The SOTW NHS Telehealth Project

The two year project was formed with the objective of innovating new cost effective ways of delivering and applying Telehealth solutions set against the background of QIPP Reforms.  The intention was to test, learn and innovate to find cost-effective ways of driving clinically led Telehealth pathways and it was not the intention to try and roll Telehealth out at scale by procuring a Telehealth Platform up front and investing heavily in one type of platform. 

Gaining Clinical buy-in to Telehealth

The South of Tyne and Wear is no different to other parts of the NHS.  It is difficult to gain Clinical Buy In to Telehealth Applications.  Therefore we gave ourselves the best chance by:

• Appointing a Senior Clinical Director to Head up the Project
• Formation of a Telehealth Board to Steer Activities
• Local Authorities (LA’s) engaged to partner and assist (even more relevant now with Public Health in LA’s)
• Focusing on Clinical Champions - clinicians often influence each other!  As one clinician successfully implements a Telehealth Pathway, others tend to follow the good practice and adopt the learning, particularly with locally generated evidence.  A single clinical champion can generate significant interest and buy-in, especially in a local context: Foundation Trust to Foundation Trust or GP Practice to GP Practice

Why is it so difficult to obtain Clinical buy-in to Telehealth?

Apart from the well documented arguments around evidence and system costs, there are other factors at work.  The statement below was made by Dr Hussien.  I believe (and most clinicians I have spoken to over the past 18 months also agree) that Dr Hussien has succinctly summed up one of the main reasons Telehealth Systems can struggle to get clinical buy- in:

How we Addressed this Factor

Start with a clean sheet of paper - don’t ask the clinician to use a system that has been bought previously and works in one way only, or has a high unit or maintenance cost as it is likely to bring objections immediately. You can’t procure a ‘one size fits all’ system.

• We began by developing the ethos that a clinical system can only be developed by an enthusiastic clinician.  Therefore in order to develop this in the first wave we sort out clinicians that would conceivably be receptive to Telehealth.  We then deployed Pathway Development Officers who actively met up with clinicians and clinical teams gaining a clear insight as to the clinicians’ requirements and that of the patients.  The Pathway Officer also takes ownership of the clinicians Telehealth Application which starts with concept and works through to end delivery.  This gives continuity to the clinician and a centre of contact for the clinical team which leads to standardisation of process.
• Once the clinician/patient requirement is understood, the team used Total Quality Management Tools developed in industry in order to identify exactly the clinician/patient requirements.
• Quality Function Deployment (QFD) was used to identify the “Ranked requirements” of the clinician and patient.  Then the deployment aspect of the tool was used to identify the “How we satisfy” these ranked requirements.  Once fully understood a Telehealth system was matched to the clinician’s medicine and patients needs. 
• Our Telehealth team has a mix of technical, managerial, political and communication skills which work well in developing the Telehealth pathway.  Clinicians are busy and it has been found that by rapidly and systematically solving locally Technical, Political and Managerial aspects of implementation, this can significantly encourage clinical uptake of Telehealth as a concept.

Telehealth Platform Choice

By using the QFD techniques outlined above and in developing some 27 different pathways so far, it was quickly understood that any Telehealth Model would consist of several Telehealth Platforms.  For example it may not make financial sense to ask a person with diabetes to use a home based 1^st or 2^nd Generation system as the costs could potentially outweigh the potential benefit.  Also a patient being delayed discharge because of the delay time taken to set up broadband or install a home based system may also be equally undesirable.  Therefore a one platform solution may not provide the wide clinician and patient appeal required to gain Telehealth traction.    

A point relating to life styles is that if the Telehealth system does not fit the patient’s own lifestyle, then it will inevitably fail as a solution as the patient will quickly opt out.  For example a system that is home based and requires the patient to place readings into it at 10.00am each morning when normally at 10.00am the patient is out and about. Many patients with LTC are also “long term well” as the disease pathway may not be advanced enough to make them house bound.  Therefore they often go out and about or work for a living, making a home based fully structured system impractical.

One example of this is our Pregnancy Induced Hypertension pathway.  The Consultant felt strongly that the only method his patients would use to transmit readings would be a mobile phone as all are young, normally healthy and virtually attached to their mobile phone.  However mobile texting on small devices can be equally problematic for patients with sight loss or conditions which effect cognitive ability.  In these cases we have found Bluetooth enabled devices often can provide a solution.

Innovative Approach to Exploit the Span of Telehealth Applications

We currently have 27 individual pathways developed or in development which range from patients with Heart Failure and COPD to Gestational Diabetes.  Also we have Telehealth applications in Public Health such as Smoking Cessation and Weight Management.   As we have spoken to clinicians we became aware that disease management must start with prevention and this leads to lifestyle choices.  

Therefore today’s smokers are often tomorrows COPD sufferers, so within SOTW NHS, we have extended the use of the Florence System to the Local Authorities Public Health practitioners and developed multiple pathways in alcohol, smoking and even breast feeding.  

The span of the application even expands to remote wound monitoring via Woundsense allied to the Florence System and an ambitious intention to introduce Florence into family planning for those women with diabetes.  The reason for this came about during pathway development in Gestational Diabetes.  Consultants told us that often it can take 3 to 4 months to satisfactorily control a mother’s HbA1c during pregnancy, hence the simple idea of using Florence in family planning for appropriate patients.

Our SOTW NHS Model also uses 3G enabled rapidly deployable systems for patients who require a portable take home system that will allow Bluetooth connection with peripheral medical devices.  Our model also uses home based solutions that are designed for those in the advanced stages of the disease pathway or for those patients who require ongoing virtual ward at home installations and struggle with other smaller portable devices.  

SOTW NHS Experience with Florence

During the development of our Model we have found that most pathway developments have occurred with the Florence System as experience has shown it can be configured easily around the clinician’s medicine and patient’s life style.  Another aspect that has clearly influenced this is the low costs of a Florence Telehealth Pathway.

The table below shows a sample of some of SOTW NHS pathways to date: