Digital Healthcare: The Essential Guide

Part One

What is digital healthcare?

Chapter 1

Where we are now with technology enabled care and services

Dr Ruth Chambers

Digital technology offers great opportunities for transforming health and social care services and associated outcomes, and for improving the experiences of patients or service users and their carers.

Despite the common usage of the Internet and other technologies in people’s personal lives, take up of telehealth and technology enabled delivery of care across the NHS and social care settings has been very slow. There are many national strategies that promote the potential benefits to be gained from integrating technology into the wide-scale delivery of care – in particular Skype, telecare and telehealth. There has also been much discussion about how to minimise the barriers to its deployment by NHS and social care organisations, health and social care practitioners and managers, and patients or service users and their carers in the move to enhance high-quality, financially sustainable care in the future.¹,²,³,⁴,⁵

There is a national drive to focus on ‘supporting people in making the right health and care choices through digital access to health and care information and transactions’.²,⁴ This should result in enhanced prevention and self-care and improved quality of delivery of care as well as contribute to future sustainability of health and social care services. The five ‘big enablers’ of the shift in modernising healthcare are thought to be: finance, integration, workforce, technology and empowerment.⁶ Technology enabled care services (TECS) can therefore underpin more effective and productive working and thus save money, aid integration across health and social care settings, support the workforce in more efficient and virtual delivery of care as well as empower citizens.

The infrastructure needed to make TECS work effectively as integrated care includes ready access to digital patient records by health and social care professionals – in a paperless culture. People’s real-time health and social care records need to be shared according to national technical and professional data standards within and across care settings. Practitioners can then share information along patient pathways with informed consent, governance and assurance of safeguards.⁴ This extended sharing of a person’s care records will include interactions with individual citizens too.

If we focus technology enabled care on all the common organisational priorities in health and social care settings we will be able to show that successful remote delivery of care:

saves money (e.g. fewer unplanned hospital admissions, less medication wastage)

is more convenient (for patients, carers and practitioners)

enhances productivity of NHS or social care teams (e.g. fewer home visits or face-to-face consultations)

enhances clinical outcomes (so people live longer in a healthier state).

But it takes time – and many new technology enabled care schemes can take up to three years to set up, recruit or train the workforce and achieve impact from delivery of the scheme.⁷

We do need to optimise the power of individuals to take more responsibility for self-care and shared management of their conditions and their lifestyle habits, hopefully aiding prevention and management of any long-term illnesses. This might be via personalised care plans, with technologies being an option to help people track and analyse their own health data, and social innovation with different approaches to peer support, such as via social media.⁸ We should make best use of the Internet access that nearly 90% of UK adults have.⁹

The vision for TECS for all NHS organisations and local authorities in the UK is to optimise the ‘potential of technology to transform traditional models of care and support and to enable greater self-management of care and support people and their carers to be as independent as possible’.¹⁰ This will empower people of all ages to take greater responsibility for their own health and well-being and make their own choices, with more control over their own health and lives. It will also reduce admissions and readmissions to hospital and enhance long-term care of older people. The goal is also to find particular technology and TECS that work in trusted ways for the clinical team or individual practitioner using them.

NHS England promotes the incorporation of TECS in all commissioning and organisational delivery of care plans. The range of TECS includes: telehealth, telecare, telemedicine, Skype or video consultations and apps;¹¹ but social media channels of communication should be included too.

The national vision for TECS is that everyone with a long-term condition should be routinely reviewed as to what technology might be appropriate to help them or their carers, as well as health and social care professionals, to better manage their conditions or lifestyle habits. Effective technology should therefore enable appropriate planned interventions for patients with greatest need, to improve the quality and timeliness of the delivery of their care.

With people living longer and the proportion of older people in our society growing, pressure is placed on current and future health and social care resources. More proactive prevention is necessary for all individuals with chronic health conditions or adverse lifestyle habits. TECS can improve access to care and provide prompt responses for the older population, hopefully allowing earlier intervention. With these challenges comes high demand on services, requiring new and innovative approaches to delivering care.

Given the significant shortage of financial and clinical resources, better use of TECS may mean that the gap between health needs and available resources is not as wide as anticipated. Doctors and other clinicians will never be replaced as direct providers of acute healthcare (unless by robots?), but what we can do is to utilise TECS to address public health and self-care aspects of care, in order to free up clinician time for seriously ill patients.

While all this progress and transformation of care is exciting, we need to continue to protect personal data and ensure that usage and access is in line with information governance requirements, in order to assure patients of the confidentiality of their personal information.

Collaborative working via TECS

TECS are a combination of equipment, information, monitoring and response that can help clinicians and patients to manage a person’s health and social care. There might be a particular focus on managing long-term conditions (LTCs) effectively, so preventing avoidable deterioration or minimising the consequences of the conditions. This might be through titration of medication, reminders to take medication regularly or attend review appointments, relaying of bodily symptoms, signs or measures by remote means, encouraging improved lifestyle habits, or giving patients (and clinicians) more understanding of their conditions. The essential ingredient to the success of TECS is the dual management plan agreed between patient and clinician – with hopefully more than one clinician involved along the relevant patient pathway – interfacing between general practice, secondary care, mental health and community settings. It should be the drive to improve clinical outcomes for individual patients that dictates whether digital delivery is useful and, if so, what types of remote delivery of care suit the patient’s needs and preferences for the resources available.

The role of a practitioner or manager will be to spot, adopt and roll out technological solutions and enhancements for cost-effective delivery of safe, good-quality care for people with LTCs in their patient population. The role is also to prioritise anticipatory care focused on local priorities so as to minimise avoidable healthcare usage.

Keele University and Stoke-on-Trent Clinical Commissioning Group (CCG) have developed a really useful website: www.digitalhealthsot.nhs.uk. This online resource for clinicians, commissioners and patients describes all types of technology enabled care and has been developed to cover a wide range of TECS initiatives. These include informational videos about LTCs and ‘how to do it’ about technology that can support patients, such as video conferencing for patient consultation.

Virtual access to patient records

With the required infrastructure requirements being addressed nationally, the potential for TECS use is endless. The future is fast approaching and technologies are constantly evolving, adapting and improving around us. The Industrial Revolution lasted for 80 years. The digital revolution started in 1980 and if it lasts as long as its industrial predecessor, it has another 44 years to go! The health-related digital revolution only started recently and is therefore just in its infancy, with many years of advancement ahead of it.

There is a UK-wide push to publish data on individual teams’ and practitioners’ everyday practice, and to continuously invite individual patients’ feedback – comments, complaints and suggestions. Online access in general practice to a person’s medical records, booking of appointments and ordering repeat prescriptions is usually available. Individuals can (or will be able to, in some cases) request that access to their records is extended to other clinicians; or the person use an appropriate app to link to their medical record of their clinical condition and its clinical management. All this improved access to a person’s medical records must be underpinned by appropriate clinical governance for safe care management and information governance for conserving patient confidentiality and safe data sharing. Recent legislation has endorsed the use of a person’s NHS number so that all organisations in health and social care can identify the individual person in the same way with a view to sharing personal data in valid, reliable and safe ways.¹²

Patient online access

People are increasingly choosing to book appointments at their general practice and order repeat prescriptions online. Some want to view their own health records online. They are used to the out of working hours system for accessing medical advice or proceeding to a consultation after telephone triage. Soon, hopefully, people in England will be able to view their GP records, including blood test results, appointment records and medical histories, and speak to their doctor online or by a video link, via their smartphones or apps. There should be associated benefits from such information sharing including increased patient safety with fewer mistakes, duplications or erroneous drug doses; hopefully fewer unnecessary phone calls to practices if patients can book or cancel their appointments; and increased ability for patients to make informed decisions about their health and well-being.¹³ But there are potential risks too: people might be coerced by family members or friends to share access to their medical records with potential harm and safeguarding issues if there is sensitive information in the content. If online services become the prime way to book appointments, those who are more technologically able might snap up the majority of appointments at the expense of poorer people who live without home Internet access or are not digitally competent.

Some ambulance services share patient records through digital systems with accident and emergency teams; some healthcare providers interact with others in different settings through shared records or multidisciplinary interactions via a Skype ‘meeting’ with or without the patient present in person.

How can virtual access to care help the general public?

The adoption of digital technology is happening all around us. People are increasingly using digital communications in their everyday lives, whether that be online shopping, Internet banking, Skype or FaceTime calls with relatives and friends or using apps to search for information or services. Over-55 year olds appear to be the fastest growing age group in terms of Internet usage. These technologies will support self-care, support carers and help people better manage their LTCs.

For patients: flexible access, including access to video, Skype consultations and social media, can lead to:

better access to health services

care closer to home

automated interaction with general practice-based clinician by patient (and carer)

better time management for carers

greater flexibility in how patients access healthcare.

More productive delivery of digital care might provide:

teleconsultation integrated into care pathways with technology enabled services in practice and care/nursing home settings

fewer unnecessary face-to-face consultations for follow-up care of LTCs or redressing adverse lifestyle habits

better time management

learning by doing and sharing care; being more confident and competent with Skype or video consultations

reduced healthcare usage, e.g. unplanned hospital admissions, use of A&E, face-to-face consultations with patient/clinician

multidisciplinary team virtual meetings

reduced health inequalities as those whose work or care responsibilities make daytime access difficult have improved access to care

a behaviour change in patients with rapid anticipatory care that improves self-care and compliance with medication/interventions, and prevents deterioration of health conditions

enhanced patient quality of life, while living with their LTCs

regular follow-up care with appropriate healthcare staff

better integration between community and acute care settings, to ensure that patients are not admitted inappropriately and can remain within their residential setting

reassurance and support to care home staff

earlier discharge from hospital.

The use of technology, such as vital signs monitoring and communication with patients through the use of telehealth equipment, should enable more effective management of resources, as it frees clinicians to focus on and engage in treating and reviewing a housebound patient’s medical condition, rather than spending time travelling to the patient’s home or care home.

The added advantages of technology from a patient’s perspective are their increased ability and confidence to self-manage their health conditions. Interactive communication and information that has a focused purpose may well increase their adherence to clinical interventions and improve lifestyle behaviour. Such change in behaviour (physical and psychological) is likely to continue after the digital mode of delivery is withdrawn (e.g. they might continue ongoing home monitoring of blood pressure) once the patient is empowered and understands the significance of their condition and agreed shared care. This improved virtual access to health or social care is a great help if they have commitments that limit usual access arrangements; for example, because they are carers, work shifts or are away from their home base.

Choice of technology

Choosing the type of technology for digital delivery of care will depend on what is available locally, or is affordable within financial and other resource constraints, maybe after a risk/benefit analysis to match the strategy and local or national priorities. It will also depend on the needs and preferences of a particular patient or service user, their capability (e.g. cognitive function or familiarity with a type of technology or willingness to learn or interact) and the competence of their health or social care professionals or carers. A friend or family member might be prepared to help them out in the use of a particular technology and extend the choice of what is affordable or available.

Choice of technology to underpin the clinical or social interventions will also depend on what support services are available. So, for example, where the functioning of the technology is interactive and the patient’s or service user’s responses are rated on a scale ranging from ‘good’ or ‘no problems’ to ‘concerns’ or ‘red alert’, there will need to be a health or social care response service. This might be simple and cheap, such as automated response messaging that guides and signposts the user to the next steps they should take (what/who/how/when) or provides a real-time or timed active response from a clinician or carer (by text or voice via telephone or face to face depending on purpose or pre-agreed protocol). The patient or service user must have given informed consent to the nature of this interaction and extent of support available and there should be written proof that they consented to an automated interaction, if that is the case.

All of these aspects should have been considered at a pan-organisational level where patient safety and mitigation of risks are covered in a ‘privacy impact assessment’, the ‘standard operating procedure’, ‘information governance’ and ‘clinical governance’ documents approved by the respective Caldicott Guardian. It may be that there is a commissioning board, or health and well-being board, to sign off such policies and aid synchronisation across local NHS, local authority, and third sector or voluntary group settings. This promotes multi-provider delivery and integrated care.

Range of technology commonly used in health and social care settings

Telemedicine

‘Telemedicine’ is a term that has varied interpretations. It sometimes relates to the use of sensors and electronic means of communication from one clinician to another, to aid diagnosis and clinical management; this might typically be by a pre-booked video conference between GP or community nurse and consultant for a shared patient consultation (the patient may or may not be present too).¹¹ Sometimes the term ‘telemedicine’ has a wider application, such as ‘distance medicine using information and communication technologies to examine, monitor, treat and care for patients over a distance … both within and between all kinds of healthcare institutions as well as to monitor and provide support to patients living at home’.¹¹ Even a consultation generated by a clinician phoning an individual patient to relay information might be considered as telemedicine by some.

There is much debate as to the benefits and challenges of telemedicine. On the positive side, video consultation should be more convenient for patients and potentially save costs of travel (for health and social care staff and patients/service users); on the negative side, there are significant technical, logistical and regulatory challenges and potential clinical risks.¹⁴ Read more about telemedicine in Chapter 5.

Skype

Skype or video consultation can provide a remote facility for clinicians to deliver face-to-face care without the patient attending an in-person consultation. It doesn’t directly replace face-to-face meetings but can be used in an integral way for the right person as an alternative to the patient attending a clinic session or the clinician making a home visit.

Video consultation might be provided via an encrypted connection rather than a non-confidential video interaction via Skype. Skype might be set up between the clinician and a patient who has their own access to Skype via their mobile phone, tablet, computer or other device; or it might be set up for clinician to clinician interaction for a remote peer professional meeting or between practitioners in different settings (such as acute hospital and general practice settings). Sometimes connectivity can be difficult, such as in multi-dwelling occupancies such as a care home with flats for independent residents, or with particular mobile phone services. This type of delivery of care has become increasingly well established in rural communities where travel can be challenging, such as remote areas in Australia. People with disabilities or who have mobility issues or mental health problems such as agoraphobia can really welcome video conferencing or Skype which enhances access and availability of care. According to Greenhalgh et al., ‘Having a multidisciplinary team working on a Skype consultation or video or teleconference with team, carer and patient stops people having to go in for an appointment and saves money.’¹⁵

Read more about teleconsultation in Chapter 5.

Telecare

Telecare or assistive technology (AT) maintains or improves the well-being and independence of people with cognitive, physical or communication difficulties. This might include jar openers, bath seats or stairlifts, and electronic sensors and aids that make a home environment safer or which may link to a triage system where alerts can be relayed to social or healthcare teams.¹¹,¹⁶ When a telephone network is included, the AT might be termed ‘telecare’, in which the monitoring of care relates to personal safety, security and home environmental risks via communication over a distance by telephone (mobile phone or landline). Sometimes a non-clinical triage centre is established to monitor users’ responses in real time and trigger face-to-face or other direct help if agreed thresholds are breached – as in Example 1.1. In other systems the monitoring might be automated and overseen intermittently. Telecare also includes the use of electronic sensors and aids to make the home environment safer so that people are more secure and live independently.

It may be that some people prefer face-to-face personal delivery of care from, for example, community nurses or social care workers with whom they’ve developed good relationships. They might resent substitution of technology as an alternative method of delivery, as this might make them feel more isolated. Although some people prefer personal face-to-face delivery that reduces their social isolation, their practitioner or local service pathways might need to prioritise a more effective and productive type of TECS that supplements or replaces face-to-face health or social care.

There is a relatively low uptake of telecare or AT by older people. One way forward for potential users and their carers is to co-design future technology applications and services, evolving ways to co-produce useful and useable solutions.¹⁷

Read more about telecare and AT in Chapters 3 and 4.

Example 1.1 Stoke-on-Trent City Council Telecare Service

The telecare service provides expertise and technology for remote monitoring of clients at home or in residential settings.

Provision of telecare services includes the assessment, provision and monitoring of sensors in the person’s home. When the sensors are activated they communicate automatically with the 24/7 control centre where staff can talk to the person to find out the problem, and dispatch a suitable response when and where required. These sensors include:

community alarm pendant worn by the person

smoke alarm

bed occupancy sensor (pressure pad) to detect if a person has left their bed, or not returned to bed

chair occupancy sensor

door contacts (e.g. to convey an alert about a wandering client)

passive sensors (to detect movement or absence of movement)

fall detectors

automated pill dispenser

flood detector (for overflowing bath, sink etc.)

carbon monoxide detector (to detect a faulty fire/heater)

temperature extremes sensor (to show if a house is getting too hot or cold)

epilepsy sensor (based on detecting the vibration and noise of different types of seizure)

enuresis sensor

combinations of such sensors in a ‘just checking’ system which can be used to assess a person’s activity and mobility at home over a defined time period.

Telehealth

Telehealth includes linked equipment, monitoring and responses that can help individual people to remain independent at home.¹¹ So a telehealth deployment might relay specific physiological data from patients at work or in their homes to clinicians in a health setting to support informed (and hopefully shared) decisions about their clinical management. Telehealth might underpin a ‘virtual ward’ of specific patients with remote monitoring of their vital signs that is overseen by specific clinicians. Telehealth can relay a patient’s vital signs or test results or bodily measures to clinicians caring for them from afar – in real time or close to real time. A great advantage is that patients or service users (and their carers) are much more aware of how their body is functioning and whether their condition is controlled (or not!).

The international code of practice for telehealth services¹⁶ includes sections on:

ethical perspectives

governance and financial issues

personal information management

staff management

contact with users and carers

interpretation of responses to information

communications networks

hardware and technological considerations.

The code of practice domains¹⁶ cover:

health/motivational coaching and advice

activity and lifestyle monitoring

safeguarding and monitoring in care settings

gait, seizure and falls prediction and management

point of care testing and diagnoses

vital signs monitoring

mobile health technology systems

medication or therapy adherence

rehabilitation and (re)ablement

responses to adverse events and incidents

teleconsultations and virtual presence.

Read more about telehealth in Chapter 2.

Apps

Around three-quarters of adults in the UK have a smartphone.¹⁸ Already smartphones are being used for medical applications, coupled with wearable biosensors, and are able to sense, analyse and display vital signs, and generate alerts to significant changes or deterioration, highlighting escalation of a condition which can then be identified and addressed in a timely and proactive way. As part of this smartphone revolution, attachments that can track heart rhythms or monitor mental health via apps can lead to better health outcomes while being more convenient for the patient, their carer and their clinicians.

Health-related apps are often bought or obtained by individual members of the public and uploaded onto their mobile phone or tablet or accessed via website – as in Example 1.2. Health apps can enhance a person’s understanding of their health condition and empower them to manage their health or to be more aware of their lifestyle habits and the associated effects on them. An app might support delivery of health or social care, maybe enabling sharing of provision of care across care settings. Uses of a health app include:

enabling remote monitoring of a patient’s adherence to an intervention or medication, or bodily measurements such as their weight

supporting self-diagnosis or monitoring

providing professional support and education

signposting to appropriate services

sharing visual images and information to enable remote diagnosis

underpinning clinical networks.

Example 1.2 Migraine diary app

See http://apps.nhs.uk/app/migraine-diary/

This app provides a diary for people with migraine. The diary content is derived from Patient.co.uk. The diary lets the user track their symptoms, log possible triggers, record medication taken and access information about migraine and possible interventions and treatment.

The app is freely available. The user can capture:

severity of the pain

length of migraine attack

whether there was an aura

nausea or sickness

possible triggers

medication taken.

Users are advised that recorded details of their migraine attacks can help:

their doctor make a firm diagnosis of migraine

them recognise warning signs of an attack

them identify triggers

them assess whether their treatment is working.

The NHS in England has an online apps library: http://apps.nhs.uk/ (currently being updated). Apps that are loaded in this library are regarded as being ‘clinically safe’. There are European regulations about medical apps; a ‘CE’ mark confirms that an app has been deemed to meet essential criteria, works and is clinically safe. Apps that are for administrative functions, or give general guidance or support training, are not classed as ‘medical’ and thus do not require accreditation. Those that provide personalised advice and are diagnostic or used for medical purposes such as calculation of treatment are regarded as ‘medical’ apps and thus do need a ‘CE’ mark. Read more about apps in Chapter 6.

Social media

There are various ways in which social media can support health and social care organisations or teams. It can work with health communities, motivating them and linking with services offered by the NHS or social care. Social media can also support the introduction of technology, empowering patients or service users to take personal responsibility for their health by giving them access to information, so reducing the need for face-to-face consultation. Social media can also motivate people who may be experiencing significant life changes, bringing them into contact with people suffering from similar conditions. Often these support networks are via closed groups and forums.

Read more about social media in Chapter 7 or access the social media toolkit on www.digitalhealthsot.nhs.uk

Telephone consultations

There’s a lot of emphasis on the types of technology that can be used for digital delivery of care – especially mobile phones and tablets. The benefits to patients or service users come from the enhanced delivery of clinical or social care and associated shared care management, not from a particular