NHS England - Transformation Directorate

Using remote blood monitoring to promote safety for patients on disease-modifying drugs

In 2010, monitoring the blood of patients on disease-modifying drugs was not a planned process.

There was little or no oversight of patients having blood tests. Monitoring was inconsistent across GP practices where patients were registered.

Situation

The Royal Berkshire Foundation Trust raised a safety concern that patients on disease-modifying anti-rheumatic drugs (DMARDs) were not monitored adequately.

Monitoring according to the British Society for Rheumatology (BSR) guidelines across GP practices was patchy.

Aspiration

The team wanted to provide a solution to remotely monitor patients on DMARDs to ensure their safety.

They wanted to:

  • improve blood monitoring compliance
  • reduce unexpected demand for phlebotomy services and urgent emergency care
  • avoid hospital admission by detecting deterioration earlier
  • reduce the need to attend follow-up appointments
  • improve the patient’s self-management of their condition and show them blood results
  • identify abnormal blood test results quickly, allowing teams to act quickly
  • greatly improve patient safety when on high-risk or specialist medication
  • free up time to see other patients by having fewer outpatient follow-up appointments
  • reduce the amount of time spent manually checking blood test results
  • reduce the risk for clinical prescribers when placing patients on high-risk drugs
  • communicate with patients and other healthcare professionals to remotely adjust treatments, ensuring continuity of care
  • lower the cost of monitoring patients on specialist drugs
  • reduce the number of patients attending hospital, releasing car parking spaces
  • reduce the clinical burden for monitoring these patients in both primary and secondary care

Solution

The rheumatology department at the Royal Berkshire Foundation Trust trialled a digital solution to monitor patients undergoing regular out-of-hospital blood tests. In 2010, 4s DAWN Clinical Software was introduced to facilitate this activity.

Before the introduction of DAWN, GP practices and the hospital clinical team had to check blood test results from 3,500 patients every day. There was no clear governance or oversight of the process.

Now, all patients in Berkshire West on DMARDs are monitored using DAWN.

The software identifies and flags abnormal blood test results according to parameters set by the clinical team. The results are shown automatically on DAWN to the hospital clinical team every day. With this system, only 10 to 20 patients every day need a follow-up of the abnormal result.

Impact

Closer monitoring reduced hospital appointments and admissions because any required intervention could be offered earlier by checking the trends in a patient’s blood results. This has facilitated follow-up for patients most in need of care and improved safety processes.

Implementing the DAWN system has helped patients feel better informed and involved in their blood monitoring.

DAWN:

  • allows the workforce to be used in a more dynamic way
  • enables earlier intervention for patients on DMARDs through remote home monitoring
  • frees up clinical time for nurses and doctors as less time is taken to manually check the results
  • saves the clinical team time which is reinvested into increasing capacity to see new patients in the clinic

Functionality

  • DAWN is a software designed for disease management or medication management.
  • The system lets healthcare professionals monitor long-term patients taking potentially harmful drugs.
  • It recognises if a patient misses a blood test appointment. This is flagged and reminders are sent in a pre-populated letter.
  • There are set parameters to create alerts for clinicians when results are out of approved range.
  • Parameters can be set at group or individual level according to disease or patient characteristics.
  • Patient’s blood results can be retrieved from any location the test was performed.
  • DAWN alerts the clinician and patient of how often they need blood tests according to a set schedule such as the BSR monitoring guidelines for DMARDS.
  • The system alerts the clinical team if patients do not attend their blood test appointment. The clinical teams can text or call the patient to check all is well.

Capabilities

  • A hospital administrator triages results, while a team of dedicated specialist nurses assess the abnormal results every day.
  • These clinicians, alongside a DAWN administrator, clinical nurse specialist and consultant rheumatologist, form a DAWN multidisciplinary team to determine what the appropriate intervention should be.
  • There are protocols in place for actions to be taken based on the abnormal blood tests.

Scope

The system database stores huge amounts of drug and disease data. This can be used as a resource to pull audit data to shape care and identify patients who may be suitable for different therapies.

For governance purposes, DAWN has a detailed audit trail for when:

  • changes are made to a patient's record
  • blood results are reviewed
  • actions need to be taken or the record can be closed

Key learning points

  • Some GPs were hesitant to adopt the blood monitoring system as funding needs to be allocated to it.
  • GPs value the safety net that DAWN provides.
  • Using the solution, abnormal results are flagged and the clinical team can provide earlier intervention to patients to prevent their condition getting worse.

Key figures and quotes

  • Blood tests are now conducted every 3 months rather than every month. Money is saved as patients have 8 fewer blood tests each year.
  • BSR DMARD monitoring guidelines are now implemented.
  • There is a 100% compliance rate for blood testing.
  • There is a standardisation of blood monitoring across specialties for the same drug, for example methotrexate, is used in rheumatology, dermatology, gastroenterology and neurology.

Remote monitoring using DAWN provides safety for our patients on DMARD, quick advice to GPs, reduces hospital visits and supports our models of care including patient-initiated follow-up. It is a user-friendly, efficient and customisable system that can free up healthcare professionals’ time for direct patient care.”

Dr. Antoni Chan, Consultant Rheumatologist and Physician

Key contact

Dr. Antoni Chan, Consultant Rheumatologist and Physician, Royal Berkshire NHS Foundation Trust

antoni.chan@nhs.net

Alistair Stewart, Sales and Marketing Director, 4S DAWN Clinical Software

alistair@4s-dawn.com