Stoke-on-Trent: telehealth helps patients manage their own conditions
A text message system that received patients' blood pressure readings from home and responded with advice.
The Advice and Interactive text Messaging (AIM) for Health programme began across England in March 2013.
The programme included:
- lead clinician developing 4 protocols to support diagnosis or managment of high blood pressure (hypertension) in different circumstances
- registering nearly 300 patients in 10 months to follow the protocols through their primary carer team (GPs) and take part in the programme
- patients submitting their blood pressure (BP) readings regularly by text
- telehealth system, ‘Flo’, sending automated text messages back to patients with advice, instructions or other messages based on their readings
- clinicians checking their submitted readings (at least weekly review on Florence website) and contacting patients if necessary with further instructions
For additional information, visit www.digitalhealthsot.nhs.uk.
Contacts
Further information about clinical applications:
- Dr Ruth Chambers, Stoke-on-Trent CCG
Further information about the Flo simple telehealth system:
- Phil O’Connell, NHS Midlands and Lancashire Commissioning Support Unit
Region
Based in West Midlands but Flo service rolled out across England
Location
The programme was based in general practices. The Flo telehealth system can be used in all health and social care settings.
Partner organisations
Stoke-on-Trent CCG, Department of Health and NHS England
Target population
- people with a new diagnosis of hypertension
- people already diagnosed with hypertension but whose condition is managed sub-optimally
Aim
The AIM project uses a simple telehealth system (‘Flo’) to support patients to take responsibility for the monitoring and shared management of their condition, treatment or lifestyle.
Programme structure
Patients followed 1 of 4 hypertension protocols that covered:
- diagnosis of hypertension (used most frequently in this project)
- controlling BP in those who were newly diagnosed or who have had poor control
- monitoring patients with stable BP
- controlling BP in those who were newly diagnosed or who have had poor control, among patients with CKD or diabetes and/or ACR≥70 mg/mmol
The primary care team registered patients and agreed a shared management plan, which provided a range of information about acceptable or concerning blood pressure readings, and agreed actions if BP readings rise outside the acceptable range.
When patients sent BP readings outside the acceptable range, the telehealth system sent automatic responses detailing instructions on what to do next. These messages reinforced information in the patients’ agreed management plan.
The patients’ responsible clinicians periodically checked their submitted readings (at least weekly, looking on the Flo website) and contacted patients if necessary with further instructions (such as to increase their medication).
Activity to date
During the service evaluation period 2,963 patients registered on a hypertension protocol between March 2013 and January 2014.
The AIM team’s service evaluation indicated:
- GPs chose the hypertension diagnosis protocol most often for patients enrolled in the programme
- of those hypertension diagnosis patients who had high blood pressure reading in the clinic, up to one-third who submitted readings from home had readings in acceptable range, and did not require a follow up appointment
The West Midlands Academic Health Science Network is investing in a region-wide rollout of Flo telehealth as an exemplar of integrated care.
NHS England included the outline case study in its forthcoming Technology Enabled Care Services (TECS) Commissioning Toolkit.
Stoke-on-Trent CCG is continuing to support the evolution of Flo telehealth in applications relating to hypertension and asthma and COPD.
The CCG is reinvesting royalties from NHS CCGs and Trusts use of Flo telehealth in equipment (sphygmomanometers and pulse oximeters) for clinicians to lend to Flo to underpin the Flo protocols for these conditions.
Outcome measures
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Proportion of patients who register on each protocol who undertake a pre-defined minimum days of texting (success criterion = 50%).
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Proportion or patients on diagnosis of hypertension protocol who have diagnosis confirmed or refuted (success criterion = 100%).
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Proportion of patients on monitoring protocols who have controlled BP at the end of their use of the protocol (success criterion = 75 to 80% depending on the protocol).
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Patient satisfaction using an adapted friends and family test: ‘Please text #1 if you agree with the statement “I would recommend this service to my family and friends”, or #2 if you disagree’.
Outcomes to date
The success criterion for the proportion of patients undertaking a minimum days’ texting was met for the diagnosis of hypertension (84%) and 1 of the monitoring protocols (56%).
For the remaining 2 protocols, 1 nearly reached the success criterion (47%) and the other fell short by far (15%).
Although the success criterion of 100% of patients having a diagnosis of hypertension confirmed or refuted was not met, 79% of patients ever registering on the protocol did submit sufficient readings to reach a conclusion.
Of those who finished using the monitoring protocols only 5 to 22% of patients had a BP in target.
Over 80% of responding patients agreed that they would recommend the service to their friends and family each time they were asked except for month 3, for one of the monitoring protocols, where 79% agreed with the statement.
Lessons learned and tips for others
Simple telehealth can be an acceptable and valuable tool for diagnosing hypertension in a primary care population, particularly if ABPM is not possible or is declined.
However, we found patients started to disengage (stopped sending in BP readings) after a month or 2. Based on this experience we recommend use of telehealth messages for as short a time as possible, depending on the purpose of the protocol.
Practice teams value incentives that allow them protected time to learn about an innovation and put it into practice. A national enhanced service incentive will likely aid the spread of remote delivery, such as this example (remote monitoring DES for England) or individualised bursaries as in a previous pilot.
See Cottrell E, Chambers R, O’Connell P. Using simple telehealth in primary care to reduce blood pressure: a service evaluation. BMJ Open, November 2012..
External evaluation
Lead evaluation member is GP academic registrar at Keele University Primary Care Sciences
There are 4 known RCTs in progress by 3 independent university and academic groups across England, examining other conditions: Sunderland (gestational diabetes), Birmingham (public health and obesity) and Oxford (hypertension; throat infections)
Peer-review publications are currently in draft, due for submission November 2014.
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