A digital follow-up care model providing remote monitoring to reduce the need for unnecessary hospital appointments for patients

Outpatient services can be difficult for many people to access and they do not always meet the needs of the patients. This often leads to high rates of non-attendance and poor patient engagement, which can lead to poor health outcomes and greater use of emergency care.

These factors, in addition to an ageing population, mean that new models of care are needed to meet the rising demand on services in a cost-effective way. In partnership with clinical teams, new digital pathways were developed to support the remote management of patients to help Trusts reduce the need for traditional, routine face-to-face follow-up.

Situation

In the past, patients living with or after prostate cancer have been seen at regular intervals for up to 10 years by their clinical team for follow-up care. Some patients find these pre-arranged appointments reassuring, while some find them not particularly helpful when they are stable and well, unless they have something specific they wish to discuss. In addition to this, the severe shortage of urology specialist nurses means that services are struggling to meet the rising demand.

There is strong evidence that symptoms and concerns are addressed more quickly if patients report them as and when they occur, rather than waiting for a routine appointment. University Hospital Southampton NHS Foundation Trust (UHS) has therefore changed the way it manages the care of patients, with the use of an online digital patient record and a patient-triggered follow-up approach.

Aspiration

UHS developed an online digital patient record to reduce the need for hospital appointments and to create capacity for the clinical teams to focus on the more acutely unwell patients.

The initiative is in line with the NHS Long Term Plan’s ambition to reduce face-to-face outpatient appointments by up to a third, and its commitment to deliver a stratified follow-up approach after treatment for prostate cancer.

Solution and impact

Following the success of a My Medical Record at UHS, the online record was adapted in partnership with the TrueNTH programme to improve prostate cancer care. The new model enables consolidated data to be shared digitally with the patients to promote self-management and remove any unnecessary outpatient appointments for post treatment stable patients.

My Medical Record is an online service that enables patients to co-manage their healthcare. It allows patients to connect with their care team and gain access to information about their condition, test results and clinical letters. The wellbeing of patients can be monitored using dashboards and alerts to report key data collected from wearables and tools such as care plans or surveys. Patients in follow-up are only seen in clinic if their conditions deteriorate based on the agreed criteria, while patients are encouraged to self-manage. Instead of routine follow-up appointments, patients are able to contact their hospital team to arrange an appointment if they have any concerns.

Within the prostate cancer service at UHS, where the solution is used for surveillance, test results, patient information, signposting, and interactive web access to the clinical team, a specialist cancer nurse can save clinic time by remotely reviewing 20 patients per hour, who do not then need to attend a clinic appointment. This is compared to 6 patients in a traditional outpatient setting.

The platform supports service transformation of clinical pathways which can reduce costs, save staff time and improve patient experience.

Impact

My Medical Record is now in use in 15 NHS organisations across the country. It is widely used for follow-up care in cancer, but it has also been used by many other pathways as part of follow-up care and proactive disease management. The service is already returning on investment for hospitals through benefit realisation for both staff and patients.

From prostate patients audits in 2018/19, it showed that:

• on average, patients waited 13 fewer days to have their PSA blood test reviewed by their clinical team using My Medical Record compared to in clinic
• using My Medical Record, 75% of patients were reviewed 3.5 weeks earlier

The platform’s digital workflow allows for the removal of unnecessary outpatient appointments, replacing them with more efficient online reviews. In 2018/19, the prostate service at Southampton:

• replaced 1,449 outpatient appointments with online, paperless reviews and saved £40,000
• saved clinical commissioning groups (CCGs) approximately £31,000 through a reduced tariff
• saved patients £20,000 on travel cost and time to and from the hospital

Functionality

My Medical Record is a cloud-based service, hosted in Microsoft Azure (UK data centre). It is available 24/7 from any location and device with an internet connection.

Capabilities

• A secure record that the patient owns, enabling ongoing interaction between patients and clinical teams
• Simple 2-way integration between hospital data and patient
• Built on a modern open platform, enabling multiple apps and wearables to connect to the same data store

Scope

To support 2-way transactions between the patient and the hospital. Patients can access information on living with or after prostate cancer, complete regular assessments and provide information by, for example, survey completion, direct submission of biometric data, or through wearables. Clinical teams can share blood test results with patients and monitor them remotely to support their continued surveillance and provide safe follow-up care.

Further information

Find our more about My Medical Record, and about the NHS Cancer Programme resources to support personalised stratified follow up (PSFU) with digital remote monitoring systems (RMS) from the Cancer Alliances Workspace on the FutureNHS Collaboration Platform (access via your Cancer Alliance).

My Medical Record is included in the NHSX/NHS England and NHS Improvement 2021 Digital Remote Monitoring System Implementation Guide, available from theFutureNHS Workspace (account required).

Read the BMC cancer academic paper for the evaluation of prostate cancer stratified follow up at Southampton, using My Medical Record.

Key contact

My Medical Record, University Hospital Southampton NHS Foundation Trust

mymedicalrecord@uhs.nhs.uk