Remote clinical management as part of standard care for rheumatology patients

As a result of the COVID-19 pandemic, patients under regular review by the rheumatology department at the Oxford University Hospitals NHS Foundation Trust (OUH) were unable to attend hospital. This was because of a lack of clinical resources and reduced clinical capacity.

Situation

The team had approximately 7,000 patients waiting for a follow-up appointment. However, there was no capacity in clinics for face-to-face, telephone or video consultations.

The purpose of this project was to digitally collect disease activity markers and clinical information before a patient’s clinic appointment.

It also aimed to act as a substitute for a face-to-face appointment for patients with existing conditions who were unable to attend hospital.

Aspiration

The Trust wanted to:

• identify which patients needed to be seen in person and when
• use remote technology for disease assessment to provide evidence that expensive biologic drugs were being prescribed appropriately
• ensure that all in-person assessments were as efficient as possible

Solution and impact

Clinicians can now rapidly review the health of a large number of patients who are unable to attend their appointments.

The team used existing licensed software (Microsoft Forms, Microsoft Excel and Microsoft Access) and the electronic patient record (EPR) to design a purpose-built system.

The system collects clinically-relevant information using 5 bespoke Microsoft Forms. These can easily be completed by patients using a smartphone, tablet or computer.

Each form includes:

• common questions about medication
• new problems noted by the patient
• information about their last appointment
• a published, validated patient-reported outcome measure (PROM)

Patients are sent a link to a form by email or text message.

To help patients access this remote pathway, there is helpful information on the Trust’s rheumatology website.

The data is extracted from Microsoft Forms and saved on the secure hospital server as an Excel file. Each Excel file is then imported and stored in the rheumatology assessment database innovation in Oxford (RhADIO) for data processing. This calculates a disease activity score.

The information collected is used to prepopulate 5 forms created in RhADIO.

Clinicians can view a summary and use the hospital EPR to make an informed decision about how soon patients need to be reviewed and in which format. This ensures the correct clinic stream is identified, making contact with patients as efficient as possible.

Once the clinician completes the evaluation, a report is automatically generated. This is pasted into the EPR and automatically sent as a letter to the patient and their GP as a formal consultation.

The new system aided:

• communication between patient and physician
• shared decision making
• identifying appropriate targeted treatments

Functionality

• There are 5 Microsoft Forms (1 for each patient group) which can be completed on a smartphone, tablet or computer.
• All data is stored on a secure hospital server.
• An existing Microsoft Access database stores data and synthesises the information into a meaningful summary for each patient. This helps clinicians to quickly complete patient assessments and create semi-automated reports.
• EPRs contain bespoke clinic templates to allow reports to be sent quickly to patients and GPs through the standard hospital system.
• The system includes a patient feedback form.

Capabilities

The system can rapidly process information about a patient’s clinical condition based on a combination of:

• the information they submitted
• completed PROMs
• a review of their medical record

A summary report can be sent to the patient and GP to outline any changes in condition management and to arrange a follow-up assessment.

The system provides relevant information to the administration team to arrange the follow-up.

To audit the performance, teams can record:

• the number of patients processed
• types of patients evaluated
• how many assessments revealed evidence of stable disease without intervention versus the number of unstable diseases needed urgent face-to-face review

Scope

• Patients can complete their form at home.
• All patients who are already known to the rheumatology service are eligible.
• Remotely collected data is processed in the clinical setting to complete the assessment.

Key learning points

• Most patients aged 30 to 80 completed the forms.
• Some patients were unwilling to complete the form.
• Some patients did not respond to the request to complete the form.
• Administrative support is key to send form links, check on incomplete forms and re-send links to patients who do not initially respond.

Initially, the team allowed patients to select a face-to-face appointment even if their condition was stable, which many accepted.

As a result, the team changed the questions so that only patients who had a self-declared unstable disease could request a face-to-face appointment.

Digital equalities

Patients unable to complete the forms remain on the backlog. However, the likelihood of an appointment increases as the team reduces the overall size of the backlog.

These patients are reviewed in a telephone, video or face-to-face appointment.

Key figures

From December 2020 to June 2021, the team triaged 555 patient records.

• There were 364 patients with rheumatoid arthritis of which 52% had a telephone appointment and 37% a face-to-face appointment. Of these, 33% needed an appointment in less than 3 months and 67% in more than 3 months.
• There were 72 patients with systemic lupus erythematosus or connective tissue disease. Of these, 47% had a telephone appointment and 32% a face-to-face appointment. 11% of patients needed an appointment in less than 3 months and 89% of patients needed an appointment in more than 3 months.
• There were 48 patients with ankylosing spondylitis of which 50% had a telephone appointment and 44% a face-to-face appointment. Of these, 40% needed an appointment in less than 3 months and 60% in more than 3 months.
• There were 47 patients with psoriatic arthritis of which 45% had a telephone appointment and 47% a face-to-face appointment. Of these, 50% needed an appointment in less than 3 months and 50% in more than 3 months.
• There were 42 patients with vasculitis of which 62% had a telephone appointment and 21% a face-to-face appointment. Of these, 24% needed an appointment in less than 3 months and 66% in more than 3 months.

The system is designed to assess patients who are in the backlog without any appointments. If patients were able to complete the form, the team analysed their information and provided clinical advice, which is the equivalent of an appointment. In over 60% of cases, these patients did not require an appointment within 3 months.

Based on feedback from 39 respondents:

• 85% used a mobile phone and 15% used a computer or tablet to submit the forms
• 70% said the process was extremely or somewhat easy
• 20% were neutral
• 10% found it somewhat difficult

The team compared the results of the remote assessment with face-to-face clinics across a sample of 45 patients. They found:

• remote and face-to-face clinics had an agreement rate of 69% to 84% when it came to assessment
• remote and face-to-face clinics had an agreement rate of 31% to 84% when it came to therapy

Find out more

Demo patient form

Key contact

Professor Raashid Luqmani, Professor of Rheumatology, Consultant Rheumatologist, Clinical Lead in Rheumatology, University of Oxford

raashid.luqmani@ouh.nhs.uk

Dr Anushka Soni, Consultant Rheumatologist, University of Oxford

anushka.soni@ndorms.ox.ac.uk