Special Report: Remote monitoring and self-care

The use of technology to support self-care is considered to be a holy grail of any sustainable health service. So how can the NHS utilise and share such information to improve patient experience and empower them to manage their health better? Jennifer Trueland reports.

In the relatively short time since Mona Johnson started working as a GP she has noticed a significant shift in the way that patients and clinicians interact.

Rather than almost every contact being face-to-face and in person, there’s an ever-increasing menu of options including video appointments, text messaging, sending information via remote monitoring devices, and even the distinctly old-tech telephone.

Technology transforming healthcare

“Ten years ago when I qualified as a GP it was fairly radical to do telephone triage in practices,” she says. “Now, particularly in out-of-hours services, telephone triage is normal. More people are finding different ways of incorporating better technologies; it’s more possible for people to connect in non-in-person ways.”

Currently Johnson is clinical lead for self-care and prevention at NHS Digital, although she still practises as a GP in Greater Manchester around one day a week.

As such, she has an excellent overview of the technological possibilities that are out there – as well as the grounding experience of seeing how well (or otherwise) they are taking off at grassroots level.

And that’s where remote monitoring and self-care comes in. With her NHS Digital hat on, Johnson can point to a plethora of initiatives designed to harness the power of technology to revolutionise care.

Some are already happening. For example, the NHS Apps Library, currently available in beta, will (all being well), finally go live in alpha form later this year, and aims to help patients gain access to accredited applications that they can use to improve their health and care.

Other parts of NHS Digital’s self-care and prevention programme include work to widen digital participation, and the NHS Wifi programme, which is rolling out wifi access for staff and patients across all health settings, including general practice.

But is this enough – and is it happening quickly enough?

Holy grail of health service?

The use of remote monitoring to improve patient care has long been hailed as a potential saviour of health services.

Logic suggests that by putting the power literally in patients’ hands – in the form of remote monitoring devices, including wearables – you support people to better manage their own health.

This is particularly the case with long term conditions such as asthma and diabetes; in theory, better self-management should lead to fewer hospital admissions, less face-to-face contact with GPs and practice nurses and, of course, healthier patients.

And with more of us living with at least one chronic disease, likely two or three or more as we age, this should surely be seen as something of a holy grail for struggling health services.

But despite all these arguments – and some pretty fabulous tech – remote monitoring has not taken off in the way that some early adopters had hoped.

Barriers to remote monitoring

Persuading commissioners and providers of the advantages of remote monitoring is not easy, says Adrian Flowerday, managing director and co-founder of Docobo, one of the main players in this arena.

He points out that when implemented properly, and with the right patient cohort, remote monitoring can help people stay out of hospital and reduce visits to GPs – yet it’s difficult to turn this into actual implementation. “Patients love it, but there are barriers, not least the fragmented provider landscape,” he says.

Other issues include the difficulty in changing established working practices and the requirements of annual budgeting: it is difficult to persuade people to invest in technology that won’t necessary show a return of investment in their particular part of the health service or, in terms of prevention, won’t see a “pay-off” for five years or more.

Zahid Deen is digital health and care strategic lead with the Health and Social Care Alliance Scotland, a third sector intermediary for more than 2,200 health and social care organisations with a particular focus on long term conditions.

He agrees that digital has huge potential for this group of patients – but that more needs to be done to make the case for change. “Citizen engagement is very important,” he says. “You have to involve people to find out what they want so you are meeting their real needs, not their perceived needs.”

He points out that digital will never replace human contact. “A lot of support and time will still be face-to-face. We don’t want digital to be the only way forward – it’s one of many facets.”

Johnson agrees: “Technology isn’t the panacea for all things; it’s one of the elements, but it’s not a magic bullet. The health service is under enormous pressure, and it’s hard to be imaginative when you’re under a lot of pressure.”

Sharing good practice

She says that national organisations like NHS England and NHS Digital have a role, not least in sharing and spreading good practice throughout the whole service, ensuring consistency and avoiding duplication of effort.

The Digital Exemplar programme is part of that – and some trusts are already showing good results. For example, Salford Royal NHS Foundation Trust recently reported an update on its efforts, which now include more than 50 digital projects.

These include a digital ecosystem initiative to develop the infrastructure for patients to send clinical and lifestyle data directly to clinicians, via wearables and apps to enable real-time clinical monitoring of patients.

While the exemplars might point a way forward, challenges remain. For example, how do you bring together data from sources as diverse as an acute hospital, community team, and, increasingly, health-related apps on a patient’s own devices?

Interoperability is key

With interoperability already an issue even within the NHS, will patient information from wearables, for example, be seamlessly integrated into the patient record?

Richard Mangeolles, business manager for integrated care with Agfa Healthcare, believes this is a challenge that can be overcome. He points to his company’s solution that aggregates health and care data from all sources, bringing them together on one platform that is viewable by clinicians and the patient.

There’s a clinical and financial imperative to make it work, he says. “There are something like 15 million people in the UK with a long term condition. It’s increasingly difficult to manage these patients. It makes sense to give patients help to manage their own conditions away from hospital.”

He points out that for each condition, patients might see between five and 10 different clinicians; allowing them to share that information can save clinician and patient time, and generate a financial saving for the health service – and remote monitoring is a part of that.

He gives the example of a patient with a cardiac issue released from hospital with a remote monitoring or wearable device. Instead of multiple follow-up appointments or home care visits, the patient can measure and transmit vital signs such as blood pressure and temperature which can then be monitored by healthcare staff – without the need for an appointment.

Digital ecosystem

Mangeolles acknowledges that this scenario is not yet widespread, but believes that the culture is changing.

“We’re at a crossroads: we are starting to see people use their own mobile devices to do more about their personal and social health, such as using apps on their phone to measure their steps, or monitoring what they’re eating.

The danger is that we’re creating our individual eco-systems, creating our personal data silos, because we’re not sharing that information. But the potential is there to make a real difference.”

This kind of individual, condition-specific monitoring is one thing, but some of the real excitement at the moment is around the potential use of personal health data at large scale, to better facilitate early diagnosis and prevention.

Using artificial intelligence or machine learning to predict the factors that lead to something going wrong with our health at the earliest possible stage optimises the potential for successful intervention, at least in theory.

Condition and surveillance monitoring

US physician and remote monitoring enthusiast Ben Kanter believes there needs to be a paradigm shift from “condition” to “surveillance” monitoring – where healthy people are happy to share their anonymised data for the public good.

Kanter, who is chief medical information officer with Vocera Communications, says it’s an exciting area. “Surveillance monitoring is relatively new, and it’s a tough nut to crack,” he says.

Not only do we not necessarily know the data we need to make predictions about when people get sick, he adds, but we need to get the buy-in of healthy individuals to make that data available.
“We need to answer the question of ‘what’s in it for me?’. It’s a question of patient engagement – people need to feel ‘this is important for me’.”

For the NHS, of course, using information from wearables and apps brings its own challenges, not least in terms of data security and privacy. Johnson is very clear on NHS Digital’s position: “Any monitors, apps or wearables would need to have stringent security and data sharing policies in place before they could be approved for use either on the NHS beta library or for research purposes,” she says.

With even condition-specific remote monitoring being slow to spread in the UK, the prospect of utilising big data, however exciting, seems a long way off. But the journey has started, says Johnson. “We’re taking small steps in the right direction, and that helps you get to where you want to be.”