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FAQ




Do we need to redesign our service to use Simple Telehealth?

No.  You can use Simple Telehealth in virtually any setting to improve the quality of outcomes and to reach hard to engage patient groups without any re-design.  Simple telehealth helps patients to engage in the existing pathway/treatment to improve the quality of outcomes.

It is fundamentally wrong to design a healthcare pathway around a telehealth service of any kind.   Follow the advice of Sir John Oldham: "Design the health system first and only then consider if technology can assist to attain better outcomes."


How safe is SMS for use in healthcare?


SMS (Short Message Service) continues to be the most widely used data application with over 80% of all mobile subscribers using it globally. But for many reasons, without careful adaptation and management, depending upon the field of use, SMS communication may not be safe for use in the support of healthcare.

However the robust methods and technological processes built into Simple Telehealth systems, Florence and Annie, turn SMS into a reliable, assured and safe communication channel for use in healthcare to support patients with their shared healthcare management plans.

Top concerns:

1)     Delivery Delays.      With standard SMS, on an odd occasion, messages can get delayed in the network or the target mobile phone could be switched off or have no signal and the messages are not delivered at the time at which they were scheduled to be. This is a particular cause of concern regarding medication prompts and other time dependent uses of SMS in healthcare. However Simple Telehealth systems have built in sensitivity to these possible delays and a clinically appropriate time window within which a particular message can be delivered is set for each message by the members local team. This ensures that if a message can not be delivered within the clinically appropriate window, it is not delivered at all, thereby ensuring that only relevant messages are delivered to the patients handset within a clinically determined safe time window.

2)     Data Confusion.      Should SMS be used to record answers to healthcare questions and self reported biometric measurements without the use of ‘keywords’, due to latency in the SMS telecoms infrastructure and keying errors, it would be possible for a system to record and react to incorrect information. For example if a patient is asked to send in two ‘readings’ each day, say an oxygen saturation level and a pulse. Without preceding keywords, these two ‘readings’ could be confused by a system.

a. A patient, used to sending in both readings daily is prompted to send in the oxygen saturation level of 98, and this message gets delayed slightly, the patient may choose to send in their pulse of say 75 ahead of getting the next question. The system could receive the 75 pulse and record that as oxygen saturation and then record the 98 as pulse.
b. A patient sends both pulse and oxygen saturation in one SMS. The system could incorrectly attribute the readings or become confused.
c. The patient is going out for the day and chooses to send in the readings prior to getting the first prompt. The system could incorrectly attribute the readings or would not be able to determine what the data represents.
d. The patient could inadvertently send in the same data a number of times. Without keywords, the data may be incorrectly attributed by the system.

For safety assurance, Simple Telehealth systems use preceding keywords to identify each data as to its intended purpose, thereby providing assurance that these data will be correctly attributed in any of the scenarios above.

3) Identification.     It is important that only the registered handset is allowed to send in messages to healthcare systems. SMS messages carry an originator identification such as the originating mobile phone number, however this is easily spoofed and messages can be sent from readily accessible websites or computers pretending to be from the patient and this would result in incorrect information being recording in the receiving system and subsequent incorrect messages being sent to the patient. To address this safety concern, Florence not only validates the originating number, but it also validates that each message has originated from a physical handset with an associated mobile network contract.

4) Stalling & Latency  (UK).   Due to the store and forward nature of SMS transit and the inherent nature of the SMS infrastructure to queue and delay delivery of SMS, a number of critical factors need to be implemented to ensure safe, reliable and timely delivery & receipt of SMS for use in healthcare.  To mitigate these and other similar issues faced by every service that uses SMS ,  they have been addressed in the design of Florence to provide a safe and reliable service in the UK.

a. Multiple connections to each SMS network provider/aggregator.
b. Automatic error detection and re-routing away from stalled SMS services.
c. Route load balancing to avoid inevitable ( and normal )  queues and delays.
d. Continual automatic 'heart-beat' testing to provide assurance that the end-to-end service continues to function correctly within an acceptable latency tolerance.  ( testing all of the sending and receiving  processes & functions of Florence, latency, and the routing & queueing functions of Florence's SMS platform, and those of the SMS networks and aggregators.) 




Who designs content and uses?


The methodology creates an innovative environment in which clinicians can develop and apply the shared knowhow and methods in their own particular field.  The content and its uses are limited only by the vision of clinicians.  However, one condition applies to all who use the system: they must freely share their work for the benefit of patients and the NHS.


Is Simple Telehealth really an NHS initiative?

Simple Telehealth was designed and developed by Phil O'Connell as a private individual outside of the NHS.  Phil went on to assign the Intellectual  Property to Stoke on Trent PCT.  Ownership moved to Stoke on Trent CCG in April 2013.   Phil assigned "stewardship" as he calls it, to his local NHS body in Stoke for them to develop and share the concept for the benefit of all NHS patients.

With the continued growth of the Simple Telehealth Community, there are now two licensed organisations involved in the delivery of NHS's Simple Telehealth in the UK, Simple Shared Healthcare Limited ( Social Enterprise) and Mediaburst Limited.

Beware!  there are some private 'telehealth' companies, where Senior NHS staff have taken NHS knowhow and intellectual property gained during NHS employment, and used that for personal gain with no consideration to the NHS or Social Purpose!.  Some even continue to practice in the NHS but use their NHS credentials to lend credibility to their private companies.  Its worth checking out your own telehealth provider!!!


How is Simple Telehealth different from other "telehealth" systems?

There is a general misconception that "telehealth" is about remote biometric monitoring.  However, telehealth actually covers a large range of "tele" approaches to provide convenient and potentially effective ways of engaging with patients. Its about getting health to catch up with techniques and methods already in everyday use outside of health.

Technology wise, telehealth spans from telephone and Skype consultations at one end through to robots helping clinicians to do ward rounds in remote locations. From a clinical perspective it ranges from just a tool such as a telephone through to automated clinical decision engines using validated clinical protocols. There are of course many mixes and matches creating a rich but immature marketplace and the Department of Health are working to make it less confusing and easier to access.

Simple Telehealth has a different purpose than other 'Telehealth' systems and is typically used by clinicians to target genuine and recognised problems by helping to  improve the effectiveness of current care.  Patients are helped to help themselves to improve adherence and confidence with their existing pathway/treatment though a mix of automated and interactive communication.  At the same time it should introduce benefits for clinicians using the system without increasing the cost/time of providing the healthcare service.

Simple Telehealth technologies such as Florence and Annie are instinctive & intuitive and quick & easy to use by both patient and clinician.  Designed to be deployed immediately taking less than 20 seconds to enrol a patient, which can be done by the responsible clinician during a consultation.

Another interesting point that makes Simple Telehealth stand out is that following appropriate governance procedures, data can be shared with a patients healthcare team irrespective of NHS organisational boundaries.  Also, we use NHS intellectual property for the benefit of all, it is low-cost, can be used through a patients own mobile phone and SSHC's trading surplus funds are re-invested in the Community for Social Purpose.


Does Simple Telehealth compete with other "telehealth" systems?

Simple Telehealth should compliment other telehealth services and can happily work alongside them.  "Bio-metric remote monitoring" type systems tend to use a daily triage/monitoring approach which targets higher risk patients for prevention of admissions.   Even within this sub-group there is a large range of services, some offering basic and inflexible services and others offering sophisticated behavioural change, education and automated clinical management.
So in a nutshell, Simple Telehealth does not compete with other services as far as we are aware as its purpose and techniques are quite different.


How much will it cost?

Simple Telehealth with Florence is transparent and based on a pay as you use model.  To get started £11,360 could cover around 3,000 patients and the first 37,500 messages*.

£6,360 contribution towards maintaining this NHS Community of Practice giving access to our shared IP, forums, remote assistance and consultancy via the SSHC team plus access for your patients to the 'free to text' short code.
£2,000 towards the cost of provisioning and maintaining Florence.
£3,000 bundle of 37,500 messages for Flo including the cost of SMS.  ( the cost of each message covers; transaction processing; high quality & safety infrastructure; low latency SMS)
£650 +expenses per day for on-site assistance/training.**

*   "message" cost includes provision of bandwidth, infrastructure and messaging channel (SMS/API)
** New member organisations may benefit from 1-2 days on-site assistance/training to kick start the programme.


Equipment

If you chose applications that need bio-metric monitors such a Blood Pressure monitor for example;
your patient may already own a suitable BP monitor that can be used for home monitoring;
you can ask your patient to buy their own monitor for use with Simple Telehealth.  Some localities have made special arrangements with local pharmacies to stock suitable devices.
your local procurement team can supply a suitable model or we can recommend high specification but low cost devices and put you in touch with a not for profit supplier.
If you do use monitors, then you should factor in the cost of a device against the business case, limiting the "life" of any device to the length of the manufacturers warranty.
Although it is desirable to re-use devices, you may find that it is a lower cost approach to gift the device to the patient as recycling a low cost device through an infection control process may cost more than a new device!
It is usually the patients own clinician ( or suitable team member) who will show them how to use any equipment properly to get the best results rather than outsourcing this crucial activity.

Regarding devices, such as BP monitors, you'll need to adopt a policy appropriate for the intended use and frequency of use in line with manufacturers instructions.  For example a BP monitor for home use may be used once a day as opposed to many times a day for a BP monitor in a clinical setting.   Therefore formal testing of the device needs to reflect this and testing annually could be inappropriate as the device may be guaranteed for five years.

For home use, it could be acceptable policy for the device to enter a testing regime at the expiry of the guarantee ( or replace it with a new one ).  The MHRA advise to follow the manufacturers instructions and CE marked devices are clinically calibrated at manufacture and may have a five year guarantee for that accuracy during which time the manufacturer advises not to do anything to it.   Also for example, a pulse oximeter is typically guaranteed for life and almost impossible for anyone but a specialist to test.  Simply put, provided the manufacturers instructions are adhered to and it is used during the guarantee period for home use only, theres not much to do other than track it, keeping a record of each device, its serial number etc and where it is at any particular time.  You'll also need to advise the patient on how to keep the device clean and to check the battery level indicator and to let you know when they need replacing.  We've found that most pts replace the batteries themselves.


Does it cost my patients anything?

No,  we have provisioned a "free to text" service for members on every UK mobile network so patients are not charged to use the service whether they have a mobile phone on contract or PAYG.


Are we restricted to numbers of patients, clinicians, teams or pathways?

No.


What about patients who can't text or don't have a mobile phone?

Innovative clinicians have developed pragmatic ways to work with patients who can't text or don't have a mobile.   Interestingly, the same methods have been developed independently by very different teams across the UK and USA.
Firstly, they found that age is not a barrier and many older patients may own a mobile phone, but keep it for emergencies only.  So many will own a mobile and the majority of those will already know how to text.
Others methods developed by clinicians for Long Term Conditions patients are:
to invest 20 minutes to show a patient how to text, which also reduces social exclusion.
to work with a patients partner/carer who would be able to interact with Flo via their mobile whilst the patient takes any observations or answers questions.
to work with a social care carer who would be able to text on behalf of the patient during routine visits.
to "loan" a patient a standard PAYG mobile phone (Florence is free to text)
In one instance where a patient was living alone in a remote rural area, clinicians worked with the patients son, who did the texting whilst speaking to his mum on the phone each day.

Technology solutions include the use of a landline telephone (1), the use of a smartphone based telehealth system with bluetooth peripherals (2) and a locked down app on a smartphone (3)

(1) Message Dynamics, (2) Whzan, (3) TellFlo: University of Hull/Stoke CCG


What hasn't worked?

In common with all telehealth solutions, implementation needs the support of senior clinical leaders.  In the early days, our approach meant that we engaged teams via telehealth commissioners, which in some cases put distance between senior clinicians and the project, thereby denying the project essential support.

Simple Telehealth can face recruitment challenges if trying to use it to step older Long Term Conditions patients down from more intensive/contact based services.  Why would a patient opt to come off a service on which they have become dependent and which provides regular reassuring contact (even if not clinically necessary)? The same teams though have succeeded when using it with patients new to the caseload before dependency is established.

Simple Telehealth philosophy is about NHS clinicians keeping clinical responsibility whilst establishing a clinically appropriate level of interaction and/or monitoring to achieve better and faster clinical outcomes than normal care.  We discourage use of Simple Telehealth to put distance between the responsible NHS clinician and patient and industries outsourced "fully managed" services fill this role better.

Some patients are not willing/able to self manage.

Ultimately, the service works well where; patients are carefully selected for a protocol, professional users are familiar with the system and the programme addresses a problem or gap in previous service delivery that was identified by clinicians/users. 


Is there any academically robust "evidence" that Simple Telehealth and Florence work?

As of July 2015 there are 5 academic quality peer reviewed studies published in journals, some covering over 3,000 patients.

VIEW JOURNAL ARTICLES


Is texted, self reported information reliable?

Interestingly, we have found that texted self reported data is probably more reliable than that delivered by automated systems.
There is emerging evidence as to why this might be the case:
Professor of psychology Michael Schrober, University of Michigan:   "it seems that texting may reduce some respondents' tendency to shade the truth or to present themselves in the best possible light"



How long do patients use Simple Telehealth for?


Because Simple Telehealth is used primarily to assist the attainment of clinical objectives, use is usually limited to appropriate points in a pathway or treatment where Simple Telehealth can be effective, so long term use is the exception.

For some cohorts of patients though, longer term use is desirable and a small number have been using Flo for a number of years.   So long as patients and clinicians feel the system is providing a useful and better engagement experience than normal care alone, then use can continue, however patients always have the option to opt-out at any time just by sending STOP to Flo.


What can Simple Telehealth be used for?

Clinicians use Simple Telehealth to support 100's of distinct pathways, conditions and treatments and it's potential is virtually limitless:

COPD, CHF, new hypertension, hypotension, diabetes type 1, dementia, vascular cognitive impairment, sexual health, retinopathy,  medication compliance, diabetes type 2,  medication titration, orthopaedic,  pulmonary fibrosis, cervical smear, smoking cessation, speech therapy, carers wellbeing, mental health behaviour,  long term hypertension, asthma,  alcohol support, weight management, early hospital discharge, outpatient therapy, acute specialist follow up, long term monitoring, prothrombin time, oximetery review,  asthma, depot injections, pregnancy, pain management, physiotherapy, palliative care, learning disability, oncology, neurology, pediatric asthma, health self-assessment, virtual wards including primary, secondary and community providers, falls, neuropsychology, DNA management, CKD, hypothermic, kidney transplant, learning-disability, gestational diabetes, rheumatology,  asthma, obstetrics, interstitial lung disease, dietetics, depression, pregnancy induced hypertension & proteinuria, urology + many more


Is Florence/Annie a medical device?

Florence/Annie, is general purpose short message communication software intended for use in a healthcare setting and is not a medical device. It's 'intended purpose' is;  for use as a tool to accentuate and reinforce the key points of a mutually agreed-upon healthcare plan between a patient and a healthcare provider; It is a reminder/communication service for patients, to help patients engage better with, and adhere better to their existing shared healthcare plan.

Florence/Annie does not contain any 'diagnostic' methods or clinical 'algorithms', it 'measures' nothing nor does it 'calculate', 'interpret' or 'embellish' data submitted by the patient.  It is simply an automatic reply service designed for use in a healthcare setting.   It replies with information pre-set and approved by a clinician and it shows the responsible clinician the actual data sent in without 'embellishment'.   

Examples of what Florence/Annie does not do:

Measure: To detect and transpose physical attributes, such as a pulse, into a standard unit of measure ( such as that done by a pulse oximeter or weighing scales)

Diagnostic/algorithms: To replace professional clinical judgement/expertise with a calculation thereby "dumbing down" the need for professional clinical judgement/expertise.

Embellish/Interpret: To represent data in a way that changes what a clinician sees away from the raw data format. Flo shows clinicians the actual data/data points submitted by the patient. Charts in Flo show the exact data points and Flo does not take any actions based on its own interpretation of the raw data submitted by the patient.

Monitor: To record and apply clinical diagnostic algorithms to data, and to interpret those to support clinical decisions.