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Telehealth

Delivering Telehealth at scale in Northern IrelandA Service Provider Perspective

Jim O’DonoghueS3 Group

Northern Ireland Chronic Disease

S3 Confidential Slide 2

Department of Health (2008 ) Raising the profile of long term conditions careINIsPHO (2010) Making Chronic Conditions Count

60% of all GP visits

72% acute bed days

69% of health & social care

spend

2/3s of over 75s

Population 1.8M

H&SC budget £4.3Bn

Rising to £4.66Bn in 2014/2015

• Bring information to professionals, enabling more proactive, effective and co-ordinated community based care

• Provide greater support for self-care and for carers

• Part of a new way to manage increasing burden of chronic disease which is both more efficient and better quality

“…investing to build the capacity to cope”

NI Vision for Remote Telemonitoring

• Should the remote telemonitoring service be provided from within the public sector or outsourced to the private sector ?

• If outsourced• What should be procured – products ? Technology ?

Services ?• What should the scope of the service be?• How would the service be used and how would it

integrated with other aspects of care delivery ?• How can it be designed to be scalable?

First Questions for NI Authorities

Models for procuring Telehealth

Managed Service - Outcome Based Risk/Reward

Managed Service - PAYG Customised / integrated service

Combined Technology Purchase + Service Purchase

Technology Purchase + Service purchased separately

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• Defining Service Requirements

• Defining KPIs (as SLAs and Quality Metrics)

• Defining how health professionals will interact with and support the service interface points (e.g. escalations from Triage)

• Stakeholder engagement

• Selecting patients to be referred on to the service

Managed Service Model – Commissioner Responsibilities

Managed Service - Outcome Based Risk/Reward

RTNI - Managed Service - PAYG Customised /Integrated Service

Combined Technology + Service Purchase

Technology Purchase + Service purchased separately

• Providing all aspects of a joined-up service involving people, process and technology

• Responsible from Referral to discharge

• Meeting defined service requirements & SLAs

• Technology selection, maintenance and equivalence

• Incentivised to generate service delivery efficiencies

Managed Service Model - Provider Responsibilities

Managed Service - Outcome Based Risk/Reward

RTNI Managed Service - PAYG Customised /Integrated Service

Combined Technology + Service Purchase

Technology Purchase + Service purchased separately

Managed Service – A Shift in Concept and Language

Buying Kit / Units

Becomes Buying Monitoring days

Buying Technology

Becomes Buying a service

Selecting Technology

Becomes Defining your service requirements

Building service delivery capability

Becomes Building capability to use the service

RTNI Programme Structure

• 6 year contract awarded March 2011

• Procurement, service definition and implementation process led by ECCH – a part of Public Health Agency

• 1 Service Definition, 5 customers

• 3,500 patients per annum

• 12 condition categories

• 2 - 52 week monitoring periods

• >2.8 million monitored days

• £18m investment

Daily Monitoring

GP/Clinician

Community NurseDaily

Readings

escalation

Overview of the Basic Service

Partnering to deliver integrated servicesIn Northern Ireland

•Patient Assessment

•Patient Care Plan

•Patient and clinician engagement

Patient Selection and Referral

•Programme Governance

•Programme Management

•Stakeholder Communications

Governance•Clinica

l•Busin

ess Processes

•Technical

Service Design

•Clinical Service Delivery

•Clinical Service Management

•Patient service Delivery

Service Delivery

•Patient equipment

•Managed Service Platform

•IT Infrastructure

Service Infrastructure

Partnering to deliver integrated servicesIn Northern Ireland

•Patient Assessment

•Patient Care Plan

•Patient and clinician engagement

Patient Selection and Referral

•Programme Governance

•Programme Management

•Stakeholder Communications

Governance•Clinica

l•Busin

ess Processes

•Technical

Service Design

•Clinical Service Delivery

•Clinical Service Management

•Patient service Delivery

Service Delivery

•Patient equipment

•Managed Service Platform

•IT Infrastructure

Service Infrastructure

Service Requirements

Service Design

Service Operation

RTNI Managed Service Requirements Definition

Identify Drivers of Change Define Desired Benefits

Define Model & Implementation

Approach

Assess Cost/Benefits

NationalLocal

Clinical OutcomesPatient ExperienceClinical StaffFinancial

Service ModelRoles/ResponsibilitiesPathway ChangesDelivery model

Clinical outcomesFinancial benefitsImplementation costs

Service Requirements Definition – Iterative Approach

Identify Drivers of Change Define Desired Benefits

Define Model & Implementation

Approach

Assess Cost/Benefits

What’s possible

What’s practical

What’s desirable

Commissioner Provider

• Comprehensive and robust Office of Government Commerce contract detailing all aspects of Commissioner and Provider responsibilities

• High level of detail of service definition & contractual requirements:

• Detailed definition of every aspect of the service to be provided (221 Authority requirements)

• Detailed service levels and associated penalties (20 for ‘core’, 8 for ‘additional’ & a further 19 quality markers)

• Extensive reporting, automated performance monitoring

• 1 Service definition with 5 customers:

• Joint specification, governance and central infrastructure• 5 local implementation plans

Capturing Requirements in a Contract

Service Requirements

Service

Design

Service Operati

on

Service Design Processes

Service Planning

Establish Service

Governance

Design Service Delivery

Design Service

Infrastructure

Service Readiness

Testing

Pathway DesignProcess DefinitionService Interfaces

ClinicalProgramme

FinancialMetrics

Clinical processesNon-clinicalOperating

ProceduresProcess/Policies

Solution DesignService integrationService platform

Service IT

PeopleProcess

Technology

Service Design – Collaborative Process

PlanDesign

Process and interface Definition

Workshops / Expert Feedback

Usability Tests

Commissioner

Provider

Service Planning

Establish Service

Governance

Design Service Delivery

Design Service

Infrastructure

Service Readiness

Testing

Elements of service to be delivered

Referral to Discharge

• Clinical Triage• Service Desk• Clinician Portal• Patient Portal• Reporting• Performance

Management• Service Integration• Patient services• Training

Patient Pathway – Service Design Considerations

Service Delivery Components

Patient Selection Process

• Patient Selection Process

– Driven by the risk stratification approach and specific goals and focus of

each Trust

– Captured in Trust implementation plans

– Rolling forecast of patients per condition communicated to provider

• Patient Referral Process

– Online Referral Form is completed with all the required information to enrol the

Patient on to the Telemonitoring service

– Referrer specifies the priority of the Referral – “Urgent” to be completed within 20

working hours or “Standard” within 48 working hours (SLA)

– Notifications on progress through referral process or issues encountered

– On receipt of the Referral, the Clinical Triage Team will review the Clinical

information and will seek clarification from the Referrer if necessary

Patient Referral Process

• Service Design Considerations

– Comprehensive referral information required to support clinical triage

– Maximise auto-population of data to speed filling of forms

– Access from inside and outside of Trust networks (single sign-on)

– Need for an integrated service desk to co-ordinate tasks

– Need for an automated tracking of and reporting against SLAs

Patient Referral Process – Design Considerations

• Patient Set-up

– Service Desk contacts the Patient to arrange an Installation Appointment

– Referrer is informed by the Service Desk of the appointment details

– Installers train the Patient on how to use Equipment and access the Patient Portal

– Test Readings are completed – the Service Desk notifies referrer of the completion of

Installation and the Patient is now set-up on the Telemonitoring Service

Patient Set-up Process

• Service Design Considerations

– Tracking of each stage of the process co-ordinated by a Service Desk application

– Being able to report on where patients are in the process

– Automatic notifications to referrers on completion or issue

– Ability to co-ordinate and manage issues throughout the process

Patient Set-up Process – Design Considerations

• Patient Triage

– There are two services available – “Track and Trend” (no provider triage) or “Triage” -

covering 12 disease packages

– Each disease package has vitals, questions, default thresholds, planned monitoring

period

– Provider Clinical Triage Team responsible for Triaging Patients by phone

– Definition of Level 1, 2 and 3 Local response

Patient Triage

• Service Design Considerations

– Triage SLAs – to align timing of escalations with availability of local response

– Clear definition of what providers clinical triage team can and can’t do

– Medication updates ? Changing monitoring parameters ?

– Method of escalation (phone, email, sms); Method of closing the escalation

– Clinical governance procedures

Patient Triage - Design Considerations

• Monitoring Care – Setting and Reviewing Parameters

– Default monitoring parameters per vital defined on referral form

– Defaults parameters can be changed to Patient specific parameters

– Referrer responsibility to review parameters to avoid unnecessary alerts and

escalations

Monitoring of Care – Reviewing Parameters

• Design Considerations

– Threshold setting and scope of triage activity has a big influence on provider triage

staffing levels

– Key is to train clinicians and have agreed protocols

– Need automated SLAs/Performance Tracking to monitor triage process

– Need an audit trail of all changes to plan and monitoring regime

Monitoring Care – Design Considerations

• Patient Review & Discharge– On the Referral form the Monitoring Period is requested and will automatically show the

anticipated patient review date

– The Referrer is notified 3 weeks, 2 weeks and on the anticipate review date for a Patient Review

– This involves the Referrer completing a Patient Outcome Review Online Form

– If no response is received, we continue to monitor the patient until notified differently

– Unscheduled reviews may also be completed at intervals decided by the Referrer

– Referrer discharges via an on-line form

Patient Review & Discharge Process

Our Integrated Managed Service Platform

Service SupportDecision support software Referral, Reporting Patient Portal

• Pressure is on the provider to deliver services that the commissioner wants NOT on the commissioner to map the available technology to meet their requirements

• Significant up-front investment on both sides to define service requirements and design how the service will integrate with other services

• Keeps the commissioner “out of the weeds” – Defining what service is required and not how to arrange people, process and technology to deliver the service

• Demands a high level of working in partnership through service definition and design

• Shares the risk of delivery between the commissioner and provider

Managed Services Model – Lessons LearnedDelivering at Scale