Creating a new remote monitoring service for rheumatology patients at Guy’s and St. Thomas’ NHS Foundation Trust
Ensuring patients with chronic conditions are cared-for away from the hospital
Chronic conditions, such as rheumatoid arthritis, can be effectively managed with medication, but patients in remission must still visit the hospital periodically to check-in with their clinical team. Whilst some patients value this face-to-face contact, others find it unnecessary and inconvenient, especially if they are feeling well.
Conversely, when a patient’s condition is in “flare”, they find it difficult to get a hospital appointment and seek help from their GP, or even A&E services, rather than the specialist care the hospital can provide. Subsequent delays in treatment can lead to significant long-term harm.
The COVID19 pandemic has exacerbated this problem, with thousands of routine appointments cancelled and a backlog that will take years to clear.
Fewer outpatient appointments from April 2020 to March 2021 due to COVID19 pandemic (BMA)
Rheumatoid arthritis sufferers in the UK (NRAS)
Working closely with clinicians and service managers within the hospital, Unboxed helped the team create a brand new remote monitoring service, supported by a new digital product, to give clinicians the confidence that their patients were receiving high quality care, and help patients feel cared-for without the need for scheduled appointments.
Patient Reported Outcome Measures (or PROMs) are an established way to assess the status of disease activity, based on simple patient questionnaires. They are, however, rarely used systematically nor considered a central part of patient care.
Early research with patients suggested they were perfectly happy to complete PROM questionnaires online, and would do so on a regular basis, if they felt it would be useful to their care team. Having prototyped and tested a simple mobile friendly version of the existing paper-based PROM forms, we worked closely with clinicians to understand their requirements regarding frequency of PROM collection, and how best to present PROM scores over time.
We devised a solution consisting of: an SMS messaging service to prompt patients to “check-in” and also provide support as needed; an online PROM form to collect simple, structured information regarding their condition; and a clinical “dashboard” to allow clinicians to view and analyse incoming data.
Working in the open
At Unboxed we consider openness and transparency as central to our core values, and we always prefer to work in the open by default, using collaboration tools like Slack and Trello to ensure our decision-making is visible to stakeholders.
Working closely with the clinical team, encouraging them to join research and design sessions, and having a “Clinical Product Owner” from the hospital lead the daily activities, we were able to build trust, and build confidence across the directorate.
Our frequent, open Show & Tell sessions, where we shared progress and learning with stakeholders inside and outside the trust, and gathered feedback on the work in progress, created a sense of shared ownership between the project team and the organisation.
“Taking the role of Product Owner in a truly collaborative cross-functional team is empowering and inspiring”
Melanie Martin, Advanced Physiotherapy Practitioner and Clinical Product Owner
An “MVP” approach
Having adopted aspects of the Lean Start-up approach during the early phases of the project, we identified our Minimal Viable Product and with funding from the Guy’s and St Thomas’ Charity, assembled a cross-discipline team within the hospital to create the new digital tool.
As customary at Unboxed, we ran a series of two week “sprints”, each one focused on delivering value to users. During our fourth sprint, we onboarded our first five patients, with features to enable SMS messaging and online PROM completion. In subsequent sprints we added additional functionality such as PROM reminders and a clinical view of incoming data, whilst gradually increasing the number of patients on the system to 100.
The MVP approach allowed us to rapidly test our assumptions about the potential value of the service and prioritize enhancements and changes based on “live” user feedback.
Patients enrolled on the new service (Spring 2021)
NHS trusts using the service
Outcomes and impact
The new service has proved extremely popular with patients, making them feel more in control of their condition and cared-for by the hospital team.
A non-clinical service coordinator monitors incoming SMS messages and assesses fluctuations in patient PROM scores, which are automatically “flagged” in the system. Support and advice can be offered and clinical involvement called upon only as necessary.
With the support of local Clinical Commissioning Groups, the service has been rolled out to five more hospital sites within the SE London Integrated Care System.
“Before I began to use the remote monitoring service, you were given long forms to fill out, and rate this and draw lines and things. I noticed the last time I went to the hospital, I did not have to do that.”
Rheumatoid arthritis patient
The service is still in an extended pilot mode, with patient numbers limited to 500 whilst a thorough evaluation takes place. However, a new phase of enhancement is underway to extend the service into additional rheumatic conditions and other service areas. This work is due to be completed during the summer of 2021.