Digital Innovation in Advanced Practice

Introduction

Data and technology is one of the fastest growing industries in healthcare. In recent years we have seen the focus on digital healthcare increase with the development of NHS Digital and the focus on technology in the Long Term Plan. In physiotherapy we have seen the emergence of the first digital network group within the Chartered Society of Physiotherapy (CSP), the first app library and a new digital physio series hosted on the CSP website. Data is driving more and more healthcare decisions than ever before and in an increasingly automated way. The effective use of data to make clinical commissioning decisions is changing the way funding is allocated and how organisations are incentivised.

While on my Churchill Fellowship I spent time with advanced practice services who had implemented innovative ways of working and many of these innovative practices involved data, technology and digitalisation. In this article I will discuss some of the services and solutions I found interesting and more importantly that clinicians and patients found effective.

Brisbane, Queensland

Telehealth

Telehealth is a mode of delivering health care related services to patients using technology. It can be used to deliver rehabilitation assessment and treatment using video consultation software and can mitigate many of the traditional environmental barriers to patients accessing services (Cottrell et al. 2018).

Simon Whitehart is the Telehealth Coordinator for the Royal Brisbane and Womens Hospital (RBWH) in Brisbane, Queensland. They run a telehealth service for patients referred to the Spinal Physiotherapy Screening Clinic & Multidisciplinary Service (SPSC & MDS). The SPSC & MDS telehealth service mirrors their face to face services with physiotherapy, occupational therapy, psychology, dietetics and pharmacy clinicians working as a multidisciplinary team for both assessment and treatment services.

RBWH implemented this service in 2017 to achieve two main aims. Firstly, to improve access for patients to treatment services and secondly to reduce waiting times for rehabilitation. Around 60% of patients referred to the SPSC reside outside of a metropolitan area. Patients living away from a regional centre behave differently when making healthcare choices to those with more readily available services. They might wait until the problem becomes unbearable before seeking specialist opinion, they might not attend an appointment or they might decline physiotherapy management due to travel distances. One patient who attended while I was visiting had travelled for 9 hours, including a flight and an overnight stay in order to access the clinic. This can be a huge disincentive to accessing care.

Regional and local treatment services had long waiting lists and although large regional centres such as Brisbane were not struggling to staff their treatment departments there were staff shortages at treatment centres outside of the metropolitan areas. Referring more patients’ to the regional centres to avoid long waits locally risks increasing waiting times all round. Telehealth can be cost and time effective and so telehealth services were implemented to help with waiting times in these areas.

Simon reflects:

“if that patient has no access to follow up and they might live in the Queensland interior, 200km to their nearest hospital. Or their local hospital has a two year waiting list for chronic. You think, right, I’m going to have to refer you to telehealth. To improve access we refer to telehealth”.

Alongside the implementation of telehealth for their multi-disciplinary assessment and treatment services RBWH also established a research fellow position which has resulted in a proliferation of evidence around the implementation of telehealth. Through this research they found a lack of clinician acceptance, resistance to change and poor technological self-efficacy were barriers to implementation of technological solutions or services. Before using telehealth clinicians were often concerned about safety and privacy and how they would establish the clinician-patient rapport online.

To address these barriers the RBWH team implemented a telehealth induction programme which included individualised training in the use of the telehealth platform and 3-5 days of offline time allowing clinicians to become familiar with the software and gather patient resources for online use before clinicians went live with patients. Cottrell et al. (2018) found that clinicians’ knowledge and confidence in using the technology and in delivering assessments and treatments via telehealth increased after this induction period.

In RBWH they use a web based telerehab platform called NeoRehab. I observed a patient telehealth session with Steven who is the telehealth treatment physio at RWBH. We are sat in a small office with a computer and a webcam attached to the top of the monitor. After Steven and the patient had logged into the system we could see into the patients’ home and she explained how her neck exercises had been helping her pain. Steven asked the patient to demonstrate her exercises side on to the camera so we could see her neck retraction exercise. Steven could take pictures or videos of the patient doing her exercises and either play them back to her or annotate on the pictures for her to see. This enabled a further means of coaching the exercise using the web-based programme.

Through my discussions with clinicians at RBWH and from the research they have published in this area a number of benefits to utilising telehealth as a mode of service delivery have been identified. For example, initial concerns such as safety and privacy of using telehealth were displaced after induction and once clinicians had been using the software. Clinicians felt clinical outcomes were similar with telehealth and face to face interventions and telehealth physiotherapists felt patients engagement levels were often higher when using telehealth rather than face to face rehab.

This assumption was tested by Cottrell et al. (2016 and 2018) by looking at agreeableness between telehealth and face to face outcomes and decisions in both treatment and assessment. They found that telehealth services improved physical function and pain outcomes. For physical function, telehealth in addition to face to face was more favourable than face to face alone. Telehealth alone was equivalent to face to face for improvements in physical function. Outcomes for pain were comparable between face to face and telehealth modes of delivery.

For services such as SPSC & MDS and orthopaedic assessment services they looked at agreement on a number of measures between face to face and telehealth assessments. They found substantial agreement (83%) for decisions regarding management pathways and diagnosis, moderate agreements (81%) for decisions regarding referral for further investigations and near perfect agreement for onward referral to other Allied Health Professionals. This suggests telehealth is a reasonable consideration for both treatment and assessment services in the future.

Overall there was a high level of satisfaction from clinicians who felt telehealth was cost and time effective and accepted that telerehab would be of clinical benefit to the majority of patients.

Education

Education of advanced practice physiotherapists is another area in which I found innovative practice being developed digitally. In Queensland they have developed a statewide education programme which has been covered in detail elsewhere in this report however here I would like to discuss the educational programmes digital capabilities.

Participants applying for the Extension Programme (the statewide education programme for SPSC & MDS teams) must ensure their work space is enabled with video conferencing equipment and software. The educational coordinator, Patrick Swete-Kelly, has learnt that using a laptop or substandard equipment is not sustainable for a 12 month distance learning course. The quality of the equipment and the users familiarity with it allows participants to engage in clinical debate, presentations to their peers and even observed assessments with patients while their peers give real-time feedback.

I was able to experience this digitally enabled medium several times during my visit through talks and presentations which were routinely broadcast to other hospitals and departments with colleagues logging in from several venues at once to watch the slides, see the presenter, engage with their colleagues and ask questions.

Utilising digital technology to run established education programmes such as the Extension programme and to share more informal presentations and gatherings like those I was involved with enables an equitable educational offering across organisations regardless of distance from the main hub. This approach is also time and cost effective allowing more clinicians to be involved from a more diverse area. Although there may be an initial outlay to ensure each site has the most useful equipment it can be used in many ways and is certainly beneficial for both educators and learners.

Christchurch, New Zealand

While in Christchurch I spent time with a number of services involved in innovative projects including community integration services, Canterbury Clinical Network and the Design Lab. These projects have been discussed in more detail elsewhere in this report but here I would like to highlight some of the digital and technological solutions they have implemented.

Integrated Community Services

The Integrated Community Service is led by Mardi Postill who shared with me her teams’ unique approach to identifying complexity within their community. In the aftermath of the Christchurch earthquake in 2011 Ms Postills’ team were involved with approximately 6000 clients who were in immediate danger. Despite this risk the team knew they couldn’t access all their clients at once. They needed to prioritise but they didn’t know who to go to first.

In response Ms Postills’ team has since created a complexity mapping system. This system allows teams to immediately assess the most in need by area code enabling individualised levels of risk to be assessed and care to be modified specifically for each client. This was achieved by analysing data the team already held due to national standardised data collection requirements combined with data sets which provided additional prioritisation knowledge such as medication, living situation and area code.

They used a nationally standardised frailty index called the interRAI as a key metric of patients’ complexity. The data provided by interRAI incorporates physical, mental, cognitive, clinical and psycho-social elements of frailty and provides a more holistic view of the patients’ complexity. The team overlaid the complexity assessment onto a map of the city. This allowed teams to identify which patients were most at need due to their frailty and which patients were most at need due to their proximity to any potential disaster.

The team now felt more prepared for any further disasters. Ms Postill suggested:

“if we get a notification a tsunami is coming and we know which area it’s going to affect we can quickly pin point who we need to evacuate”

This demonstrates the immediate benefit of the interRAI system in a disaster response scenario but they have also found this to be effective in long term strategic views.

“On a planning level we can see the complexity of the client, we can be strategic about where the population is that needs us.” Mardi Postill.

This unique approach to prioritisation in a disaster response has been maintained as a key metric in the years post disaster and has improved care quality from providers and changed the conversation around funding. Ms Postill considers how using data has allowed them to see the bigger picture:

“It (the data) has been a significant driver in us being able to see the system.” Mardi Postill.

The Integrated Community Team use provider organisations to provide care directly to their clients. Maintaining the use of the interRAI data sets has fuelled competition between providers which has driven up quality standards. Each provider submits basic data such as hours per client. This is compared on a dashboard to improvements in the interRAI assessment. If a provider introduces a new initiative which improves the interRAI for the same provider expense the open nature of interactions between the team and their providers encourages other providers to improve their offering equally. This approach drives an improvement in care quality for the clients.

Using data as their key metric has also changed the way they communicate with their providers about funding. They are able to use the data and the competition it creates between providers to analyse disparity between providers. Ms Postill reflects the ease of bringing providers to account when the team have objective data sets which demonstrate any outliers and help to bring care and costs into agreement.

Data Analysists

Dr Greg Hamilton is Team Lead for Planning and Funding, Transformation and Business Intelligence in Canterbury District Health Board. His team is involved in system-wide planning and funding for community services across commissioning, funding and service providers. They see themselves as future-focused system problem solvers. Their goal, as Dr Hamilton describes it, is “to allow citizens to fulfil their grand plan of keeping them at home as long as possible”.

The team includes an analytics team who are concerned with how data is collected and used from the provider networks. Data analysts work with clinical teams to test hypotheses. Dr Hamilton suggests that the best analyst is in the room with the clinician co-discovering the outcome and building trust between the data teams and the clinicians. This approach also assists with the transformation process because clinicians can find change difficult. Often feeling that change has been imposed rather than discussed and solutions discovered together. However, using this workshop style approach brings clinicians on board from the beginning.

The transformation team also provide clinical teams with a project management resource. Using a project manager directly involved with a clinical team drives projects forward by allowing someone from a portfolio background to step into the team, do some of the ground work and keep the project moving even if clinical needs increase. The project manager can process and manage the data which helps the transformation work go faster and clinical teams feel supported.

Dr Hamilton expresses his ambitions to be a truly data driven system. This is evident when heading into their headquarters where you are greeted by a wall of monitors showing the live admissions and discharges from any of the facilities in Christchurch. This database allows teams to predict bed blocking and plan for suspected increases in admissions. It also allows them to analyse the impact of small scale changes such as an additional role in ED, to large scale changes such as the expansion of their Acute Demand Management Service.

Recommendations

A specific and individualised induction programme is recommended for the implementation of telehealth services. This should include time for clinicians to familiarise themselves with the technology offline prior to use with patients. In recent times we have seen the dramatic shift of face to face consultations to online mediums such as AccuRx and Attend Anywhere in response to the Covid-19 pandemic. My observations and reading suggests that for telehealth to remain sustainable the choice of technology is importance and may be different for different professions or purposes. There is also a need to support ongoing skill development and provide technical support to ensure these changes remain a positive part of our service choices in the future.

Digitalised education programmes allow for more equitable educational opportunities and should be encouraged in all organisations. They can also be more time effective allowing clinicians to finish clinic lists prior to attending rather than having to cut patient lists short to travel to other sites. Investing in the most appropriate equipment is highly recommended as this is a key enabler to the success and sustainability of utilising technology in education.

Combining datasets already collected and using these to prioritise immediate care and strategise for future need has been successful in the Christchurch model and may be effective if applied in other contexts. It is important to develop the clinical question prior to engaging with the data rather than collecting or analysing without a clear purpose. This process should be linked to key strategic priorities in the organisation and the national direction of travel.

A clear ambition towards a data driven system and data driven innovation is admirable and the approach in Christchurch has been to encourage their transformation teams to reach out to the frontline, to provide support for clinicians, to collaborate with them on their projects and to graft alongside. This is not an innovative use of data or technology but an innovative use of resource and skill mix to reach data and technology goals.

Conclusion

Data and technology impacts all areas of healthcare. The innovative projects I have observed spanned the fields of education, integrated services, transformation and analytics, strategic planning and patient consultations. Collaborating with the available data, planning data collection aligned to organisational priorities and scanning the horizon for possible technological solutions are constant and evolving goals for any individual, team or organisation.

References

https://onlinelibrary.wiley.com/doi/abs/10.1002/gps.5171

Hospital avoidance: an integrated community system to reduce acute hospital demand

https://www.researchgate.net/publication/336877712_Hospital_avoidance_an_integrated_community_system_to_reduce_acute_hospital_demand

The impact of the Canterbury earthquakes on dispensing for older person’s mental health

https://www.researchgate.net/publication/334384424_The_impact_of_the_Canterbury_earthquakes_on_dispensing_for_older_person’s_mental_health

Impact of integrated health system changes, accelerated due to an earthquake, on emergency department attendances and acute admissions: A Bayesian change-point analysis

 

https://www.researchgate.net/publication/302984289_Impact_of_integrated_health_system_changes_accelerated_due_to_an_earthquake_on_emergency_department_attendances_and_acute_admissions_A_Bayesian_change-point_analysis

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s