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Telehealth




Delivering Telehealth at scale in Northern Ireland
A Service Provider Perspective
                                               Jim O’Donoghue
Copyright © S3 Group                           S3 Group
Northern Ireland Chronic Disease
                                                                                    2/3s of over
                                                                                        75s


                                                   Population 1.8M                60% of all GP
                                                                                     visits
                                                     H&SC budget
                                                       £4.3Bn
                                                  Rising to £4.66Bn
                                                    in 2014/2015                     72% acute
                                                                                      bed days


                                                                                 69% of health
                                                                                 & social care
                                                                                    spend

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

                                                                                S3 Confidential    Slide 2
NI Vision for Remote Telemonitoring
• 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”
First Questions for NI Authorities
• 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?
Models for procuring Telehealth
                                                                                                            Managed Service - Outcome
                                                                                                               Based Risk/Reward
Provider Responsibility & Risk




                                                       Flexibility and Scalability


                                                                                     Partnership Working
                                 Contract Complexity




                                                                                                             Managed Service - PAYG
                                                                                                           Customised / integrated service



                                                                                                           Combined Technology Purchase
                                                                                                                + Service Purchase



                                                                                                           Technology Purchase + Service
                                                                                                               purchased separately
Managed Service Model – Commissioner Responsibilities

 • Defining Service Requirements
                                        Managed Service - Outcome Based
                                        Risk/Reward
 • Defining KPIs (as SLAs and
   Quality Metrics)
                                        RTNI - Managed Service - PAYG
 • Defining how health professionals    Customised /Integrated Service
   will interact with and support the
   service interface points (e.g.
   escalations from Triage)             Combined Technology + Service
                                        Purchase
 • Stakeholder engagement

 • Selecting patients to be referred    Technology Purchase + Service
                                        purchased separately
   on to the service
Managed Service Model - Provider Responsibilities

• Providing all aspects of a joined-
  up service involving                 Managed Service - Outcome Based
                                       Risk/Reward
  people, process and technology

• Responsible from Referral to
                                       RTNI Managed Service - PAYG
  discharge                            Customised /Integrated Service

• Meeting defined service
  requirements & SLAs                  Combined Technology + Service
                                       Purchase
• Technology
  selection, maintenance and
  equivalence                          Technology Purchase + Service
                                       purchased separately

• Incentivised to generate service
  delivery efficiencies
Managed Service – A Shift in Concept and Language


    Buying            Becomes      Buying a
  Technology                        service


   Selecting          Becomes       Defining your
  Technology                    service requirements



   Buying Kit /       Becomes      Buying
     Units                      Monitoring days


 Building service     Becomes     Building capability to
delivery capability                 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
Overview of the Basic Service



                                 escalation



                                              Community
           Daily      Daily                     Nurse
         Readings   Monitoring




                                              GP/Clinician
Partnering to deliver integrated services
In Northern Ireland
Patient Selection   • Patient Assessment
                    • Patient Care Plan
  and Referral      • Patient and clinician engagement


                    • Programme Governance
  Governance        • Programme Management
                    • Stakeholder Communications


                    • Clinical
Service Design      • Business Processes
                    • Technical


                    • Clinical Service Delivery
Service Delivery    • Clinical Service Management
                    • Patient service Delivery


    Service         • Patient equipment
                    • Managed Service Platform
 Infrastructure     • IT Infrastructure
Partnering to deliver integrated services
In Northern Ireland
                    • Patient Assessment
Patient Selection   • Patient Care Plan
  and Referral      • Patient and clinician engagement


                    • Programme Governance
  Governance        • Programme Management
                    • Stakeholder Communications


                    • Clinical
Service Design      • Business Processes
                    • Technical


                    • Clinical Service Delivery
Service Delivery    • Clinical Service Management
                    • Patient service Delivery


    Service         • Patient equipment
                    • Managed Service Platform
 Infrastructure     • IT Infrastructure
RTNI Managed Service Requirements Definition


          Service                       Service                    Service
        Requirements                    Design                    Operation




                                                      Define Model &
                              Define Desired                                    Assess
Identify Drivers of Change                            Implementation
                                 Benefits                                     Cost/Benefits
                                                        Approach


                       Clinical Outcomes       Service Model            Clinical outcomes
  National                                     Roles/Responsibilities   Financial benefits
  Local                Patient Experience
                       Clinical Staff          Pathway Changes          Implementation costs
                       Financial               Delivery model
Service Requirements Definition – Iterative Approach




                          What’s               What’s
                         desirable            possible

   Commissioner                                             Provider



                                   What’s
                                  practical


                                                   Define Model &
                             Define Desired                              Assess
Identify Drivers of Change                         Implementation
                                Benefits                               Cost/Benefits
                                                     Approach
Capturing Requirements in a Contract
• 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
Service Design Processes


        Service                   Service                   Service
      Requirements                Design                   Operation




                      Establish        Design              Design           Service
 Service Planning      Service         Service            Service          Readiness
                     Governance        Delivery        Infrastructure       Testing



 Pathway Design        Clinical   Clinical processes Solution Design          People
Process Definition   Programme        Non-clinical   Service integration     Process
Service Interfaces    Financial        Operating      Service platform      Technology
                       Metrics        Procedures         Service IT
                                  Process/Policies
Service Design – Collaborative Process

                             Usability
                                                      Plan
                              Tests




                                   Commissioner

                      Workshops          Provider
                       / Expert                              Design
                      Feedback



                                          Process
                                            and
                                         interface
                                         Definition


                     Establish            Design                 Design        Service
 Service Planning     Service             Service               Service       Readiness
                    Governance            Delivery           Infrastructure    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
Patient Selection Process




• Patient Selection Process
                    Service Delivery Components

   – 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




• 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 – Design Considerations




• 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 Set-up Process




• 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 – Design Considerations




 • 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 Triage




• 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 - Design Considerations




• 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
Monitoring of Care – Reviewing Parameters




• 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 Care – Design Considerations




• 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
Patient Review & Discharge Process




• 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
Our Integrated Managed Service Platform




Decision support software   Referral, Reporting   Service Support   Patient Portal
Managed Services Model – Lessons Learned
Delivering at Scale
  • 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

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Delivering Telehealth At Scale In Northern Ireland - Jim O'Donghue

  • 1. Telehealth Delivering Telehealth at scale in Northern Ireland A Service Provider Perspective Jim O’Donoghue Copyright © S3 Group S3 Group
  • 2. Northern Ireland Chronic Disease 2/3s of over 75s Population 1.8M 60% of all GP visits H&SC budget £4.3Bn Rising to £4.66Bn in 2014/2015 72% acute bed days 69% of health & social care spend Department of Health (2008 ) Raising the profile of long term conditions care INIsPHO (2010) Making Chronic Conditions Count S3 Confidential Slide 2
  • 3. NI Vision for Remote Telemonitoring • 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”
  • 4. First Questions for NI Authorities • 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?
  • 5. Models for procuring Telehealth Managed Service - Outcome Based Risk/Reward Provider Responsibility & Risk Flexibility and Scalability Partnership Working Contract Complexity Managed Service - PAYG Customised / integrated service Combined Technology Purchase + Service Purchase Technology Purchase + Service purchased separately
  • 6. Managed Service Model – Commissioner Responsibilities • Defining Service Requirements Managed Service - Outcome Based Risk/Reward • Defining KPIs (as SLAs and Quality Metrics) RTNI - Managed Service - PAYG • Defining how health professionals Customised /Integrated Service will interact with and support the service interface points (e.g. escalations from Triage) Combined Technology + Service Purchase • Stakeholder engagement • Selecting patients to be referred Technology Purchase + Service purchased separately on to the service
  • 7. Managed Service Model - Provider Responsibilities • Providing all aspects of a joined- up service involving Managed Service - Outcome Based Risk/Reward people, process and technology • Responsible from Referral to RTNI Managed Service - PAYG discharge Customised /Integrated Service • Meeting defined service requirements & SLAs Combined Technology + Service Purchase • Technology selection, maintenance and equivalence Technology Purchase + Service purchased separately • Incentivised to generate service delivery efficiencies
  • 8. Managed Service – A Shift in Concept and Language Buying Becomes Buying a Technology service Selecting Becomes Defining your Technology service requirements Buying Kit / Becomes Buying Units Monitoring days Building service Becomes Building capability to delivery capability use the service
  • 9. 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
  • 10. Overview of the Basic Service escalation Community Daily Daily Nurse Readings Monitoring GP/Clinician
  • 11. Partnering to deliver integrated services In Northern Ireland Patient Selection • Patient Assessment • Patient Care Plan and Referral • Patient and clinician engagement • Programme Governance Governance • Programme Management • Stakeholder Communications • Clinical Service Design • Business Processes • Technical • Clinical Service Delivery Service Delivery • Clinical Service Management • Patient service Delivery Service • Patient equipment • Managed Service Platform Infrastructure • IT Infrastructure
  • 12. Partnering to deliver integrated services In Northern Ireland • Patient Assessment Patient Selection • Patient Care Plan and Referral • Patient and clinician engagement • Programme Governance Governance • Programme Management • Stakeholder Communications • Clinical Service Design • Business Processes • Technical • Clinical Service Delivery Service Delivery • Clinical Service Management • Patient service Delivery Service • Patient equipment • Managed Service Platform Infrastructure • IT Infrastructure
  • 13. RTNI Managed Service Requirements Definition Service Service Service Requirements Design Operation Define Model & Define Desired Assess Identify Drivers of Change Implementation Benefits Cost/Benefits Approach Clinical Outcomes Service Model Clinical outcomes National Roles/Responsibilities Financial benefits Local Patient Experience Clinical Staff Pathway Changes Implementation costs Financial Delivery model
  • 14. Service Requirements Definition – Iterative Approach What’s What’s desirable possible Commissioner Provider What’s practical Define Model & Define Desired Assess Identify Drivers of Change Implementation Benefits Cost/Benefits Approach
  • 15. Capturing Requirements in a Contract • 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
  • 16. Service Design Processes Service Service Service Requirements Design Operation Establish Design Design Service Service Planning Service Service Service Readiness Governance Delivery Infrastructure Testing Pathway Design Clinical Clinical processes Solution Design People Process Definition Programme Non-clinical Service integration Process Service Interfaces Financial Operating Service platform Technology Metrics Procedures Service IT Process/Policies
  • 17. Service Design – Collaborative Process Usability Plan Tests Commissioner Workshops Provider / Expert Design Feedback Process and interface Definition Establish Design Design Service Service Planning Service Service Service Readiness Governance Delivery Infrastructure Testing
  • 18. 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
  • 19. Patient Pathway – Service Design Considerations
  • 20. Patient Selection Process • Patient Selection Process Service Delivery Components – 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
  • 21. Patient Referral Process • 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
  • 22. Patient Referral Process – Design Considerations • 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
  • 23. Patient Set-up Process • 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
  • 24. Patient Set-up Process – Design Considerations • 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
  • 25. Patient Triage • 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
  • 26. Patient Triage - Design Considerations • 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
  • 27. Monitoring of Care – Reviewing Parameters • 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
  • 28. Monitoring Care – Design Considerations • 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
  • 29. Patient Review & Discharge Process • 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
  • 30. Our Integrated Managed Service Platform Decision support software Referral, Reporting Service Support Patient Portal
  • 31. Managed Services Model – Lessons Learned Delivering at Scale • 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