Building a Digital First Future: Digital Primary Care Congress - - PowerPoint PPT Presentation
Building a Digital First Future: Digital Primary Care Congress Chamber of Commerce, Manchester 5 th of February 2020 8:00am 15:15pm #Convenzi s Dimitri Varsamis Senior Policy Lead, General Practice Strategy and Contracts at NHS England
Chamber of Commerce, Manchester 5th of February 2020
8:00am – 15:15pm
#Convenzi s
Dimitri Varsamis
Senior Policy Lead, General Practice Strategy and Contracts at NHS England and Improvement
“Comparing drivers and delivery of digital- first general practice across California, Australia and New Zealand; lessons for the NHS.”
#Convenzi s
Made possible with funding from the Winston Churchill Memorial Trust February 2020
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I will talk about
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GP contract team
emerging digital-first GP models.
https://www.wcmt.org.uk/
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Churchill fellowship-related meetings
Board
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Common people
All healthcare systems are dealing with the same issues:
All healthcare systems are dealing with the same digital health issues:
protection and exploitation,
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Health expenditure
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Semantics and concepts
their system insurance?
system has the word social?
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What I heard and what I saw
Key issues at national governments level:
Digitising the present or towards a digital future?
digital health, will be replaced by those who do I observed in every country :
care, general practice, community pharmacy or other community services
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Norway
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Norway – secondary
for use in specialist health services under certain conditions.
consultations.
remoteness, a history of early adoption of telehealth, a strong policy push, and adoption in principle by 75% of all hospitals, fewer than 1% of outpatient consultations in participating specialties were actually undertaken via telehealth in 2013. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5688245/
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Norway – primary
health services.
practitioners has explicitly forbidden charging consultation payments for video consultations.
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Sweden
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Sweden and digital general practice
Accessing primary care
care provider, although used in practice a lot by the county councils. Rules akin to temporary resident / out-of-area urgent primary care
county, with provider getting a fee.
council area have been pro-actively advertising and offering appointments to residents of other counties. All change?
in light of digito-physical care models https://www.regeringen.se/4ad5e9/contentassets/6e3786584628447986 30946d5bf12fc3/digifysiskt-vardval-_-tillganglig-primarvard-baserad-pa- behov-och-kontinuitet.pdf
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Sweden and digital general practice
On the concept of registration:
practice and patients can choose between them. On out-of-area rules:
contractors or sub-contractors in other county council area.
all county council areas.
sub-contractors.
contractors by established / ‘traditional’ primary care providers to enhance their in-person appointments with video ones.
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Denmark
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Denmark
Many similarities to the UK:
! Denmark has capitation for hospitals; any underspent is reinvested by the provider High ICT-maturity
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Email consultations
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Digital General Practice via an App
Elderly
Gives patients:
vaccinations, notifications from practice, record of referrals and of doctor's appointments
the My Doctor app.
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Digital General Practice via an App
For staff, the online consultations / digital platform allows:
Who pays?
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Australia
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Lessons from Australia:
via fee-for-service.
In general practice:
and the GPs pay “rent”. Small margins.
access for episodic care. Fee for service.
available.
by a couple of large General Practice companies.
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New Zealand
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Lessons from New Zealand:
commissioning functions, organisation of primary care.
(apart from a major programme for telephone based advice)
at-scale models have existed for a while.
and policy, to set up and deliver.
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USA
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US healthcare
(SHI or single-payer)
based on multiple sources of private financing (insurance coverage / OOP) and not on need alone.
for a serious medical condition because of cost
family member in the past five years who died after not receiving needed medical treatment because they were unable to pay for it.
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Health insurance in the United States
sponsored program, while about 9% purchase health insurance directly. Initially all-private, increasingly complex public/private mix
delivery parties.
healthcare system chasing and maintaining provider data.
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Primordial soup, but a v networked one
some other managed care organisation. But also more integrated “health systems” than we have:
physicians only, or of physicians and hospitals.
coordinate delivery of care (and manage population health).
health insurers, evolving from an existing ACO into a licensed health insurance company, JV with established health insurers.
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Integration across providers and payers
BUT
Evidence of positive impact of this:
Main requirement for better use of digital: health system integration Unified health system like KP or even: UCSF, UCLA, VA, USC, CS
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Adding to the mix: telehealth / tele-primary care providers: synergy?
and direct-to-consumer primary care
DtC has struggled to take off. Why do we bother with PC?
surgical intervention or LTC treatment.
Why digital PC:
cheaper to access for patient as lower co-pay, and employer doesn’t lose you for half a day.
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Continued
How to drive utilisation?
compared to a $25 to $35 copay if a member visits face to face their primary care doctor.
acute non-urgent care, found telehealth saved 6% in costs by diverting members who would otherwise have gone to the emergency room.
and they will come' kinda of thing" "You really need to develop strategies to drive utilization.“
in rural areas.
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Continued
VA Video Connect platform
more than 490,000 Veterans in 2018.
Synergy example: partnership between Anthem, American Well, and Samsung
Galaxy phones, via the Samsung Health app
health, share data, and communicate with healthcare professionals. Doctor on Demand in 2019 made a deal with Humana to sell what it calls the first "virtual only" plan design, which involves assigning primary care doctors upon sign-up based on a set of questions from the worker.
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I have not seen a health system that has answers to all these (and does it matter?):
additional face to face visits?
than e.g. surgery?
US
prioritise, consider, act
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Take home messages
What has worked:
(video consultations without leaving work / home) and
What hasn’t worked:
and implementation.
that works.
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Thank you Dimitri Varsamis PhD
Senior Policy Lead, General Practice Strategy and Contracts Primary Care Strategy and NHS Contracts Group, NHS England https://www.england.nhs.uk/gp/gpfv/investment/gp-contract/ Made possible with funding from the Winston Churchill Memorial Trust, and represents the views of the author only, not of NHS England or the Trust. Hear more from me on: HIMSS SoCal podcast https://himsssocalpodcast.wordpress.com/2019/11/14/episode-27- developing-digital-first-models-of-primary-care-ft-dimitri-varsamis/
Dr Minal Bakhai
National Clinical Lead Digital First Primary Care at NHS England and Improvement
“Building a Digital-first Primary Care.”
#Convenzi s
NHS England and NHS Improvement
Presented by Dr. Minal Bakhai Deputy Director and National Clinical Lead for Digital First Primary Care, NHS England and Improvement General Practitioner, Brent CCG
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“A 2016 Lancet paper said GPs’ workload had risen by 16% in the seven years up to 2014, with more frequent and longer GP consultations”
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services
patient pathways
Current “as-is” patient pathway
Digital First Accelerator change to current process 41 |
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There are significant opportunities to use primary care capacity more effectively. Investing in and harnessing digital technology is a necessary and important part of the solution in
workload
satisfaction
complex health conditions
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askmyGP data (n=44 practices, total list size 447,000) The assumption that every patient in contact with a GP wants or needs a face-to-face appointment is false and is a major cause of GP
Do patients want a face- to-face appointment?
Median time to respond = 38 minutes
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RESPONSE
SIGNPOSTING
Get the right help (triage) Book appointments
View records online
Tele[hone & Video consults
Right person/team in the GP practice
Self Care Self referral Social Prescriber A&E UTC Hub Finding the most appropriate care pathway Pharmacy Order meds
Online messages Get advice, check my symptoms
Go online
NHS App NHS.uk 111.nhs.uk Practice website Local Apps
E n t r y p
n t s
Secondary care referral Outpatients Patients are able to easily access and flow through primary care pathways using digital tools.
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Continuity: did patients get the staff they requested?
A B C D E F A B C D E F
Average waiting times are going down and monthly DNAs are reduced.
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Number of appointments moved to an online consultation on the first day. Number of patients who prefer to contact the practice
Patients reporting that the new online system is better.
The number of face-to-face consultations has reduced by 43%, home visits by 73%, with an overall saving of 10% of clinicians’ time.
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Continuity: did patients get the staff member they requested?
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Increase in face-to-face time with patients due to ability to plan appointment length appropriately.
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askmyGP, weekly activity as a proportion of patient list
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Number of patients who prefer to contact the practice
Patients are seen on the same day. Patients reporting that the new online system is better.
Overall productivity has doubled. Time to respond is less than 30 minutes. Increase in face-to-face time with patients that need it. When asked: “Would you go back? Not a chance” Practice Manager
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Resident is able to access a platform which allows them to consult online with eHub clinicians
eHub could be set up as: 1. Separate entity 2. Part of access hub 3. Linked to UCC/UTC if applicable
Online consultations are managed centrally by a group of clinicians working
Practices
eHub provides digital and possible F2F services. Where eHub appointment is not in patients’ best interest, capacity at registered GP is sought.
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Hours saved in administrative time for practices Increase in GP recruitment interest Online consultations closed remotely
Average online consultation takes three minutes Integration of wider clinical workforce Improved staff satisfaction and retention
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What can patients expect? The NHS Long Term Plan commits that every patient will have the right to be offered digital-first primary care by 2023/24. The use of digital channels will be at the choice of the individual patient, with those who can’t or don’t wish to use digital tools still able to access services
Patients should be able to easily access advice, support and treatment from primary care using digital and online tools. These tools should be integrated to provide a streamlined experience for patients, and direct them to the right digital or in- person service for their needs.
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Digital First Primary Care
Transformed care processes
By looking beyond existing organisational structures, care becomes more person-centred, better coordinated and
but gaps in key digital enablers limit the scope, speed & effectiveness of change
Current state
Low levels of digitisation limit the potential impact of efforts to improve existing processes and service models. Does not address fundamental issues affecting long-term sustainability of individual providers or local health economies as a whole. Low levels of digital maturity, particularly regarding infrastructure & cyber security, create operational risk
Service transformation enabled by technology
Digital technology is a core component of quality improvement across STPs and Integrated Care Systems. This enables the scale & pace of change required to manage population health and address :
Digitally enabled services
Technology drives improvements in the quality, safety and efficiency of healthcare delivery within existing service models. Providers are better placed to deal with the pressure of rising demand but cannot fully address the root causes of it
Technological maturity Clinical transformation Service transformation Consumer transformation
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Digital first primary care
Essential Infrastructure The core infrastructure and IT systems needed so practices and PCNs can deliver digital first primary care and can work collaboratively and share information. Functional Capabilities The core functional capabilities practices and PCNs will need to have to deliver digital first primary care (such as online appointment booking, triage mechanisms and secure messaging) Integration Across PCNs and health systems (e.g. at ICS/STP level) to deliver streamlined services for patients (so patients can be directed to the right service quickly and easily) Effective Utilisation Primary care staff and patients are appropriately trained and supported to use digital tools – leading to high levels
A learning culture Primary care has access to data, analytics and evaluation to support learning and a focus on impacts. Supplier Engagement There is effective engagement with suppliers to encourage compliance with standards, innovation and development.
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Commissioners are designing integrated digital primary care pathways Health systems are deploying both nationally commissioned and locally procured products to build these pathways Digital products meet nationally developed standards to enable effective integration and to ensure safety Digital products can be easily procured and deployed by commissioners Primary care contracting, regulation and payments support development of these integrated digital pathways
Patients are able to easily access and flow through primary care pathways using digital tools safely and effectively Staff receive time, resource, training and implementation and service improvement support to
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Twelve accelerator site have been selected to develop digital first primary care. Other regions are working to establish their own accelerator sites.
1 2-6 7 8 9 10 11
Devon East Kent London
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Shropshire, Telford and Wrekin Hereford and Worcester West Birmingham and Black Country Cambridge and Peterborough Norfolk and Waveney
2-6 7 1 8 10 9 11 12
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IT IS NOT JUST IT IS
…….Digitising alone doesn’t mean anything
driven learning healthcare system supported by tech
changing workflows, aligning digital strategy with outcomes, aligning incentives
improving high-quality care
and behaviours
…….digitising alone doesn’t mean anything
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Case study library Implementation support Evaluation standards and data analytics Training Community of Practice Deep dive evaluation Funding DPS framework Blueprinting
Dr Ed Turnham
Clinic Lead for GP Online Consultations at Norfolk and Waveney STP and CCIO at Arden & GEM CSU
“Digital-First General Practice using Online Consultations in Norfolk and Waveney.”
#Convenzi s
Dr Ed Turnham
Clinical Lead for GP Online Consultations at Norfolk and Waveney STP CCIO for Norfolk and Waveney at Arden & GEM CSU
Bolt-on Online Consultations to practice website
0.2% of consultations (Edwards et al., 2018) Disagreement about what it should be used for (Banks et al., 2018) Seen as a short-cut to getting an appointment Extra work for GPs
Online request Admin triage GP triage Admin resolve Send to other team Phone request
Phone Online message Face-to- face
Requested by patient How practice resolved
Reproduced with consent of
Reproduced with consent of
Reproduced with consent of
Demand is stable over time at 8% of patients per week Average response time around 90 minutes 78% of patients say the new system is better
https://www.aclemedicalcentre.co.uk/
https://www.aclemedicalcentre.co.uk/
0% 1% 2% 3% 4% 5% 6% 7% 8% 40 41 42 43 44 45 46 47 Requests as a proportion of practice population Week
Requests by source
Self Proxy Staff
Requested by patient How practice resolved
Reproduced with consent of
5.8 4.9 5.0 3.7 4.5 8.0 6.8 7.0 5.1 6.2 8.4 7.2 7.4 5.4 6.5 5 10 15 20 25 Monday Tuesday Wednesday Thursday Friday
Encounters per clinical session, by mode of resolution
Messages Phone F2F
0.2 0.2 0.2 0.1 0.2 0.8 0.7 0.7 0.5 0.6 2.0 1.7 1.7 1.3 1.5 0.0 0.5 1.0 1.5 2.0 2.5 3.0 Monday Tuesday Wednesday Thursday Friday Hours
Time taken per clinical session, by mode of resolution
Messages Phone F2F
0.2 0.2 0.2 0.1 0.2 0.8 0.7 0.7 0.5 0.6 1.5 1.6 1.6 1.3 1.5 0.6 0.2 0.0 0.5 1.0 1.5 2.0 2.5 3.0 Monday Tuesday Wednesday Thursday Friday Hours
Time taken per clinical session, by mode of resolution
Messages Phone Same day F2F Prebookable F2F
c
p wo
s a
Assign the first request of the day to Dr A, the second to Dr B, and so on. Workload will be fair between doctors, but there is no continuity of care for patients. Assign each request to the doctor who knows the patient best, or the doctor whom the patient requests. This is good for continuity, but the popular doctors will get more work than
doctor is away for a day or more, they may come back to a huge backlog of work.
The solution:
are most complex, and therefore are most in need of continuity (i.e. use simple population segmentation).
doctor who knows them best.
with by any doctor.
workload evenly while maintaining continuity when it is important.
PATIENT AND DOCTOR BENEFITS SCALE
Verifying patient’s identity Integrating into clinical system Online booking Video Tools to support practices: demand- supply calculators, population segmentation etc.
Online request Admin triage GP triage Admin resolve Send to other team Phone request
Phone Online message Face-to- face Video
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md&int_medium=cpc&int_campaign=usage-042019
Dr Ed Turnham
Clinical Lead for GP Online Consultations at Norfolk and Waveney STP CCIO for Norfolk and Waveney at Arden & GEM CSU
Kieran Waterson
Head of Sales (UK) at iPlato
‘myGP – delivering digital-first primary care in 2020’
#Convenzi s
1. Demand growth for healthcare services is unsustainable 2. Healthcare is behind other sectors in adopting digital In an attempt to change this patients are being given the right to have digital first service
What does digital look like elsewhere?
Appointment Booking & Cancellation Appointment Reminders Consultation Prescription Ordering Medical Record Access Queries Signposts Screening Advice
Patient Engagement Patient Intake & Care Navigation
Appointment Triage & Remote Consultation
Patient Insight (PHR) Book, Cancel & Request
Clinician Reception
25m patients
24/7 appointment booking & cancellation
Patients can manage their access to healthcare wherever they are via myGP. Links directly with INPS, TPP & EMIS
Appointment reminders
Patients receive appointment reminders as in-app messages. You can configure reminder settings in myGP platform. SMS costs removed automatically (typically 30%)
Improve uptake and awareness of health campaigns
Patients who are entitled to a free flu jab or NHS screening test can be invited to book via myGP. Hidden appointments just for eligible patients
Cervical Screening Programme in London Organisation NHS England (NHSE) and Public Health England (PHE) Goal Invite thousands of women to their due/overdue smear test appointments. Start August 2018 End August 2021 Description Female women across London surgeries will receive a letter from Capita and 2.5 weeks after a text reminder to encourage them to book the smear test appointment. If no appointment is booked, a second letter will be sent from Capita.
Consent No consent
Engagement Hub
Practice 2 Practice 3 Practice 1
From Station Road Medical Centre. Your cervical smear test is due. Please call 020 3345 7891
to download our app to book on your phone.
97% of practices in London signed up to the project 384,112 women were invited for screening from consenting practices Mobile phone numbers were extracted for 88% of these women For women who received a text reminder, uptake at 18 weeks was higher by: 4.8% in all age groups 4.8% in women aged 25 to 49 5.9% in women aged 50 to 64 The average time between invitation and screening: 54 days for women who received an invitation letter and a text reminder and 71 days for women who received an invitation letter only
myGP Patient Surveys (FFT)
Feedback is automatically shared with you so you can make informed improvements to your services.
Medication Reminders
Patients can set up daily, weekly or monthly reminders for all of their medications. Push notifications are sent when it is time to take the medication. Adherence tracking helps patients to take control over their condition.
Repeat Prescriptions & Medical Record Access
users (Jan 2020)
Directions to the nearest pharmacy
Patient's may be able to get their queries resolved at a pharmacy via a minor ailment scheme
Add Dependants
Patients can book and cancel appointments for their children, family and dependants. 273,000 dependants have been added (Jan 2020)
Mary Smith Jane Smith Alex Smith
Patient self-care tracking
Patients can record and monitor their blood pressure and weight on myGP. This module is for patient use only and helps with long-term condition management. Almost 100,000 patients are doing this (Jan 2020)
Remote Monitoring
Self-monitoring is clinically proven to improve patient health outcomes. Request patients to capture biophysical data such as blood pressure or weight. Upon request, a temporary monitoring module will appear in the app.
Patient Appointment Booking Data capture Intelligent Care Navigation Remote consultation
preGP remoteGP
Intelligent care navigation
When booking an appointment, patients are signposted to alternative pathways depending on appointment reason, e.g. pharmacy. Automated, clinically safe sign-posting. Proven to successfully reduce appointment demand by 20%.
F2F appointment (£3,330 cost savings)
Appointment Triage- All online appointments visible on one screen
Remote Consultation
Decrease unnecessary face to face appointments by resolving requests remotely. Check appointment details and make informed decisions about triaging. Organise a video or telephone consultation on myGP. Send in-app messages to request additional information.
The ability to start a Video call with just one click
Simply click here to initiate Video
During the call you can control: Sound Microphone Camera End Call
Video Call Controls
Is the myGP active at the practice? Yes Registration with just mobile number and DOB Book & Cancel Appointments Signposting Video Consult Remote Monitoring If they add their Online credentials Prescription Ordering Medical Record Access No Patient has to have their online credentials Book & Cancel Appointments Prescription Ordering Medical Record Access
Please email any questions to myGPSupport@iplato.net.
Dr Pritesh Mistry
Clinic Innovation and Research at the Royal College of General Practitioners
“Primary care innovation: from frontline ingenuity to AI”
#Convenzi s
I do not have a conflict of interest (financial, commercial, personal, professional, advisory, research-linked or other) relating to this event.
Not just tech! Supporting ethical innovation
Leaps and iterations not destabilising
unmet needs
addressing type 2 diabetes burden
prevention
existing resources go further
processes saving time and money
learn
systems
conditions
workload and recruitment
elderly
we train professionals for digital consultations
with CCG to accelerate innovation in Medway
key areas: service redesign, workforce, workload, digital and analytics
practices with broad demographics and challenges
provider
£3M VC £400k grants
1 NHS contract
Peer support confidence learning credibility networks
Clinical safety Evidence generation
3 new innovations
Professional Development
change in culture
Adaptive algorithms Black box systems Trust, bias, explainability, regulation How much data is enough? Quality and biases? Remote ECG system, (symptom checkers), radiology & ophthalmology Translate the secondary care advances to support primary care – dermatology, retinopathy New data sources: E-stethoscope, ultrasound
Voice to text, text to voice and querying free text Alexa used to access health information Consultation support Chatbots to provide trusted information Privacy, accuracy, terminology, error correction Free text section of EHR, consultation, asynchronous support
Rotas, admin automation, workflow optimization Robotic and remote surgery Nascent field of AI Multi-disciplinary teams, complex patients, insufficient workforce numbers, automation Improving and deskilling surgical interventions Minor surgery