Virtual Clinics

From women’s health to pre-operative assessment

Setting up & sustaining virtual clinics

28th April 2017

2017

Stephen Radley MD FRCS FRCOG

Stephen.Radley@sth.nhs.uk

Urogynaecologist

Director of Research Jessop Wing

Sheffield Teaching Hospitals NHS FT

Director of R&D, ePAQ Systems Ltd

An NHS spin-out technology company

Understanding service virtualization: Where to start?

Case study: Virtual clinics: From Gynaecology to Pre Op Assessment

Understanding service virtualization: The theory

Tools and pathways

Where to start? Lessons from our virtual clinics

Developing a web-based ‘Virtual Clinic’ in Urogynaecology

The benefits of virtual clinics for ‘sensitive’ conditions

Practicalities and a walk through how the clinic works in practice

Understanding service virtualization: The theory

Virtual Clinic Provision of remote or non-face to face medical care, utilizing communication media

e-Health Healthcare practice supported by electronic processes & communication

Cybermedicine / Telemedicine Use of internet / electronic media to deliver medical services

(e.g. consultations & prescriptions)

Remote transmission of data

(e.g. images, results & assessments) supporting health care

Cyber Clinician Medical professional providing consultation via the Internet

Tools and pathways

Face to face… Post… Telephone… Internet… Cloud… Mobile

Retail, travel, financial services…… …healthcare

Pathways

NHS England

Technology Enabled Care Services: TECS Resource for commissioners

‘Maximise value of TECS for patients, carers, clinicians, health economy’

Defined as…

Telehealth, Telecare, Telemedicine, Telecoaching, Self-care

Aiming to…

Improve long-term conditions: convenient, accessible & cost effective

www.england.nhs.uk/ourworld/qual-clin-lead/tecs

Value & Burden: Virtual Clinics

Appropriate, accessible, practical

Is it clinically useful to patients & clinicians?

Can it be used in different settings?

How does it impact on patient care?

What is the cost - benefit to patients, society & providers?

80.471.4

59.3 58.4

39.0

11.1

0%

20%

40%

60%

80%

100%

would

recommend

would

undergo

again

subjective

improvement

or cure

no GSI normal

urodynamic

study

subjective

cure

The ‘Science’ of Outcomes Assessment

Symptoms vs Investigations

(BFLUTS): "Does urine leak before you can make it to the toilet?"

0%

20%

40%

60%

80%

100%

Never

(n=6)

Some- times

(n=20)

Occas-

ional

(n=32)

Most of

time

(n=27)

All the

time (n=10)

% w

ith d

etr

usor

overa

ctivity

Ambulatory

Urodynamics

Standard

Urodynamics

Bristol female urinary

tract symptoms - Q

Birmingham

bowel & urinary

tract - Q

Sheffield prolapse

symptoms - Q

Female sexual

function index

ICS

Male

Pelvic Floor

Assessment (PAQ)

Questionnaires

Developing a web-based ‘Virtual Clinic’ in Urogynaecology

Why an electronic

questionnaire ?

Burden

Value (interactive, simple & easy, help pages)

Radley S et al. Development & validation of a questionnaire for the

assessment of bowel symptoms in women. BJOG 2002

Radley SC et al. Computer interviewing in urogynaecology. BJOG 2006

ePAQ – Pelvic Floor

Structure

• Introductory pages

• Questionnaire dimensions (up to 120 items)

Urinary

Bowel

Vaginal

Sexual

• Analysis, summary, printed report

Interactive &

optional

dimensions

ePAQ – Pelvic Floor

A questionnaire for clinical use

Would you recommend this service

to Friends & Family?

2 year data – Follow up patients

N %

Extremely likely 445 66

Likely 173 26

Neither likely nor unlikely 35 5

Unlikely 7 1

Extremely unlikely 12 2

Total 672

‘Likely’ or ‘Extremely likely’ 92

ePAQ-PF Summary report

ePAQ – MPH (Menstrual, Pain, Hormonal)

Symptoms

Impact

ePAQ Detailed report

(Lower Urinary Tract Symptoms)

QoL

29 year old, Pakistani, Non-English speaking

Schizophrenia

Not examined

MSU -ve

Solifenacin 5mg

Routine clinical care

The Virtual Clinic

2006 survey of ePAQ users in urogynae clinic

• 80% of under 50s had internet access

• 45% of over 50s had internet access

95% of those with home internet access…

‘Would have liked to have used system before coming to clinic’

The Virtual

Clinic

Name Tel Time

Anna Smith AS1234 078212344 14:00

Beryl Jones BJ8765 0114 3098909 14:10

Connie Lewis CL2345 0114 3897890 14:20

Diane Cole DC4567 07989997654 14:30

Edna Rose ER3847 07635668234 14:49

Fiona Groves FG2783 0114 3897890 14:50

Greta Holmes GH1783 0114 3897890 15:00

Heidi Hill HY7896 0114 3897890 15:10

Ida France TA1256 0114 3897890 15:20

Joanne Davies JD3456 0114 3897890 15:30

Kay Somers KS2365 07885668234 15:40

Lisa Tandy LY5698 0757 3897890 16:00

Margaret Smith MS3452 0114 3897890 16:10

Nora Bates NB2344 0114 3897890 16:20

Orla Charles OC3567 07835668234 16:30

Penelope Roper PR5702 07835668234 16:40

Rose Doyle RD5098 07835668234 16:50

Selena Bird SB8090 07835668234 17:00

Tina Moores TM3409 07835668234 17:10

Ursula King PL0987 07835668234 17:20

Violet Bonnett VB0934 07735668239 17:30

Benefits of virtual clinics for sensitive conditions

• Disclosure, discussion & shared decision making 1

• Embedded outcome measures (PROMs & PREMs) 2

• Avoiding clinician bias 3

• Engagement, enablement, empowerment 4

1. Schussler-Fiorenza et al. Using an electronic pelvic floor questionnaire to increase discussion rates of urinary incontinence in primary care: an RCT. (In Press)

2. Black et al Relationship between patient reported experience (PREMs) and patient reported outcomes (PROMs) in elective surgery. BMJ 2013

3. Black et al. Impact of surgery for stress incontinence on morbidity: cohort study. BMJ 1997

4. Dua et al: Understanding women’s experiences of electronic interviewing during the clinical episode in urogynaecology: A qualitative study. IUGA Journal 2013

Patient comments…

I preferred answering the more embarrassing questions via the questionnaire than

face to face

Knowing that an examination was out of the question put me more at ease

Phone consultation excellent, relaxed & stress free

Thorough & informative way of doing things

I didn’t have to worry about childcare

Helped express my problems enormously

Helped focus on urgent and relevant problem

Made me realise the extent of my problem

Helped talk at ease about my problems

It was really easy to use

Good, enjoyable, easy and quick!

Good idea, well done!

0%

10%

20%

30%

40%

50%

Strongly

agree

Mostly agree Neither

agree nor

disagree

Mostly

disagree

Strongly

disagree

'The questionnaire was helpful during my clinic visit'

Disclosure Prevalence of coital incontinence in urogynaecology clinics

Author(s) Number of women Outcome measure Prevalence

Moran et al, 1999 2153 Direct questioning 10.6%

Serati et al, 2008 132 Direct questioning 11.6%

Madhu et al, 2015 11689 Direct questioning 11.8%

Monsterrat et al, 2008

633

KHQ

36.2%

Bekker et al, 2009 136 Non-validated Q 56%

El Azab, 2011 90 Non-validated Q 66%

Jha et al, 2012 480 ePAQ-PF 60%

Gray et al, 2016 2312 ePAQ-PF 47%

Practicalities How the clinic works

1) Standard appointments booking system

Patient preference choice, patient information

2) www.epaq-voucher.co.uk

Arranged via OPD / Ward staff / Secretary

3) Monthly clinic: 20 x 10 min appointments

5 – 15 min, supported by correspondence, notes & ePAQ

4) Outcomes

Letter to GP + ePAQ report / ePAQ progress report

Letter to patient

Information leaflets

Follow up

Discharge

https://start.epaq.co.uk

Linking Internet & N3 networks

N3 (NHS)

Personalised Name, DoB, NHS number,

WWW (Internet)

Anonymous Unique Voucher code

& DoB

EPR

Users

Manchester

Liverpool

Sheffield

Birmingham

Newcastle

Derby

Leeds

South Tees

Southport

Ormskirk

Scotland (S Ayr)

Italy (Milan)

Ire (Dublin)

100,000+

Colorectal, Urology, Physiotherapy,

Urogynaecology, Nurse Specialists

0

20

40

60

80

100

U P&S Voiding OAB SUI U QOL

Incontinence surgery: TVT pre and post op mean

ePAQ urinary domain scores (n=54)

pre op mean

post op mean

Effect size: SUI = 2.4 U-QoL = 2.2

Mean waiting time between referral & VUC: 28 days

(range 7 - 46)

Primary complaints

Stress incontinence (79%)

Overactive bladder (50%)

Prolapse (27%)

Bowel problems (24%)

Sexual dysfunction (24%)

VUC Outcomes (first 50 patients)

79% Treatment planned or initiated

39% Referred to physiotherapy

44% Scheduled urodynamics

12% Clinic follow-up

8% Referred to another clinic

Virtual Clinic:

First 50 patients

Positive aspects (0 = worst, 100 = best possible)

Communication (PEQ)

84 (SD = 16)

Value (QQ-10)

77 (SD 16)

Negative aspects (0 = best, 100 = worst possible)

Barriers (PEQ)

15 (SD = 15)

Burden (QQ-10)

25 (SD = 16)

Virtual Clinic: Satisfaction Data

0%

10%

20%

30%

40%

50%

Strongly

agree

Mostly agree Neither

agree nor

disagree

Mostly

disagree

Strongly

disagree

'The questionnaire was helpful during my clinic visit'

0

20

40

60

80

100

Disagree

completely

Disagree So-so Agree Agree

completely

'I felt taken care of'%

Evaluating the impact of a ‘virtual clinic’ on the quality

and cost of patient care in urogynaecology: An RCT

Jones GL, Radley SR, Jacques RM, Wood HJ, Brennan V, Dixon S.

195 Women: New patient referrals to

urogynaecology clinic

Resource Cost per patient

(Intervention) (£) N = 27

Cost per patient (control) (£)

N = 30

Mean Difference (£)

95% CI Lower

95% CI Upper

P-value

Cost of Consultations

Consultation cost1 29.35 69.52 -40.17 - - -

Cost of software 2.40 2.40 0 - - -

Cost of computer N/A 0.25 -.25 - - -

Total consultation costs per pt

31.75 72.17 40.42 - - -

Direct costs 6/12

GP Visits 41.22 35.33 5.89 -25.29 37.06 .654

Practice nurse 0.94 2.13 -1.18 -3.77 1.41 .063

Appointments 251 188 62.67 -87.02 212.36 .405

Surgery 330 286 44.88 -353.35 442.97 .822

Other professionals

Physio 5 5 .05 -7.58 7.68 .989

Nurse 4.5 2 2.49 -5.48 10.45 .534

Consultant 8 14 -6.35 -23.22 10.51 .454

Total direct costs 641 532 108.37 -346.93 563.67 .635

Indirect costs 6/12

Personal expenditure (£)

24 16 7.9 -6.04 21.84 .261

Loss of productivity 443 481 -37.81 -847.04 771.42 .926

Total indirect costs 467 497 -29.91 -839.47 779.66 .946

Total costs per pt 1,140 1102 38.04 -1119.34 1196.03 .948

RCT: New patient referrals in urogynaecology

Resource Cost per patient

(Intervention) (£) N = 27

Cost per patient (control) (£)

N = 30

Mean Difference (£)

95% CI Lower

95% CI Upper

P-value

Cost of Consultations

Consultation cost1 29.35 69.52 -40.17 - - -

Cost of software 2.40 2.40 0 - - -

Cost of computer N/A 0.25 -.25 - - -

Total consultation costs per pt 31.75 72.17 £40 (56%) - - -

Direct costs 6/12

GP Visits 41.22 35.33 5.89 -25.29 37.06 .654

Practice nurse 0.94 2.13 -1.18 -3.77 1.41 .063

Appointments 251 188 62.67 -87.02 212.36 .405

Surgery 330 286 44.88 -353.35 442.97 .822

Other professionals

Physio 5 5 .05 -7.58 7.68 .989

Nurse 4.5 2 2.49 -5.48 10.45 .534

Consultant 8 14 -6.35 -23.22 10.51 .454

Total direct costs 641 532 108.37 -346.93 563.67 .635

Indirect costs 6/12

Personal expenditure (£)

24 16 7.9 -6.04 21.84 .261

Loss of productivity 443 481 -37.81 -847.04 771.42 .926

Total indirect costs 467 497 -29.91 -839.47 779.66 .946

Total costs per pt 1,140 1102 38.04 -1119.34 1196.03 .948

RCT: New patient referrals in urogynaecology

Mean difference between groups & 95% CI for post consultation PEQ scores

(positive mean difference indicates the intervention group has a better score)

Summary of RCT Findings Virtual Clinic does appear to positively improve patient experience of consultation, particularly communication Virtual clinics may prove beneficial in overcoming barriers, improving emotional wellbeing and enhancing communication Significant difference between the duration of consultations (Approx 50% shorter) and associated consultation costs Patient selection & tariffs important factor in cost / benefit Follow-up care, Long-term conditions

Other applications

ePAQ-PO

(Pre Op Assessment)

ePAQ-Vascular

(NIHR ScHARR)

ePAQ-PO

Summary Report

Walk-in Pre Operative Assessment

• 2 sites (NGH & RHH)

• 12 touchscreens

• Support worker

• POA nurse

• 5 long day service…

ePAQ-PO implementation in Sheffield Teaching Hospitals 2015 - 2016

‘The questionnaire helped with communication’

%

‘Willing to use again’

%

Comments

‘Very impressed with the online system has it was quick and easy to complete’ ‘I thought the questionnaire was easy to complete and very thorough’ ‘The questionnaire was far too long and had nothing to do with my condition’

Integrated care pathways

N3 + www

1o care

2o care

3o care

Web

-based

assessm

ent

Home

Internet

Standardisation

Clinical governance

Screening

& Triage

Secondary care

Web-based assessment

Supporting patient-centred, integrated healthcare

Clinical assessment

Primary care

Research, Audit

Service evaluation

Appraisal,

revalidation,

Accreditation

Appointments

Where to start? Lessons from our virtual clinics

Consider: patients, clinicians, management & managing change

Champions: Staff / Colleagues / Managers / Stakeholders

Funding: Business case / Grants

Industry / Commissioners

Integration with e-systems…

Its not all about the money….

….but

Thank You

Computer interviewing in urogynaecology: concept, development and psychometric testing of an electronic pelvic floor assessment questionnaire (e-PAQ) in primary and secondary care. Radley et al. BJOG, 2006

Increasing Discussion Rates of Incontinence in Primary Care: A Randomized Controlled Trial. Sophia Miryam

Schussler-Fiorenza Rose et al. Journal of Women’s Health. Volume 24, Number 11, 2015 The use of free text items in electronic questionnaires to record patients’ concerns, goals and questions relating to

their condition. Gray et al. Proceedings of BSUG. Int Urogynecol J. 2015 QQ-10: An instrument to measure face validity and feasibility of questionnaire use in healthcare. Moores K, Jones G, Radley SC. Int J Quality in Health Care. 2012 Prolapse surgery and sexual function. Dua A, Jha S, Farkas A, Jones GL, Radley SC. International Urogynecology

Journal. (Oct 2011) Effect of posterior colporrhaphy on anorectal function. Dua A, Jha S, Farkas A, Jones GL, Radley SC. International

Urogynecology Journal. (2011) Quality of life measurement & electronic assessment in urogynaecology. Dua et al. The Obstetrician &

Gynaecologist (2011) Factors affecting the outcome of TVT. Jha S et al. European Journal of Obs Gyn Repro Biol (2008) Responsiveness of ePAQ-PF. Jones GL et al. Int Urogynecol J Pelvic Floor Dysfunct. (2008) Impact of TVT on Sexual function. Jha et al. Int Urogynecol J Pelvic Floor Dysfunct. (2008) Electronic pelvic floor symptoms assessment: tests of data quality of ePAQ-PF. Jones GL et al. Int Urogynecol J Pelvic

Floor Dysfunct. (2008)

Pre-Operative Assessment Patient-completed, preoperative web-based anaesthetic assessment questionnaire (electronic Personal Assessment Questionnaire Pre-Operative) Development and validation. Iain M. Goodhart, John Andrzejowski, Georgina Jones, Mireille Berthoud, Andy Dennis, Gary Mills and Stephen Radley. Eur J Anaesthesiol 2016; 33:1–8 An evaluation of factors influencing the assessment time in a nurse practitioner-led anaesthetic pre-operative assessment clinic. R. H. Hawes, J. C. Andrzejowski, I. M. Goodhart,3 M. C. Berthoud and M. D. Wiles. Anaesthesia 2015; doi:10.1111/anae.13340 Electronic Personal Assessment Questionnaire Pre-Operative: Patient experience and face validity of an interactive, electronic questionnaire for the preoperative assessment of patients due to undergo general anaesthesia: Goodhart I, Andrzejowski J, Berthoud M et al. British Journal of Anaesthesia 2012; 109: 655- 668 How valid are patient-reported height and weight using an interactive computerised pre-operative assessment questionnaire (ePAQ-PO)? Andrzejowski, JC. Goodhart, IM ; Berthoud, M ; Radley, SC ; Hawes, RH. British Journal Of Anaesthesia, 2013 May, Vol.110(5), pp.861-861