Telemonitoring at scale for hypertension in primary care

Uncontrolled hypertension is the largest manageable cause of stroke and heart attack. It can be treated effectively with anti-hypertensive medication.

Telehealth smart messaging systems encourage medication use and are effective at lowering blood pressure (BP).

NHS Lothian’s Scale-Up BP team wanted to understand if integrating a telehealth system into the clinical workflow would increase adoption.

Situation

Despite the effectiveness of anti-hypertensive medication, many patients have uncontrolled BP.

Randomised control trials show that telemonitoring for hypertension is associated with improved BP control. However, healthcare systems have been slow to implement it. This is, in part, due to concerns over whether trial findings can be replicated in routine clinical practice at scale.

Aspiration

The team wanted to explore the feasibility and impact of implementing, at scale, an integrated telehealth system for hypertension. The system would integrate into:

• routine primary care
• remote patient support

Solution

Florence is a persona-based smart messaging tool which uses psychology to increase patient engagement and change behaviour.

The system is used for remote healthcare and encourages patients to interact and manage their health.

NHS Lothian developed an integrated system which uses Florence to give GPs regular summaries of patients' BP which they monitor at home.

Participating patients with hypertension are provided with the equipment to measure their BP.

Patients use the Florence system to submit readings through text message on their phone.

The readings are available to clinicians through the primary care management system.

Patients are automatically informed by Florence if their submitted readings are outside of the normal parameters. They then follow a written action plan or contact their clinician if appropriate.

Impact

The number of participating practices grew steadily following the launch.

By July 2019, 75 practices and 3,200 patients were participating. This study indicated that deployment at scale is feasible and successful.

Implementing Florence had multiple benefits.

• Compared to non-telemonitored patients, patients on Florence demonstrated increased BP control. Systolic BP reduced, on average, by 6.55mmHg and diastolic BP reduced by 4.23mmHg.
• The total number of appointments reduced by 8%, and the number of face-to-face appointments reduced by 15%.
• Total consultation time for participants fell by 15 minutes 24 seconds. This is compared to 5 minutes 30 seconds in patients not supported by the telehealth intervention.
• Patients found the system helpful, and there was a low rate of discontinuation.

Functionality

• Florence is cloud-based software for clinicians. This means it’s accessible from any web browser.
• The platform allows clinicians to build protocols for individuals or cohorts of patients. This means they can automate nudges, prompts, reminders and motivations to improve patient adherence and outcomes.
• Clinicians can choose a pre-built protocol from Florence’s library. The library contains more than 100 tried-and-tested pathways aligned to specific conditions.
• Patients interact with Florence by text messages. There are no apps to download and patients do not need a smartphone.
• The solution is totally free for patients.
• Helping patients to self-manage at home has huge impact on the clinical team’s workload. It reduces unplanned admissions.
• Florence presents clinicians with a prioritised caseload. This means they can spend more time with the patients who need more help.

The solution can also collect patient-reported readings, symptoms, or both, such as:

• blood pressure
• blood glucose
• weight
• mood
• pain

This means the solution can provide advice for the patient to act on.

The readings can also be discussed at the next face-to-face appointment as part of the treatment planning process.

Capabilities

The solution can:

• encourage patients to take responsibility for their mental and physical health
• share management of the patient as they report their symptoms and readings themselves
• improve patient engagement with medication, treatment, and lifestyle choices
• be personalised through collaboration between patients and clinicians
• improve patient health literacy and confidence to self-manage
• allow patients to be onboarded by clinical teams
• help patients enrol themselves onto protocols
• communicate with patients in their own language and dialects
• present dashboards to clinicians who can see the status of their entire caseload at a glance
• notify clinicians if patients start to deteriorate
• automatically signpost the patient to the most appropriate intervention automatically at the 1st sign of deterioration
• provide opportunity for earlier clinical intervention

Scope

Florence is used across health and social care. For example, it can help patients with healthy living and stopping smoking.

It’s also used to support patients with complex conditions, like COPD, or those who are at risk of falls.

It’s a crisis management tool which signposts patients to the most relevant place for immediate support. For example, if they have mental health problems or unstable vital signs, they will be directed to the right team.

From an acute perspective, there are a number of protocols which are designed around:

• pregnancy-induced hypertension
• pre and postoperative preparation
• outcomes reporting

Once discharged from an acute setting, the team can continue to support patients remotely via step down facilities. The team can support patients at home for as long as they need to.

Key learning points

• This intervention gives control back to patients, especially for those with mental health and long-term health conditions.
• Frequent short messages at no cost are motivating for patients.
• Therapy is more effective when patients commit to home practice between sessions. Using Florence means that patients can reconnect with what is important to them, their health, relationships, work and leisure. This reduces feelings of isolation.
• The messages stay on the patient’s phone, and they can receive messages even after treatment has ended.
• This intervention can enhance the effectiveness of therapy with little input from clinicians.
• It can enable a wide reach across the community at low cost.

Key quotes

“[Florence] prevents cancellations on the day and enables theatres to fully utilise their time.”

Kelly Crutchley, Deputy Department Leader and Nurse, Sherwood Forest Hospitals

“Everybody gains from it. I save from not having to go and wait in the doctor’s waiting room. Equally the doctors and nurses save from not having to take your blood pressure when they’ve got other people with more important issues to see.”

Bobby Blackmore, service user.

“There have been no direct trials to our knowledge exploring the impact of telemonitoring on cardiovascular outcomes, but based on previous studies of anti-hypertensive agents, blood pressure reductions of the magnitude achieved in this study would be expected to lead to a greater than 15% reduction in risk of stroke and a greater than 10% reduction in risk of coronary heart disease.”

Dr Brian McKinstry and colleagues, Scale-Up BP

“The importance of what we are trying to help teams deliver cannot be overstated. Demands on our services are continuing to increase. Utilising technology will not only enable us to shape services to suit the needs and preferences of individual patients; embracing it will also help us take on the challenges we face every day.”

Dr Ruth Chambers OBE, GP Principal, Stoke-on-Trent

“Florence is a low-cost, low-risk innovation with a strong track record.”

The Kings Fund

“The benefits Florence can deliver are wide ranging.”

The Health Foundation

“Flo has been formally evaluated, with positive results.”

Nuffield Trust

Find out more

Peer reviewed article about scale-up of Florence on PLOS Medicine website

Video on NHS Scotland about Scale-Up BP

Key contact

John Griffiths, Head of Sales, Florence

john.griffiths@pshealthgroup.com

Dr Brian McKinstry, Clinical Lead, Scale-Up BP

brian.mckinstry@ed.ac.uk