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Sustainable digital health, against the odds

posted 18 Feb 2018, 08:13 by Hollie Stirman   [ updated 21 Feb 2018, 05:20 ]
for patients, not profit  

Phil O'Connell 
Creator of the NHS's Simple Telehealth  

20 February 2018 

We couldn't have wished for a better start to 2018.  In addition to the absolute privilege and joy of working with front-line clinicians and hearing first hand, how our work has helped to transform patients' lives, independent research projects by The Kings Fund and The Health Foundation have been published showcasing our work alongside the best of the best innovations in the NHS.  

Below I have set out a few insights into the attributes that make up Simple Telehealth and our sustainable methodology.

Unprecedented recognition

We were delighted in January to read that Simple Telehealth and Florence had received unprecedented recognition as an exemplar case study in two publications; The Kings Fund - "Adoption and spread of innovation in the NHS" and The Health Foundation - "AGAINST THE ODDS : Successfully scaling innovation in the NHS".  Using independent methodologies, both organisations researched innovations in the NHS to determine how and why some innovations had become successful, whilst others had not.   Out of the thousands of innovations in the NHS, The Kings Fund narrowed the field down to 8 and The Health Foundation narrowed their field to 10 exemplars, both of which included Simple Telehealth and Flo. This adds to the recognition received in the prior year in the Nuffield Trust publication "The digital patient: transforming primary care"? where Flo was  selected to feature in the top four! 
“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

This remarkable treble achievement is attributable to the fantastic work of members of the Simple Telehealth Community of Practice who ethically and genuinely focus on the interests of patients, which in turn ultimately benefits the whole Community. 

 Adding to the recognition, last year too saw Florence cited in NHS Scotland COPD best practice and NHS England Challenging Health Inequalities

The strangest secret

Our model is one of an enabler.  We don't "sell" solutions, rather we work with and help clinical teams to solve real world problems and share their learning freely amongst peers.  Our approach, developed with the help and patience of many enthusiastic clinicians is, like our name, "Simple".  

1)  Commissioners buy clinical services based on the assumption that an investment of A will yield outcomes of B for patient cohort of C.    2)  Commissioners accept the assumption that to achieve outcomes of B, clinicians will practice "best practice" care and patient cohort C will have a certain level of engagement and adherence, both with and to the care provided.    3)  The Simple approach, is to help patients improve their level of engagement and adherence to the best practice care already being provided.    4)  Consistent with literature, for cohort C the inevitable result of improved engagement and adherence with best clinical practice is better and faster clinical outcomes.

Attainment of better and/or faster outcomes than are achievable under normal care alone helps teams to solve real world problems, freeing up clinical time, reducing cost and reducing the risk of complications developing further down the line.  In regions where thinking goes beyond short term savings, such as Scotland, significant benefits can accrue, although some of the benefits are realised in other organisations, as the first academic study of Simple Telehealth showed;

Cottrell E, Chambers R, O’Connell P (2012) BMJ Open 2:e001391

Using simple telehealth in primary care to reduce blood pressure: a service evaluation. 

A number of GP practices undertook a service evaluation where Flo was used with hypertensive & chronic kidney disease patients to reduce poorly controlled blood pressure.   The direct results showed a faster and more significant drop in systolic blood pressure than in the controls, but for this CKD group, the literature predicted that the lowering  and better control of blood pressure would delay the need for dialysis as the disease progressed.   Given the average cost of dialysis of £30,000 per year,  a delay of just six months for only 2 out of 100 patients would save £30,000, which is significantly more than the cost of Flo.   Furthermore, for this group of patients, once the effect of Flo had been established, the clinical records showed that the limited use of Flo to augment normal care for a short period of time, had in fact had a lasting effect, way beyond the Flo intervention period.

It is the sum of the techniques and methods used to help patients to better adhere to, and engage with shared care plans and clinicians that enables such results.  The underlying technology plays it's part, but it is just one aspect in a unique combination.

Community of Practice

"Florence’s central team invest in organisations for the long term"
The Health Foundation

The Simple Telehealth Community of Practice led by Lisa Taylor, is without doubt the heart of our model, bringing members together to share knowhow, stories and material and to help each other to achieve successful outcomes.  Lisa's team's primary objective is to invest in organisations for the long term to continually increase their capabilities to ensure patients and the organisation benefit from evidence based implementations for the lowest possible cost.  Our commitment to do the right thing for the right reasons for the benefit of patients, appeared somewhat counter intuitive, as we would be investing in organisations to be able to do things themselves that a protectionist industry would normally charge for.

However this very approach gives organisations the tools, skills and knowhow to adopt, adapt and to innovate, leading to a diverse array of uses in clinical areas and with patient cohorts we would never have been able to envisage.  

"The flexibility of the platform and capability support model enables adoption in a wide variety of contexts, as well as co-production of the way in which Florence is adopted in each site with clinicians and patients."
The Health Foundation

Of particular importance are the regional and national learning and network events inspired by Lisa.  At these events clinicians gather with their peers and showcase case studies and published literature on their local adaptions and uses.  With the methodology being condition independent, these events attract clinicians with diverse clinical interest but uses and techniques presented are totally transferrable.  A huge amount of energy is generated by these events and some of the patient stories evoke an emotional response leaving not one dry eye in the house.  In short these events are inspirational and a joy to attend.

The Simple Telehealth methodology goes way beyond the system itself.  One aspect covers the development and adoption of best practice shared clinical management plans, which sounds obvious doesn't it?  What we find, however is that not all clinical teams have a systematic way of implementing best practice across the team and there can be variations of "best practice" in use.  Simple Telehealth is a catalyst, it provides a framework for adoption of a common understanding of best practice and with a wealth of materials already shared in the Community of Practice there may already be something to draw on.  These materials are not specifically for use with the system, the objective of the development of the materials is that they are simply the embodiment of best practice and can be used stand alone in normal practice.   Members report that this alone delivers positive results for the team, but considerably more significant improvements are made when Florence is used to augment them.

"The Florence team highlight the importance of gathering evidence on how Florence is used in a particular context, or with a focus on a particular cohort and their clinical outcomes."
The Health Foundation

Critically, being part of the Community of Practice means uses need to be evidence based so the design of uses, evidence and sharing studies and evaluation is key to the whole community.   It is as important to share what doesn't work as what does work and how that has been achieved. 

Whats not worked

The UK landscape has changed considerably since I designed Simple Telehealth and Florence.   Many suppliers of "Telehealth" or should I now say "digital" systems have come and gone, some of which had good technology platforms too.   Reputable names like O2, Bosch and Philips have withdrawn from the difficult 'market' and other capital backed companies are struggling, recording eye watering losses year on year.  Set against this, a number of smaller companies are thriving and these tend to be those who are ethical and patient, not profit focussed.

We've observed that the usual methods to market, promote and implement haven't worked and whilst in common practice amongst tech companies even today, hyperbole will have a negative effect.  Early in our journey, Dr Ruth Chambers OBE kindly took the time ( and a lot of patience)  to educate me in the culture, desires and drivers of the clinical world, and it is this on which our methodology is based, and we've built on this ever since.    

The 'push' culture of the NHS seems not to work for us and whilst even centrally funding organisations to buy into this or that can provide a temporary 'fix', it's not sustainable as the real test comes when central funding is withdrawn.  This can also be true of regional support models.   This can look like a lower cost option on the accountants spreadsheet but a regional team can be distanced from the many real problems and opportunities on the clinical front line and so the very opportunities are lost that would enable the realisation of the desired benefits, no one wins and it is the very opposite of what is needed for successful innovation.  We have to 'trust' clinicians to do what is best for their patients and give them the tools to innovate.

"The business model is explicitly not-for-profit, and has a strong narrative that focuses on a desire to satisfy the goals that clinicians are passionate about: better patient outcomes and effective use of NHS resources."
The Health Foundation

Clinician innovators

The Simple Telehealth methodology (incl Florence) is designed to fit with clinical practice and offers clinicians the tools to easily augment best practice care.  It is condition independent and once familiar with the framework, clinicians are able to adapt it to new cohorts or even individual patients.   From a base of  COPD and mental health in 2010, the 2017 graph below shows how innovative clinicians have adopted and adapted it into their own diverse clinical areas of interest.

However there are exciting developments ahead where clinicians are using the framework to help new cohorts of patients, some of which are new to digital health interventions.  The graph below summarises some of the 'other' areas of interest in 2017.

“Its greatest strength is offering a simple, adaptable framework for clinicians to work more effectively with patients and for patients to take a greater role in managing their conditions, without the need for costly investments”
  The Kings Fund

Simple Telehealth; Next generation

We started with Florence in the UK, then worked with the VHA to bring Flo's cousin 'Annie' to life in the USA, and having almost run out of superlatives, we are extremely excited to be talking about the next generation of Flo's family, Nellie in Australia and Clara in the USA too!

This next-gen version of the persona based software uses clever technology allowing us to leverage learning from 8 years with Flo and Annie.  I'm delighted to say that Nellie successfully passed her field trials in Melbourne at the first attempt and has now graduated to use in clinical practice across a range of clinical applications.  

The team in Melbourne are firmly members of our Community of Practice and are already involved.  For a little insight, take a look at these two videos from the Nellie conference, filmed at the Royal Yacht Club, Melbourne in November 17.   

Dr Geoff Campbell - 'Nellie' in hypertension diagnoses

Dr Elizabeth Deveny - 'Nellie' in primary care

Nellie and Clara will continue evaluation in Australia and USA throughout 2018.   Some of Nellie's talents include workflow specific views, dynamic dashboards and patient records that update live as patients interact, simple to use sliders to adjust values, interactive graphs and charts, and access to local and community wide libraries to browse and share clinical protocols and resources.

One of the key considerations in the design of Nellie is it structure, which is tightly designed around the needs and capability of clinical teams and the Community of Practice.  The Flexibility of Florence is one of it's strengths and it's structure encourages innovation within organisations but there are still constraints around the ability of individual teams to be able to innovate and share their work.  The flexibility designed into Florence was considered a departure from industry norms at the time, but I'm pleased to say that Nellie goes further, allowing clinical teams to innovate in an exciting and "radically different way".  We can only wait and see where innovative clinicians take us with Nellie!

Modelling Language

With the growth of the Community of Practice over three continents and three platforms, to help members more easily share ideas and protocols we've created the Simple Protocol Modelling Language which uses a schematic approach to design and visually communicate the structure, make-up and content of Simple Telehealth protocols.

Florence data integration

Not cited in this years recognition, but worth a mention is data.  For some time members have been able to integrate their Florence data with third party clinical and analytical systems.  The process is usually automated via an API, however we've found that the real world is somewhat removed from the hype around data integration.  Pushing data like blood pressure readings into clinical systems can not only be costly but also result in in-appropriate data in a clinical system, thereby increasing legal risk for clinicians.

Indeed, hyperbole encouraged by tech companies around 'interoperability' has been called out as a "red herring" at a recent digital health European Knowledge Transfer Group meeting at the House of Lords on digital health.

In contrast, in a focussed Scottish programme for example, readings are extracted and processed analytically outside of Florence before being summarised and sent back to the clinical team or primary care practice on an exception or acceptable and appropriate routine basis for review by the patients clinician.   The value added benefits of this method reduce inappropriate clinical work and allow routine reviews to be done via the telephone, rather than needing a face to face appointment.  A key differentiator here is that the service is independently evaluated and is welcomed and needed by front line clinicians.