for use by different teams to avoid duplication in data capture and patients being asked for the same data numerous times.

Operational data capture

Confirm what data items are required for operational reporting and analysis. To minimise the burden on virtual ward providers, data items that enable reporting of patient attributes, throughput, length of stay, referral and discharge routes, clinical activity and patient outcomes should be captured by the systems in a consistent format and linked closely to clinical data capture.

Resources to support implementation

A number of technology enabled virtual wards are either live or being implemented across England. There are many examples of technology enabled virtual wards across England and a variety of innovative digital platforms supporting this work. Examples of these projects and related documents and webinars for example can be found on the Innovation Collaborative FutureNHS platform.

Examples of current virtual ward services and patient stories

You can watch a BBC News short video or read an article about David Whitlock who received care in a virtual ward following early discharge from Norfolk and Norwich University Hospitals NHS Foundation Trust.

You can watch a short video of Leigh Jones who talks about his experiences of receiving care on a virtual ward.

You can read a case study from Leicestershire Partnership NHS Trust on developing virtual wards to manage long term conditions across the Midlands.

You can listen to a podcast on how technology-enabled remote monitoring in Leicestershire has supported patients like Barry James who has heart failure (listen to episode 2).

Other relevant videos and case studies are also shared on the National Innovation Collaborative workspace. The workspace encourages members to share their own progress, learning and insights and is a community working together to deliver technology enabled services to support people at home.