Delivering Benefits for Patients and the NHS in Lancashire ...

North WestNHS

Cardiac Telemedicine in Primary Care

Delivering Benefits for Patients and the NHS in Lancashire & CumbriaA Report for Commissioners

Lancashire & South Cumbria Cardiac Network

NHS

Buckinghamshire ChilternsUNIVERSITY COLLEGE

Ipsos MORI

Cardiac Telemedicine in Primary Care - Delivering Benefitsfor Patients and the NHS in Lancashire & Cumbria

Over the past few yearstechnological developmentshave taken place which haveprovided new equipment andways of working for cliniciansand social care workers toprovide support and care forpatients in their own home,thus allowing them to remainwith their families and avoidinginappropriate hospitaladmissions.

One such development hasbeen the use of telemedicineequipment for undertakingcardiovascular diagnosis andmonitoring for patients withcardiac conditions within thehome/community environment.This report identifies theconsiderable benefits that maybe gained by using such

Foreword

3

technology. NHS North West,working in close collaborationwith Broomwell Healthwatch,an independent sector company,funded the placement oftelemedicine ECG machines inPrimary Care Centres across theCumbria and Lancashire area ofthe NHS North West. The Auditand Research Programme set upto monitor the effectiveness ofthis equipment identified thatconsiderable benefits could beachieved for patient care andclinical diagnostics as well asgains made for the healtheconomy. The full details areidentified in the body of thisreport.

The service and benefitsdescribed in the following pagesrepresent one of an increasing

number of new technologicalservices that are available forpatient care and as such helpsto address one of the bigchallenges for the NHS, that ofdelivering benefits to patients,carers and professionals. It isnow timely for commissionersto be embracing these servicesto meet the future demands ofhealthcare provision and it is forthis reason we are sharing ourfindings so widely.

I hope you find the reporthelpful and informative for yourfuture commissioning plans.

J RaffertyDirector of Commissioning and PerformanceNHS North West


In Cumbria and Lancashire theStrategic Health Authority (nowpart of NHS North West) fundedby development money from thethen Directorate of Access andChoice at the Department ofHealth worked closely withBroomwell Healthwatch, acompany that had alreadydeveloped a telemedicine ECGinterpretation service, to auditthe use of this new technologyin various primary care settings.The aim of this work was toestablish whether there were anybenefits to be gained from thisnew way of working.

This report publishes the resultsof the audit and details theopinions of clinicians who hadused this telemedicineequipment to assist them in themanagement of their patients.This information was collectedby the SHA using an auditquestionnaire and bycommissioning the service ofIpsos MORI to undertake a seriesof focus groups to collateopinion with regard to the newservice.

Executive Summary

4

The benefits to patients and theNHS identified by this work maybe summarised as follows:

• Patient Benefits• Patients may avoid

unnecessary hospital attendance

• Patients are able to access care within their local community.

• Operational Benefits• The equipment is convenient

and easy to use. • The equipment is

lightweight and portable allowing use in varying locations

• The system saves time for clinical and managerial staff.

• Clinician Benefits• The service provides access

to prompt expertise in ECG interpretation

• Clinicians have confidence in the accuracy of ECG interpretation which supports their clinical diagnosis

• The service is reliable and provides 24-hour support – 365 days per year.

• Health Economy Benefits• The number of inappropriate

hospital attendances was reduced

• Financial savings can be re-distributed in line with local priorities.

The report also outlines thebenefits as we see them ofcollaborative working with theindependent sector andconcludes with a series ofrecommendations tocommissioners who we believeshould consider use oftelemedicine technology incardiac care.

Whilst not part of the formalaudit, once it became clear thatthis technology was supportingclinical decision making to theextent that inappropriatereferrals to A&E departmentswere being prevented, anestimate of the potentialfinancial savings beingaccumulated during the pilotwas made. When extrapolatedto England as a whole wesuggest that the potentialfinancial savings could be aminimum of £45 million perannum.

Section 1

The Pilot and how it was undertaken


1.1 Introduction

In 2005 the Cumbria andLancashire Strategic HealthAuthority (C&L SHA, now partof NHS North West), supportedby the Diagnostic FuturesProgramme at the Departmentof Health (DH), undertook anAudit and Research Programmeto evaluate the ease of use andeffectiveness of telemedicinediagnostics when used in aprimary care setting.

Research such as this has beenconducted elsewhere in theworld, particularly in Italy(Scalvini et al 2005) andAmerica, where workers haveidentified that definite patient,clinical and health economicgains may be achieved by usingthis equipment.

We are also aware that othercentres in the UK have beenusing a variety of newtelemedicine technologies for a number of years withconsiderable benefits for patient care.

The Pilot and how it was undertaken

6

In order to evaluate cardiactelemedicine in communitysettings, a number of GPpractices as well as twoestablished NHS walk-in centreswere recruited with the supportof the Lancashire and SouthCumbria Cardiac Network. Thenetwork also provided adviceabout evaluation. Each wasoffered the opportunity to trialtelemedicine electro-cardiograph(ECG) machines for a period ofsix months.

Every location was asked to usethis equipment exclusively forthe duration of the pilot, and,as part of the project, wereasked to complete an auditquestionnaire; the results ofwhich are detailed in this report.Medical, nursing andmanagerial staff were alsoasked to take part in focusgroups conducted by the IpsosMORI organisation; the findingsof which are included in section2 of this report.

1.2 Why did we pilotTelemedicine and how didwe go about it?

Within primary care, ECGs areusually undertaken by nursingstaff who often have limitedtraining in interpretation of theresults. GPs may also experiencedifficulty in reading ECGs, asmany do not see themsufficiently often to interpretcomplex readings or onoccasion maintain their clinicalcompetence in this area ofpractice. In addition, questionsare raised with regard to thereliability of the ECG machinereaders, which may not alwaysgive an accurate result. One ofthe prime aims of this pilot wastherefore to investigate optionsthat would enable GPs andother practitioners to access areliable and accurate way tosupport them to interpret ECGsand so assist them with clinicaldiagnosis and management ofthe patient’s health needs. Itwas also hoped that thistechnology would provideadditional benefits includingoperational simplicity, reductionsin inappropriate hospitalattendance and achievefinancial savings that could bere-invested in patient care.


At present most primary carecentres use a conventional 12-lead ECG machine to:

• Assess patients who present with acute clinical symptoms

• Evaluate progress in the clinical condition of patients with long-term conditions such a hypertension or diabetes

• As a screening tool to provide clinical data prior to an outpatient referral.

These machines take arecording and then produce apaper tracing for the clinician(usually doctor) or the machine’sinbuilt electronic reader tointerpret.

1.3 How does theTelemedicine technologywork?

Telemetric 12-lead ECGmachines are used in anidentical manner asconventional machines but, withthis equipment, the recordingobtained is transmittedwirelessly along a land-basedphone line to a call centrewhere a team of clinicallytrained staff are available 24hours a day, 365 days per yearto interpret the results. During

7

transmission, the team are inconstant communication withthe patient’s doctor, nurse orparamedic and, havingawareness of the clinicalsituation, are then able toprovide an accurateinterpretation and provide animmediate result to supportdelivery of quality patient care.

1.4 Pilot Methodology

Telemedicine ECG machineswere placed in 15 GeneralPractices and two walk-incentres within the area in theNorth West of England coveredby the Cumbria & LancashireSHA. Centre selection wasmade at random, the clinicalteams at each location beinggiven the option to take part inthe work. The final decision toparticipate was made by theclinicians followingdemonstration of the ECGequipment and service. Thedistribution of the participatingcentres by Primary Care Trusts(PCTs) is shown in table 1. ThePCTs identified are those inexistence prior to the re-configuration in October 2006.

Table 1 - Centre distributionby Primary Care Trust

Primary Care Trust

Blackpool (1)

Fylde (3)

Wyre (1)

Chorley & South Ribble (3)

West Lancashire (2)

Hyndburn & Ribble Valley (1)

Blackburn with Darwen (1)

Morecambe Bay (1)

North Cumbria (2)

Blackpool Walk-in Centre

Skelmersdale Walk-in Centre

The practices and walk-incentres were distributed acrossthe Cumbria and LancashireSHA area with most PCTs beingrepresented in the project. Theaudit included practices ofvarying patient list sizes (3800 –15600), number of GeneralPractitioners (2 – 5) andorganisational complexity.

It was however identified by theproject team that a greaternumber of centres in Lancashireelected to be included than inCumbria.


8

The centres were asked to usethe telemetric ECG machines inthe same manner as their usualequipment so that no change inpractice would take place toinfluence the results.

The machines were fundedthrough the project for eachcentre for a six-month periodwith the requirement that, oneach occasion of usage, theclinician undertaking theinvestigation would complete abasic audit questionnaire andthat the clinical staff agreed totake part in a focus groupconducted by the Ipsos MORIorganisation at the end of theproject period.

The format of the questionnairewas designed to identify theobjectives of the audit and toensure that the workload of theclinician would not be increased,so aiding their compliance inrecording the requiredinformation.

1.5 How were the ECGsinterpreted?

The project team commissionedBroomwell Healthwatch, anindependent sector companybased in Manchester, to supplythe telemedicine ECG machinesand offer GPs and otherhealthcare professionals accessto immediate, expertinterpretation of ECGs byexperienced cardiology-trainedclinicians. Before engaging in thework programme, the team hadto ensure that clinicalgovernance and probity issuesrelating to NHS patient carewere incorporated into thecontracting arrangements.

GP surgeries using the servicewould send ECGs to theBroomwell Healthwatch Centreby telephone and receive back averbal report with a full writteninterpretation within minutes byemail or fax.

Typically, a nurse at the GPsurgery or NHS walk-in centrewould record an ECG on apatient at the surgery and wouldthen telephone the BroomwellHealthwatch call centre.Cardiology staff at the centrewould answer the call andreceive the ECG down thetelephone line and would thengive an immediate verbalinterpretation of the ECG. If theECG showed any acute changes,immediate action could betaken. Following the verbalreport, a full written ECG reportwould be sent back to the GPsurgery within minutes, togetherwith a copy of the ECG by emailor fax for inclusion in the patientrecord.

PatientNumber

1

2

Etc

Date ofBirth

Cliniciantaking ECG

ClinicalDetails

Ease/Difficulties in Use

The basic audit questionnaire isshown below:

ECG Change Patient Management Outcome


9

The ECG machine provided ishand held and easy to use. TheECG is stored in the memory ofthe device and is transmitted asan acoustic (i.e. sound) signal viaa telephone to the BroomwellHealthwatch centre, where it iscaptured and displayed onscreen. The transmission time is45 seconds. The quality of theECG trace received by BroomwellHealthwatch is extremely highand the ECG trace along with awritten report is sent to the GPsurgery by email or fax(depending on the preference ofthe surgery).

Staff at the BroomwellHealthwatch centre whoperform the ECG interpretationare all UK practising nurses ormedical staff who have hadextensive cardiology experiencein coronary care or othersecondary care units. They areselected for their ECGinterpretation skills and aresubject to ongoing training,testing and audit by consultantcardiologists who provide aquality control process for theservice.

Recording the ECG

Clinicians at the centre seethe ECG on screen and createa full report

Transmitting the ECG

1.6 Clinical Standards

Telemedicine ECGs offer analternative means of undertaking patient diagnosticsbut, as this system was replacingconventional equipment, it hadto be shown that patient careand safety was not beingjeopardised and that, as animproved service was envisaged,benefits should be seen forpatients, clinicians and thehealth economy.

For this reason the followingcriteria were set:

• On no occasion should patient safety be compromised by equipment or system failure or confidentiality be breached due to problems of data transfer

• The new equipment and service should be at least as reliable and as easy to use in clinical practice as conventionalECG machines and should represent an improvement in patient care.

Data Source

Local Audit Data

BroomwellNational Data

1.7 Consistency Check

Towards the end of the auditanalysis Broomwell supplied abreakdown of the outcomes of2750 calls that they had dealtwith in preceding years. Theaudit team extracted 55 patientswho attended one of the walk-in centres from this group anddirectly compared the decisionsmade about their care settingwith figures from Broomwell’snational data. Local datashowed a remarkable degree ofconsistency when compared toBroomwell’s larger co-hort. Webelieve that although the localaudit numbers are small, theyare a true reflection of theoverall findings of this work.

Remain withinPrimary Care

82%

86%

Refer toHospital

18%

14%

Total Numberof calls

55

2750


10

Section 2

The Ipsos MORI research


12

2.1 Introduction

Cumbria and Lancashire SHA feltit important that part of theevaluation of this pilot shouldinclude qualitative assessmentand be independent of localplayers.

For this reason it commissionedIpsos MORI to undertake fourfocus groups which includedGPs, nurses and managers whohad direct experience of usingthis service. In addition adetailed telephone interview wasconducted with BroomwellHealthwatch.

Ipsos MORI’s report is publishedin full in this section.

The Ipsos MORI research

A Review of Attitudes to Telemedicine ECG Equipment acrossthe North West – Outcome Focus Group studies conducted byIpsos MORI

Contents

Executive summary

1 Introduction1.1 Background, Aims and objectives1.2 Methodology1.4 Publication of Data1.5 Acknowledgements

2 Experiences of using telemetric ECG equipment2.1 Overview2.2 Suggested improvements to the equipment2.3 Benefits of using telemedicine ECG machines2.4 Drawbacks to using the equipment2.5 Cost as a barrier to using telemedicine ECG equipment

3 Patient views of telemedicine ECG equipment3.1 Positive views from patients

4 The impact of using telemetric ECG equipment4.1 Overview4.2 Impact on clinical procedures4.3 Impact in rural areas4.4 Training

5 Looking to the future5.1 The future5.2 Expanding the range of Telemedicine ECG equipment


13

Executive summary

Overwhelmingly, the practice staffwe spoke to in both Lancashire andCumbria say they find telemetricECG equipment very user-friendly.Furthermore, they say that it worksvery well and report no technicalproblems whatsoever.

Importantly, practice staff say thatpatients are unanimously positiveabout the equipment, and that theytrust the technology. Mostimpressed are those patients inLancashire who have not previouslybeen able to have an ECG at theirlocal surgery, but are now able toundergo the procedure at their localsurgery, rather than making a (oftenlong) trip to hospital.

Practice staff in both Cumbria andLancashire staff feel that one of themain benefits of using theequipment is its portability. As theequipment is hand-held it opens upthe possibilities of conducting ECGswhilst on home visits. In particular,staff in Cumbrian practices feel thatperforming ECGs in the patientshome could one of the main waysof using telemetric ECG equipment.They do stress however, that inorder for this to be effective it mustbe possible to transmit the ECGdown a mobile telephone line.

Additionally, among some small,Lancashire practices where no GP ison hand to interpret ECG readings,

speed of use and the knock-oneffect of time-savings to thepractice emerge as the keyadvantages. These practices feelthey have benefited the most fromthe pilot and are the mostenthusiastic about the advent oftelemetric equipment.

Sometimes having to wait for awritten report emerges as an areaof concern for some practice staff,particularly in Cumbria. Staff claimto often have to wait 20-30 minutesfor the report, which is perceived tohave a knock-on effect onappointment times and can result inreluctance to use the equipmentwhen they have a traditionalmachine which can give fasterresults.

The perceived cost of running theequipment emerges as a significantbarrier among practice staff. Inparticular, staff in Cumbria feel theequipment is prohibitively expensivegiven the amount of likely usage, asthey prefer to use their traditionalequipment and to use telemetricECG as a ‘back-up’. Staff inLancashire however, feel that theequipment ‘probably’ representsgood value for money as it mayreduce the amount of A&Eadmissions, and thus over time itmay ‘pay for itself’. However, stafffeel that GPs may be unwilling topay for the equipment as they mayfeel they are ‘losing out’ financially,and as such, staff in Lancashire

would be keen to see the local PCTfund the equipment.

Telemetric ECG equipment has hadthe most impact in practices thatdid not previously have access totraditional ECG equipment. InLancashire practices telemetric ECGequipment has resulted somepatients avoiding a visit to A&E,however, more commonly it hasresulted in increased quality ofpatient information if the patientdoes go to hospital.

However, practice staff in Cumbria(who have traditional ECGmachines) have not seen the samelevel of impact express only mutedenthusiasm for the telemetricequipment. Staff report thatpractices that do not currently haveECG machines (or a GP able tointerpret the results) should beprioritised, as the equipment is likelyto have the most impact in thesepractices.

Looking to the future, practice staffare overwhelmingly positive aboutthe advent of telemetric equipmentin primary care. Not only wouldstaff be keen to use the equipmentfor home visits but they also feelthat telemedicine could beexpanded to also include Spirometryand photographing skin lesions.


14

1. Introduction

This report contains the findings ofa study conducted by the IpsosMORI Social Research Institute onbehalf of NHS North West (formerlyCumbria and Lancashire StrategicHealth Authority).

1.1 Background, aims andobjectives

NHS North West is conducting apilot study of telemedicinediagnostic ECG equipment in avariety of NHS settings throughoutCumbria and Lancashire. Theequipment enables patients toundergo an ECG at their local GPsurgery or walk-in centre, have ittransmitted via a telephone line to aspecialist who analyses it, andreceive a diagnosis from their GPwhile they wait.

A range of GP surgeries and Walk-in Centres in Cumbria andLancashire participated in the study,the greater number being from thelatter area (3 Cumbria:12Lancashire). This balance needsconsideration during the report andmay need to be reviewed for futurework.

The aims and objectives of thisproject were as follows:

• To assess the perceived effectiveness of the telemedicine technology;

• To explore the advantages and drawbacks to using the equipment;

• To examine the impact that the equipment has had;

• To gauge clinician’s views of patient reactions to the use of telemedicine technology; and

• To discuss the possibilities of future usage of telemedicine equipment.

1.2 Methodology

Ipsos MORI used qualitativemethods for this study. The researchconsisted of the followingcomponents:

• Three discussion groups with GPs,practice managers, nurses and healthcare assistants in Lancashire;

• One discussion group with nurses and a practice manager in Cumbria; and

•One in-depth telephone interview with the telemedicine provider, Broomwell Healthwatch.

All discussion group participantswere taking part in the telemedicinepilot and were recruited by NHSNorth West, who also supplied thevenues and refreshments.

The topics covered in the discussiongroups were:

• Experiences of using the telemedicine ECG equipment;

• Advantages of, and barriers towards, using the equipment;

• Patient views and experiences of telemedicine;

• The perceived impact of using theequipment; and

• The future of telemedicine.

In addition to the discussion groups,Ipsos IPSOS MORI conducted an in-depth telephone interview withBroomwell Healthwatch, thecompany responsible for providingthe equipment and analysing theECG reports. This interview covered;background to telemedicine, patientand clinicians’ reactions to theequipment, and the future oftelemedicine.

1.3 Presentation andinterpretation of the data

Qualitative findings

It is important to note thatqualitative research is designed tobe illustrative rather than statisticallyrepresentative and thereforeprovides insight into why peoplehold views, rather than conclusionsfrom a robust, valid sample. Inaddition, it is important to bear inmind that we are dealing withpeople’s perceptions, rather thanfacts.


15

Throughout the report, use is madeof verbatim comments fromparticipants. Where this is the case,it is important to remember that theviews expressed do not alwaysrepresent the views of the group asa whole, although in each case theverbatim is representative of, atleast, a minority.

1.4 Publication of data

Our standard Terms and Conditionsapply to this, as to all studies wecarry out. Compliance with theMRS Code of Conduct and ourclearing is necessary of any copy ordata for publication, web-siting orpress releases which contain anydata derived from Ipsos MORIresearch. This is to protect ourclient’s reputation and integrity asmuch as our own. We recognisethat it is in no-one’s best interests tohave survey findings publishedwhich could be misinterpreted, orcould appear to be inaccurately, ormisleadingly, presented.

1.5 Acknowledgements

IPSOS MORI would like to thankJulie Hendry, Steve Ward and theircolleagues at NHS North West fortheir help and assistance in thedevelopment of the project. Wewould also like to thank Michaeland Joshua Rowe at BroomwellHealthwatch and the Practice Staffwho participated in this study,without whose input the researchwould not have been possible.


16

2. Experiences of usingtelemetric ECG equipment

2.1 Overview

Overwhelmingly, the practice staffwe spoke to in both Lancashire andCumbria say they find the telemetricECG equipment very user-friendlyand, as such, say it is easy to trainup other members of staff to use.Since using the machine requires arelatively low level of training, inmost cases a nurse or healthcareassistant will use the equipment,this, in turn can free up morespecialist members of staff.

“It’s brilliant. It’s quick, it’sconvenient… it’s justreally easy”Lancashire practice

A minority of practice staff say thatinitially they were dubious aboutusing the new equipment, however,they soon overcame this initialscepticism when they discoveredhow easy it is to use.

“The first couple we did Ithought ‘oh gosh this is apalaver, I don’t think Ifancy this’… but it’s likeanything else, once youactually get into it it’seasy”Nurse, Lancashire practice

Practice staff report no technicalproblems whatsoever using thetelemetric ECG machines. However,some staff say that on a fewoccasions they have had to transmitthe ECG twice due to interference.

2.2 Suggested improvements tothe equipment

All practice staff we spoke to – inparticular those in Lancashire – saythey find the telemedicineequipment works very well, andmost could not think of any furtherimprovements they would like tosee made to the current system.

One member of staff however, saysthat the machine holds the last ECGresults until this is manually cleared.As such, the staff need to ensurethat they delete the previous ECGresults before using the equipment.She thinks it would be helpful if themachine could either automaticallyclear the previous data, or notrecord another ECG if the previousECG reading is still present.

Furthermore, practice staff inCumbria say they would like toreceive speedier reports fromBroomwell Healthcare. Any delay inreceiving reports has a knock-oneffect on appointments and cancause delays at the practice.

2.3 Benefits of usingtelemedicine ECG machines

For many practice staff in Cumbriaand Lancashire, one of the mostimportant benefits of the telemetricECG equipment is its portability.Staff say their traditional ECGmachines are large, bulky and assuch, difficult to move. However,the new machines are much smaller,hand-held devices, allowing nursesand healthcare assistants to usethem in several different roomswithin the practice.

“It’s easy to transferaround the practice todifferent rooms. You canalso take it on visits,where the machine thatwe had before is quite alarge machine so it’s notthat mobile”Lancashire practice


17

“If a patient can’t getupstairs you can go to them”Lancashire practice

Similarly, practice staff in Cumbriacite portability as an importantadvantage, since it has the potentialto be used widely in the community,for instance it gives GPs theopportunity to use the equipmentfor home visits and routine ECGs.This can be particularly helpfulamong those patients who arehousebound or in care-homes.

Along with portability, the mostcommonly cited advantages ofusing telemetric ECGs amongLancashire practices (in particularthose that did not have a traditionalmachine) are the speed of use andknock-on effect of time savings toindividual practices. This isparticularly helpful in those practiceswhere GPs are not confidentinterpreting ECG readings.

“I couldn’t alwaysinterpret the ECGs…sometimes you getpeculiar readings, youhaven’t always got adoctor available andsometime you used to bea bit anxious… ‘can Ileave it ‘til tomorrow?’ ”GP, Lancashire practice

Most practice staff in Lancashire arepleased that they usually receive theECG report within about tenminutes of transmitting it, enablingthem to slot in routine or evenemergency ECGs relatively easily.However, most staff say that on acouple of occasions the ECG reporthas taken up to 40 minutes toarrive, which has resulted in delaysat the practice.

We have had an occasion wherethis patient had an ECG and itobviously showed something, andthe doctor was waiting for the ECGto be faxed back to us… and itdidn’t come through straightawayso that patient was waiting for agood 35 – 40 minutes. The doctorwas waiting. He had to go onvisits… whether that could bespeeded up would be helpfulNurse, Lancashire practice

Furthermore, staff at Cumbrianpractices say they often have towait 30-40 minutes for the report,which has resulted in reluctance touse the equipment, as they findtheir traditional ECG machines arequicker.

“It’s blocking our time up,‘cos we’re conscious thatwe’ve got to wait for thisECG, so you’re trying tosee other patients, so itcould be another 20[minutes]”Nurse, Cumbria practice

Additionally, practice staff andBroomwell Healthwatch say theability to undergo an ECG within afamiliar environment such as theirlocal surgery is an important benefitto patients. They feel that patientsare reassured if they can deal withstaff they have already built up atrusting relationship with and sotend to find the process lesstraumatic than going to thehospital.


18

“I think it’s moreconvenient for thepatients and they’regoing to be dealing withpeople that they knowand have a relationshipwith and probably trust,rather than somebodyanonymous at thehospital… They are oftenless stressed and anxiousabout coming to thesurgery rather than goingto the hospital”Lancashire practice

“From the patients pointof view imagine the …anxiety of when anambulance is called andhe’s sent to hospital”Broomwell Healthwatch

In Lancashire, one GP we spoke tohas a special interest in cardiologyand has been able to monitor theaccuracy of the ECG reports.Encouragingly, as well as thegeneral speediness of reports, thisGP was also satisfied that he foundthe reports on the whole veryaccurate.

“I think in general thereports are good andaccurate…one in twelvewhere I’ve had someminor quibbling butthere’s been nothingmajor. So in general onewould have to say thatthe reports are good andaccurate and they comepromptly”GP, Lancashire practice

This specialist GP does findhowever, that the ECG reportsreceived electronically are not quiteas clear and easy to read astraditional ECG reports.

“My only downside iswhen you get the report,whereas on a normalECG the red boxesrepresent 0.2 a secondand they’re usuallydivided into five… and onthe tracing we get youcan’t see those fivethings… you can’taccurately show that orsee that… This is slightlysmaller [than A4] and youlose some of the accuracyand the detail of the timemarkersGP, Lancashire practice


19

2.4 Drawbacks to using theequipment

By and large, practice staff inLancashire feel that using thetelemetric ECG equipment has veryfew drawbacks. However, some GPshave complained to BroomwellHealthwatch that their specialistssometimes give too much advicewhen they give the ECG report. Forinstance, in some cases specialistshave suggested a blood pressurecheck or other medical procedurewhich has lead to the GP feelingthat there is an overlapping of roles. Broomwell Healthwatch are awareof this issue and in response to this,they say their specialists tend to nolonger give recommendations withthe ECG report.

“The only concern thatwe’ve had… the doctorand nurse teamsometimes give too muchadvice… one of thedoctors was saying ‘justinterpret the ECG butdon’t give anyrecommendations’ “Broomwell Healthwatch

Furthermore, one practice whichhas not traditionally conductedECGs, has found that using theTelemedicine equipment eats intoresourcing at the surgery. Being a

small practice with limited spaceand a small number of staff, theyhave found that conducting ECGscan be time-consuming. However, itis worth noting that all otherLancashire practices we spoke tofind that the ECG equipment savesthem time.

“Historically we never didECGs because the CliftonHospital just along theroad did and practicenurse appointments arevery precious… it doestake up practice nurseappointments and wegenerally have to make ita triple appointment so30 minutes, not becauseof the speed of using theECG, it’s really quite fast.It’s the elderly peoplegetting dressedafterwards and wehaven’t got a separateroom… so the onedrawback for us is thatwe’ve had to find thoseresources” Lancashire practice

Although practice staff in Lancashiresay that the telemetric equipmentsaves them time, staff in Cumbriasay that waiting for the fax reportcosts them time. These staff saythey often have to wait 30-40minutes for the report which canhold up appointment, which haslead to reluctance among staff touse this equipment when they havea traditional machine which givesthem immediate results. These staffsay that in order for the telemetricequipment to be efficient it isimportant to receive the reportswithin ten minutes.

“I found the delay factorof getting a fax sentthrough from it is theonly major stumblingblock with it, ‘cossometimes we’ve waitedhalf an hour to get itfaxed through”Nurse, Cumbria

“The phone call nevergoes through first timeand they always phoneback and ask her to do itagain”Nurse, Cumbria


20

2.5 Cost as a barrier to usingtelemedicine ECG equipment

Practice staff in Lancashire feel thatthe advent of telemedicineequipment has the potential forhaving a massive impact on savingNHS money if it was rolled outacross the country. Specifically theyfeel that much of the savings wouldresult from fewer patients beingadmitted to hospital.

“I think it should be verycost-effective for thehospitals ‘cos I think a lotof… GPs are a little bitunsure, to be on the safeside let’s send them up tomedical assessment…which is a phenomenalcost”Lancashire practice

However, at a local level cost is anarea of concern for many practicestaff – particularly for GPs runningtheir own practices. Although staffare generally very positive about thepilot of ECG machines and feel thatthe system would benefit localhospitals, the NHS as a whole andthe general public, few GPs wouldbe willing to pay for the equipmentfor their practice, as they feel thatthey would be ‘losing out’personally.

“They all like the machineand they want it tocontinue but thedownside is the cost… itwould be too much forus to continueLancashire practiceWe’d have to look into itand how much it wasand everything else”Lancashire practice

Practice staff in Lancashire say theyfeel that the ECG equipment shouldbe funded by their local PCT, butmost do not feel optimistic aboutreceiving this funding. However,staff believe that if the cost savingsalready made by using the new ECGequipment and potential futuresavings could be measured anddemonstrated then the PCTs may bemore willing to fund the service.

“The PCT are saying ‘wellwhere are we going tofind the money for this’?You should be doing it in-house”Lancashire practice

I think you would need todemonstrate some cost savingsLancashire practiceIndeed, most practice staff feel thatthe potential savings outweigh thefinancial costs of buying andrunning the equipment at a regionalor national level, and therefore feelthat in the long-term it would morethan pay for itself.

“I think it could, long-term, actually pay foritself”Lancashire practice

Some practice staff feel that if PCTswere to fund the equipment, thosepractices that do not currently havea member of staff who is able tointerpret ECGs should be prioritisedfor funding as this is where theequipment has had, and will have,the most valuable impact. It isworth noting, however, thatCumbrian practices do not feel it isthe responsibility of the PCT to fundthe equipment, but that individualpractices should be accountable forthis.

“In a practice where thedoctors weren’t au faitwith ECGs, having anaccurate report would bevery helpful, ‘cos oftenthere are subtle thingswhich wouldn’t


21

necessarily stand out andhit you but that areclinically important. Sothat’s where I would seeit’s main benefit”Lancashire practice

“I think it’s dangerouspractice to do ECGs, havethem recorded in thepractice and somebodylook at them saying ‘er,um it looks alright’without knowing. So it’svery important for thosepractices who don’t havesomebody that’s used tointerpreting ECGs”Lancashire practice

Although cost emerges as asignificant barrier for most practiceswe spoke to, practice staff areuncertain how much the equipmentwould cost to buy and to run.Estimates for buying a telemedicineECG machine start at a fewhundred pounds ranging through toseveral thousand pounds.Furthermore, most staff think that itwould costs the practice around£10 per ECG in addition to thegeneral running costs such as pads,paper and telephone calls.

Despite feeling vague on how muchthe equipment would cost, practicestaff in Lancashire feel that thetelemedicine ECG machines offerthe NHS ‘reasonable’ value formoney, due to the potential for‘massive’ savings nationally.

“It’s probably reasonablevalue for money”Lancashire practice

“It seems very cheap tome, given whatcardiologists charge”Lancashire practice

Practice staff in Cumbria however,say that the cost of runningtelemetric ECG machines would beprohibitively expensive bearing inmind the level of likely usage.Unless the benefits of keeping theequipment can be demonstrated toclinicians and practice managers inCumbria they are unlikely to wantto keep the equipment when thepilot ends, as currently they do notfeel that the benefits of using theequipment outweigh the financialcosts incurred.

“I wouldn’t keep it…because I don’t need it,and we’ve already laidout two and a half, threegrand on ECG machines

ourselves… if [we] cameto some agreement withthe doctor taking it outor something then wewould maybe consider it,but it wouldn’t be forroutine use”Practice manager, Cumbria

“If someone’s offeringyou some free kit for acouple of months… wellfine, we’ll try it”Practice manager, Cumbria

Broomwell Healthwatch recognisesthat cost is a significant barrier formany practices, with many sayingthey would rely on funding. Theyfeel strongly, however that usingtelemedicine equipment can offerthe NHS huge financial savings.

“They’re waiting for theirPCTs to adopt it… Theyjust say ‘send the patientto hospital’… but they allsay ‘if the PCT or SHAwere to pay for this, ohI’d love to have it’ “Broomwell Healthwatch


22

3. Patient views oftelemedicine ECGequipment

3.1 Positive views from patients

Encouragingly, practice staff say thatpatients who have undergone anECG using the telemedicineequipment are unanimously positiveabout it. Indeed, staff say they havehad no negative feedbackwhatsoever from patients, and theyfeel that the equipment is ‘fabulous’and that they ‘love it’. Staff say thatpatients are especially keen to usethe equipment if they have seenlocal media coverage.

“A few of them haveseen in the paper, therewas… a press releaseabout it an a few of themhave seen that ‘ooh,that’s what I’ve seen’ “Lancashire Practice

“I think if you explain tothem what you’re doingand how it works then Ithink they’re quiteaccepting”Lancashire practice

Importantly, staff feel that patientstrust the technology, indeed staffreport that even older people arebecoming ‘blasé’ about theadvances of technology as it haspermeated their everyday lives. Assuch, they are not wary of theequipment, but instead think it is‘marvellous’ that their local practiceis keeping up with technologicaldevelopments. Furthermore, staffsay that patients have not expressedany concern about data protectionand security issues.

“Older people are gettingquite blasé abouttechnology. They justaccept that things moveon and they get surprisedall the time”Lancashire practice

“They’re quite pleasedthat they can see thepractice moving on withtechnology”Lancashire Practice

However, staff say it is importantthat the ECG procedure is explainedfully to the patient to reassure themand put them at ease.

“It’s familiarity, you canreassure them beforethey’ve gone anywherewith your verbal report…Everybody thinks it’smarvellous”Lancashire practice

Additionally, staff at BroomwellHealthwatch report that when theirprivate patients feel reassured byhaving the technology at hand theirsymptoms can fade, as they aresometimes caused by anxiety andworry.

“People used to takethemselves off to hospitalthree, four times a year,every time they felt chestsensations… now theyrarely call us and whenwe call them and say‘what’s happened, howcome you’ve changed?’they say ‘we feelmarvellous now, becauseevery time we wake up atnight and get sensations,we know that you’re atthe end of the phone…so we don’t actually get


23

any sensations’. It’spsychosomatic… Theystill call every so oftenbut nowhere near thefrequency that they hadin the past”Broomwell Healthwatch

Practice staff in Cumbria, however,say that as their patients are used tohaving ECGs at their local surgerythey feel largely ‘indifferent’ to thenew equipment. A few patientshave raised concerns about theirdata being transmitted down thephone line, but have been easilyreassured by staff.

“They’re used to it, it’snothing unusual… infairly rural areas that’snot unusual for thepractices to have ECGs”Nurse, Cumbria practice

3.2 Patient stories

A member of staff at a LancashirePractice gave examples of theimpact that telemedical ECGequipment has had on patientexperiences.

Patient story AIn Lancashire a man aged 87 came to the walk-in centre complaining ofchest pain, which he had had for 2-3 hours. As he was clinically stable,the nurse took an ECG using the telemedical equipment and within tenminutes received a report saying that the patient’s heart-rate wasabnormal. An urgent ambulance was arranged and the patientimmediately transferred to the appropriate hospital department alongwith the abnormal ECG report. This speeded up his care and medicaljourney, and avoided him having to go through the A&E department.

Patient story BA young man in Lancashire had been to the gym, where he had had hisblood pressure taken. A member of staff had noticed that it was highwithout any other clinical symptoms and suggested he get it checkedfurther by his GP.

Following this he decided to come to the Walk-in Centre as it was easierto get to than going to his GP. When the nurse practitioner took hishistory he revealed that his cousin had died of a cardio related illness, sothe nurse took an ECG using the telemedical equipment in order to get acomplete picture. The staff noticed that his ECG was abnormal, but hadno previous readings to compare it to. As such the ECG report suggestedthat he go to see his GP for follow up. In this case, the patient avoidedwhat would have been a costly visit to his local A&E department.


24

4. The impact of usingtelemetric ECG equipment

4.1 Overview

The impact of using telemetric ECGmachines depends very much onwhether or not the practice hadaccess to traditional ECG equipmentbefore the pilot. Those practicesthat did not previously have an ECGmachine or did not always have aqualified member of staff on handto interpret the results tend to havebenefited most from the newequipment and are therefore mostenthusiastic about it.

The Cumbrian practice staff wespoke to are used to having accessto traditional ECG equipment andtherefore feel that the equipmenthas had little impact on the day-to-day running of these practices.Often, the traditional machine ispreferred as it is quicker, and thetelemetric ECG equipment tends tobe used as a ‘second choice’ or‘back-up’. Therefore, the staffworking in these practices expressless enthusiasm about the advent oftelemedicine, as they have not seenit have much of an impact on howthey manage patients or on patientsthemselves. In these cases the realimpact could come from GPs anddistrict nurses being encouraged totake the equipment on home visits.

4.2 Impact on clinical procedures

Practice staff say that using thetelemedicine ECG equipment hasmeant that fewer patients are beingsent to A&E departments. This isdue to patients with minor ailmentsbeing diagnosed, and in some casestreated, in primary care.

However, most practice staff feelthat the real impact of using thenew ECG machines lies not so muchwith the management of thepatient – which in most cases doesnot change – but in enhancedinformation. When a patient isreferred to hospital havingundergone an ECG at their localpractice, this improves the quality ofinformation available to hospitalstaff, allowing the patient to betreated more quickly and efficiently.In some cases, patients are able toby-pass A&E and are taken straightto the appropriate department as aresult of already having receiveddiagnostics in primary care.

4.3 Impact in rural areas

Telemedicine equipment is designedto be used where patients may findit difficult to access hospitals (forinstance on oil rigs and in prisons).As such, some practice staff inLancashire feel that thetelemedicine ECG equipment wouldbe particularly beneficial to patientsliving in rural areas, for instancethose living in isolated parts of

Cumbria who may find it difficultand time-consuming to access ahospital for a routine ECG.

“I was based in KnottEnd… It would have beenfantastic there… you’vegot a good half an houror more before anambulance can get fromeither Lancaster orBlackpool, and you arevery isolated, so it wouldbe very good there”Lancashire practice

Practice staff in Cumbria, however,feel that this is a mis-conception.Staff actually working in ruralpractices say that most practicesalready use traditional ECGequipment and thus, telemetric ECGmachines have had less of animpact here than in smaller, urbanpractices that have not previouslyhad access to ECG machines.

“Every practice I knowhas got an ECGmachine… it’s the normnow”Cumbria practice


25

“Even small practices hereare as well equipped asthe larger ones”Cumbria practice

However, they feel there is thepotential for telemetric ECGequipment to have an impact inrural, isolated areas if doctors anddistrict nurses can be encouraged totake the equipment for home visits.

“I can see it being reallyutilised by the districtnurses, although theywould have to come backto the practice beforethey can send it downthe line”Cumbria practice

“It might be useful, say, ifthe doctor’s going out tosomeone at anemergency visit with…some type of anginaCumbria practice

Furthermore, in order to be asuccess in this context, staff feelthat it is essential that the telemetricequipment is able to efficientlytransmit data via a mobiletelephone line.

“If they could get itdictated over a mobile, itmight be quite useful ondoctors’ visits… that wasthe way I would see usworking with it”Cumbria practice

“Staff do point out,however, that if theequipment was to besuccessful in this capacityit would rely on speedyreports from Broomwell. It would be reliant onthem being able to turn itaround very fast”Cumbria practice

“If there was to be anurgent one then youcouldn’t wait around forthe paper result to comeback, ‘cos its too slow”Cumbria practice

4.4 Training

One Lancashire-based GP highlightsthe role that the new ECG machinescan play in educating clinical staff.He feels that when registrars andhouse officers are in training or are

newly qualified they are not alwaysup to speed on reading ECGs, inthis instance the telemedicine ECGequipment could be used as a‘back-up’ to their interpretation ofthe ECG results.

“From my experience alot of the registrars andhouse officers coming outof hospitals aren’tparticularly good atreading ECGs so fromtheir own personalperspective they wouldprobably welcome this”Lancashire practice

“From a GPs point ofview… for years they hadnot been asked tointerpret an ECG report…I think they probablywould’ve felt that theywould need some currenttraining and ongoingexperience of doing it tofeel confident that theywere making the correctinterpretation… I think itgives them lessresponsibility”Lancashire practice


26

“It’s back-up really… ahighly trained techniciantelling you this is whatthis means and then it’sdown to the doctor tomake therecommendations”Lancashire practice

He continues to say that the ECGreports could be used as part oftheir training if they are used‘critically’ to help with analysis andinterpretation of ECG results.

“If they had some basictraining in ECGs but usedthese reports critically andused them as aneducational opportunitythen that would be quitegood”Lancashire practice

5. Looking to the future

5.1 The future

Overwhelmingly, practice staff areoptimistic about future usage oftelemedicine ECG equipment inprimary care. Specifically, practicestaff feel the telemedicine ECGequipment has the potential forbeing used not just within GPsurgeries and walk-in centres, butalso for a greater number of homevisits. Practice staff also suggest thatparamedics in response cars coulduse the Telemedicine ECGequipment in order to ensure aspeedy diagnosis.

“Paramedics in responsecars… would be veryuseful”Lancashire Practice

Staff in both Lancashire andCumbria suggest that smallpractices that do not already haveECG equipment should beprioritised, as this is where it willhave the most impact. Furthermore,the findings from this researchsuggest that this has been the casewith the pilot.

Furthermore, practice staff feel thatfuture usage of the equipmentwould save patients with minorailments going to A&E departmentsand allow them to be diagnosed attheir local practice.

“It would save a lot ofinappropriate referrals”Lancashire practice

The telemedicine ECG equipmentmay be an important part of theNHS’ move towards morediagnostics and treatment inprimary care. By and large practicestaff are keen to keep patients inprimary care where possiblehowever, staff (and especially GPs)do stress that if extra responsibilitiesare to be put within primary care,they need to be recognised.

“Community matronscould easily make use ofit… and keep everythingin the community”Lancashire practice

“It’s fine getting peopleto do extra things, but itjust has to be recognisedthat there is a workloadissue there and torecompense”Lancashire practice


27

Broomwell Healthwatch isenthusiastic about the future of theequipment in primary care.However, they feel that due to thesize and complexity of the NHS andthe potential large-scale of theproject, it may take a considerableamount of time to roll this outacross the country.

Everybody thinks it’s marvellous andit’s amazing and it’s brilliant and justtoo good to be true… but still toput into practice takes timeBroomwell Telemedicine provider

Indeed, in the future BroomwellHealthwatch can see the potentialfor the ECG equipment to be usednot just at home, but also tomonitor the patient abroad whilston holiday.

“It’ll take an enormousburden off the patient…you can do it al fromhome… on holiday inMallorca you can call us,in Jamaica… “Broomwell Healthwatch

In order to maximise the impact inrural areas in the future, staff inCumbrian practices stress theimportance of transmitting data viamobile telephones, as they believethis will open up opportunities forusing the kit for home visits.

However, if the data could be easilytransmitted via a mobile telephoneline, practice staff in Cumbria saythey would be more likely toconsider the equipment for futureuse, as they feel it would be bettersuited to their needs.

5.2 Expanding the range ofTelemedicine ECG equipment

Broomwell Healthwatch do notanticipate any problems withexpanding the company to meetdemand, should the usage of theequipment increase, for instance ifthe project was to be rolled outthroughout the UK. Indeed, theysay that that their technology andcomputer systems have beendesigned to expand with thebusiness.

“At the moment we havegot four stations set up,and we’ve got twopeople on duty all thetime. We could easily goto five, six seven, eight,nine, ten, 20, 30, 40stations, no problem…machinery is all scalableall computers arescalable”Broomwell Healthwatch

Furthermore, BroomwellHealthwatch does not foresee anyproblems with recruiting new staffas the business grows. They saythey are able to recruit staff easily,and the job has always provedimmensely popular when previouslyadvertised. They feel this is due tothe job by its nature being flexibleenough to appeal to doctors who,for instance, do research and so areable to fit the job in around theirother work.

“Every time we haveasked for staff we getloads [of applicationforms] back. People likethe job here, especiallydoctor’s registrarsbecause they can doresearch, they can dowork during the quiettimes”Broomwell Healthwatch


28

Looking to the future, GeneralPractitioners can see the potentialfor Telemedicine innovationsexpanding to include Spirometryand photographing skin lesions,both of which they feel would bevaluable initiatives which wouldsave time and money and helpbring diagnostics to primary care –keeping patients out of hospitalswhere possible.

“If you had a facility tophotograph a skin lesionand send the photographto a dermatologist whocould look at it andmaybe magnify it and say‘yeah, that’s benign’ “Lancashire practice

“Well presumably [withSpirometry] you’d do asimilar thing as you’redoing with the ECGs andyou’d have to interpretthe breath results and thegraph into somethingmore accurate. I wouldthink electronically thatcould be then sent downthe phone and they coulddo the interpretation foryou”Lancashire practice

Section 3

Results and finance


30

3.1 Introduction

This section presents theoutcomes of this work andincludes a projection of potentialbenefits to the health economyin both service and financialterms.

3.2 Main Findings andBenefits of Telemedicine

• The audit identifies the three prime clinical indications for undertaking ECGs in the community setting as currentlybeing practiced in Lancashire &South Cumbria.

1) acute symptoms (eg chest pain, shortness of breath, dizziness);

2) screening procedures for long-term conditions (eg hypertension);

3) as a pre-requisite for clinic referral (eg memory clinic).

The table below demonstratestotal numbers of ECGs recordedand the clinical indicationrecorded during this work. Itshould be noted that walk-incentres provide only diagnosticservices whereas, of course,primary care encompasses thefull range of diagnostic andtherapeutic treatment care andthis accounts for the figuresbelow.

Results and finance

Number of ECGs

176

122

AcuteSymptoms

141 (80%)

87 (71.3%)

ScreeningProcedure

22 (12.5%)

22 (18.0%)

Clinic Referral

13 (7.5%)

13 (10.7%)

Total

Practices only


31

• The practice nurses or walk-in centre nurses recorded all 176 ECGs (100%) at the GP surgery or walk-in centre; none were taken on domiciliary visits to the patient’s home.

• Clinicians found the equipment easy to use and were satisfied by the system and service provided• 165/176 (93.75%) of ECGs

were undertaken easily and there were no reported problems with the data transfer or reporting mechanism.

• 11/176 (6.25%) uses identified technical problems,which generally related to data transfer, a situation thathas now been addressed.On no occasion was patient safety jeopardised.

• 3/176 (1.7%) uses resulted ina poor trace due to problemswith lead position and electrode contacts. Adjustment and repeat ECG resolved the problem. These difficulties can be encountered with a conventional ECG machine.

• 50/176 (28.4%) occasions resulted in a change in clinical outcome based on the result of the ECG.

• Reviewing the results from onecentre in more detail showed that 9/55 (16.3%) ECGs resulted in avoidance of unnecessary use of hospital services. This diagnostic intervention supported the clinical decision-making process and hence appropriate maintenance of the patients in the community.

• At the same centre however some of the 55 ECGs taken resulted in findings that may not have been predicted from the patient’s clinical presentation, these also influenced the outcome of the consultation and included: • 2 unknown heart rhythm

disturbances (bradycardia and tachycardia)

• 1 significant change of myocardial infarction

• 3 significant ECG changes requiring further assessment

• 5 occurrences of pericarditis.

Some patients required anappropriate hospital admissionfor further care but in otherinstances medical assessment atthe centre with amendment oftreatment resolved the problem.

• A copy of the ECG accompanied admissions to hospital thus improving patientcare as the hospital clinicians had a baseline from which to establish a treatment plan.

• Some centres undertook independent evaluation of the accuracy of the reports by doctors who also work as GPs with a Specialist Interest in Cardiology. This was done in addition to the audit work andwas not formally evaluated, but anecdotal opinions and thereport from the focus groups undertaken by Ipsos MORI (section 2) confirm the quality of the telemetric reporting.

• Patient opinion with regard to this new service was also very favourable as, although not formally documented, the feedback to clinical staff was consistently positive. Again thisis identified within the Ipsos MORI report (section 2).


32

Potential Local FinancialSavings

Regardless of the currentfinancial pressures within theNHS, any potential servicemodernisation should considerthe financial implications; thisreport therefore attempts toquantify this. On the basis ofdata we have available fromlocal work and nationallypublished NHS figures, webelieve there is a potentialfinancial saving to be gainedfrom the use of telemedicine.We accept that our figures maynot be fully robust but representas close an approximation as wehave been able to make usingtariff figures for 2007/08. Thesecalculations are made on thebasis of outcomes for patientsseen in one of the walk-incentres and, in particular, focusupon the avoidance ofadmission.

If the findings in the centre wereto be replicated (as we believethey would be) thenapproximately 16% of potentialreferrals to hospital could beavoided and if 50% of these, ona conservative basis, wouldpreviously have been admittedthen potential savings for apractice in their first year wouldbe as follows:

Potential Savings

9 (16%) of 55 A&E attendances avoided –cost per attendance = £101

4 Hospital admissions for chest pain avoided- cost per spell for patients > 69 = £1164

Hospital Attendance Savings

Capital and Revenue Expenditure

1 ECG machine

55 ECG readings (£20 each)

Total

Saving for re-investment by practice over 6 months

£909

£4656

£5565

£500

£1100

£1600

£3965

Capital Outlay


33

These local figures assume aminimal costing for a hospitaladmission for chest pain alone,and have not consideredfinancial implications of acoronary care unit admission orother intensive investigations.

They illustrate some of thepotential health economy savingfor service reinvestment thatcould be generated by onepractice, although if thesefigures are extrapolated forthose patients in the audit,savings of approximately£135,000 may have beengenerated by those practices inthe pilot in one year.

Potential National FinancialSavings

Taking the local data a stagefurther and matching it withBroomwell’s own data, it ispossible to make predictions asto the potential national savingsthat could be achieved. Again,conservative application of thefigures has been made but it isbelieved that this estimate is atthe lower end of potentialsavings to be made within thehealth economy by use of thistechnology. It is also importantto stress that figures werecalculated on an assumptionthat only 30% of patientsattending A&E with a possiblecardiac problem will have hadcontact with a primary carepractitioner.


34

Potential Cost Savings to the NHS by using Cardiac Telemetry

Total annual A&E attendances - England 05/06

Annual cardiac related A&E attendances – estimated at 10% of total

Estimated minimum of 30% of A&E attendances generated within primary care

16% of primary care generated A&E attendances prevented during pilot

Potential number of prevented A&E attendances

PBR tariff 07/08 high A&E attendance

Money saved by preventing A&E attendances

Potential number of prevented admissions if 50% of avoided A&E referralswould historically have been admitted.

PBR Tariff 07/08 HRG E35 chest pain >69

Potential saving for the NHS by avoiding inappropriate admission for chest pain

Potential saving to the NHS by use of telemedicine for ECG interpretation

Cost of a single Broomwell ECG interpretation

Annual cost to NHS of using telemetry ECG interpretation service for allprimary care generated A&E attenders with chest pain

Capital cost of 1 ECG machine per practice in England - 8500 practices 2004. Royal College of GPs Fact Sheet 5 Sept 05

Capital and revenue costs for year 1

Potential total saving to the NHS by use of telemedicine for ECGinterpretation

Number

18,750,000

1,875,000

562,500

90,000

45,000

£

101

9,090,000

1,164

52,380,000

61,470,000

20

11,250,000

4,250,000

15,500,000

45,970,000

Section 4

The benefit of joint workingbetween the NHS and theIndependent Sector


36

4.1 Cross Sector Working

Cumbria and Lancashire SHAstaff worked with BroomwellHealthwatch for a period oftwelve months in developingsystems and processes thatwould enable successful workingbetween the NHS and theIndependent Sector.

The company was set up sometwo years ago to provide acardiac tele-monitoring service,whereby 12-lead ECGs andother measurements (includingone lead ECGs, blood pressureand weight monitoring for heartfailure) can be transmitted viatelephone to a cardiac centrestaffed 24 hours a day, 365 daysper year by senior cardiacclinicians who offer immediateinterpretation and advice toimprove patient care andobviating the need forunnecessary hospital outpatientor A&E referrals.

A Medical Advisory Board,comprising of cardiologists fromacross the UK, provide expertclinical support.

Broomwell Healthwatch had toestablish a Caldicott Guardianand to adopt its informationsharing protocols to thoserequired by the NHS. A seniornurse at the centre wasappointed Caldicott Guardianand, after liaising with the SHA,established confidentialityprotocols and rules fortransmitting patient data whichall staff adhered to. Theseincluded internet and emailpolicies. Broomwell Healthwatchwas provided with an NHS.netemail address, enabling it tosend secure encrypted emails tosurgeries, which would not bedelayed by NHS servers.

Broomwell Healthwatch had todemonstrate that standards weremet regarding both staff at thecentre and equipment. Staff arehighly qualified, have many yearsexperience in cardiology andECG interpretation butnevertheless undergo a veryadvanced ECG course and testeach year. This was createdspecifically for the staff at thecentre by a senior cardiologyconsultant. The ECG equipmentprovided by BroomwellHealthwatch has all thenecessary regulatory approvals

and complies with therequirements of the EuropeanMedical Device Directive.

Clearly there are advantages, forboth parties, of working in sucha partnership and the benefitsfrom an NHS perspective weregained by taking advantage ofthe speed and flexibility of theprivate sector. The joint ventureworked extremely well and wasfacilitated by the groundworkthat took place in ensuring thatclearly defined governancearrangements were in placegiving confidence to all partiesinvolved. The main areas ofpreparatory work involvedensuring that the technology,staffing and IT infrastructure wascompatible and compliant withNHS standards and are detailedbelow.

In engaging with theIndependent Sector it wasimportant for staff in the NHS,who would be using thetelemedicine technology, toknow that it was fit for purposeand had approval by theappropriate regulatory bodiesand was ‘CE’ marked. The staffproviding the service needed tobe appropriately qualified,

The benefit of joint working between the NHS and the Independent Sector


37

trained and regularly updatedand this information wasdocumented and monitored byBroomwell Healthwatch. Thestaff and technology employedneeded to be insured againstclaims of malpractice orequipment failure.

In terms of ensuring that thetransmission of informationbetween the NHS andBroomwell was confidential andreliable, it was necessary toensure that IT systems weresecure and compatible with NHSrequirements. In addition, theNHS and Broomwell signed upto an information sharing policyto allow patient information infaxes and emails to be passedsafely between the company andthe general practitioners involvedin the audit.

The main issues faced bypractices in using the ECGmachines for patient care andtransmitting data were of atechnical nature such as delaysin transmissions of emails due torejection or ‘spamming’ in somepractices, poor networkinfrastructure in some areas ofthe SHA and the occasionaloccurrence of surgeries havingtheir fax machines turned off.


38

There were some practices whofelt that the centre was giving‘too much’ information/adviceand it was discovered that thisdepended on which member ofpractice staff was sending theECG readings over the telephoneline and their level of clinicalknowledge. Followingdiscussion with staff atBroomwell Healthwatch thisceased to be an issue once itwas brought to their attention.

Staff interpreting the ECGsprefaced all evaluations/advicewith the words ‘…always subjectto the overriding judgement ofthe clinician…’ and this led to afeeling of joint working ratherthan one opinion overriding thatof another.

In summary, the maindeterminants of successfulworking between the NHS andIndependent Sector involve openlines of communication andflexibility of approach. As aresult, the NHS has benefitedfrom the ability to use currenttechnology and rapid resolutionof issues whilst the IndependentSector has gained an insight intohow the NHS operates andknowledge of how they canovercome issues of confidenceand trust in engaging directlywith NHS frontline staff.

Valuable lessons were learned byboth parties and these barriers,having been overcome, willallow development of similarprojects in the future as othergroups can apply the lessonslearned to their own projectdevelopment.

Section 5

Conclusion andrecommendations


40

5.1 Conclusions

One of the prime aims of theresearch was to establishwhether there were any benefitsto be gained from this way ofworking. The audit hasdemonstrated that telemedicineECG is easy to use in practiceand is a valuable tool to supportclinical decision-making andbetter outcomes for patients. Assuch we believe that it supportsthe NHS in its ability to deliverbenefits to patients, carers andprofessionals.

The operational and governancestandards set at the outset havebeen achieved during the pilotand indicate that in practical usethe new technology is at leastequivalent if not better thanconventional machines. Thefindings also suggest that thereare significant additional benefitswhen using the new technologyin clinical practice. Theseinclude:

• Interpretation of the resultThe telemedicine service provides accuracy, consistency and reliability for the clinicians.Many doctors find interpretation of ECGs difficult,especially for minor but potentially clinically significant

changes that can occur, nursesare not trained to interpret ECGs unless working on specialised cardiac units and soconfidence for diagnosis is often placed in the conventional machine’s inbuilt electronic readers which may be misdirected by electrical interference or previous changes which may no longer be relevant to the acute presentation. The use of this new service provides direct interpretation of a high quality ECG by clinical teams trained in the skill of ECG interpretation. In addition, theyare aware of the patient’s clinical symptoms and so can provide the treating clinician with support for the patient’s management plan.

• Nursing staff took all the ECGs identified for this workThis is the usual practice in primary care and is relevant when considered with the feedback from the Ipsos MORI report, which identified that the immediate availability of a clinical opinion from the call centre staff with regard to the ECG enhances the decision-making process for patient care. Patients could therefore

be admitted or discharged with greater confidence by theclinical teams, either the nursesin the nurse led walk-in centres or the doctors and nurses within the general practices.

The practice and walk-in centremanagers also found this serviceof benefit as they reported thatnursing time was saved, nursesno longer needed to wait forlong periods of time to access adoctor to interpret the ECG.

• GPs have responded that someadmissions were not anticipated by the clinical findings but were very appropriate as hospital intervention was necessary because of the outcome of theECG. For example, bradycardia,pericarditis, silent myocardial infarction resulted in an unexpected admission. This demonstrated that the new service provides a diagnostic tool to enable the delivery of quality patient care. We acknowledge that some unexpected hospital attendances may have occurred and that these may have had a small impact upon the financial savings but expectthese to be minimal.

Conclusion and recommendations


41

• The use of this new technology has allowed clinicians access to a service which the audit suggests they have used to enable patient care, provide a service within the community and reduce theneed for inappropriate hospitaladmissions (DH 2006). Further consideration has now to be given to the provision of other community-based diagnostics, for example blood tests to further identify whether or nota patient presenting with chestpain has sustained a myocardial infarction. This would allow clinical staff to confidently keep patients in the community rather than resorting to hospital services.

• Whilst undertaking the audit and talking with clinicians and managers who were using this equipment, several comments were raised, which the author feels merit inclusion.

These were around the area ofservice re-design; suggestionbeing made that these machinescould be used to provide ECGclinics within primary care andthat they could be used in thecommunity either for patientswho cannot attend a medicalcentre due their long term

condition, the ECG beingrecorded in the patient’s homeor for emergency work in andout of hours.

5.2 Recommendations

The benefits to patient care, thesupport offered to primary carepractitioners and the potentialfinancial savings this technologyoffers present the NHS with anopportunity that should becapitalised upon. The followingrecommendations are thereforemade:

• Primary Care Trusts and Practice Based Commissioners within NHS North West should consider funding this technology for use within all GP practices and walk-in centres in their locality. We recommend that factors to be taken into consideration should include:• the availability of access to

expert ECG interpretation• confidence in the quality of

the interpretation• immediate support to aid

clinical decision making• the likely fall in inappropriate

hospital referrals and/or admission for chest pain

• the ability to offer care closer to home

• the potential impact upon delivery of the 18-week target through reduced outpatient referrals.

• The Lancashire and South Cumbria Cardiac Network should expand their existing ECG training programme for primary care practitioners to support effective ECG lead placement thereby maximising the quality of ECGs taken. It should also regularly review the need to offer ECG interpretation training to primary care practitioners as it is anticipated demand will fall as use of this technology increases. The remaining cardiac networks within NHS North West should discuss the requirement for such training with their constituent PCTs.

• Further evaluation of the use of this technology within othersettings should be undertaken.This should include its use in patients’ homes, particularly for those patients who require re-assurance and currently frequently present to A&E and medical admission units out of hours.


42

5.3 The Impact of and OtherUses for this Technology

This audit has focussed onlyupon the use of telemedicine inEGC interpretation and itspotential to impact upon clinicaldecision making. The financialcalculations were made only inrelation to referrals to A&Edepartments and consequentpotential reductions in hospitaladmissions.

In some places it seems GPsseeking an ECG must refer theirpatients for an outpatientappointment and that a moveaway from this would also havethe potential to reduce waitingtimes as well as save resources.The impact upon the widereconomy of offering patientsrapid access to diagnostic testslocally rather than needing totravel to hospital is incalculable.

Telemedicine is also being usedfor monitoring other clinicalconditions including arrhythmiaand heart failure. An evaluationof these is now underway andwill be published in the future.

The use of this technology is alsobeing explored in themanagement of patients withlong-term conditions includingchronic obstructive pulmonarydisease although this is currentlyat an early stage.


43

Contributors

Dr Steve WardNHS North West

Julie HendryNHS North West

Dr Joe RaffertyNHS North West

Sara ButlerIpsos MORI

Kate O’MalleyIpsos MORI

Jonathan NichollsIpsos MORI

Sally ChisholmLancashire and South CumbriaCardiac Network

Jane RileyLancashire and South CumbriaCardiac Network

Joanne TwissellLancashire and South CumbriaCardiac Network

Joshua RoweBroomwell Health Watch Ltd

Michael RoweBroomwell Health Watch Ltd

Gwyn WeatherburnBuckinghamshire ChilternsUniversity College

Ms. Glen JohnstonBuckinghamshire ChilternsUniversity College

Acknowledgements

All the clinicians and managerial staff working within theGeneral Practices and Walk-in Centres associated with thisproject.

The directors and staff at Broomwell Healthwatch

www.northwest.nhs.uk

© NHS North WestMr Joe Rafferty, Dr Steve Ward, Ms Julie Hendry, Mrs Sally ChisholmAll rights reserved. Not to be reproduced in whole or part without the permission of the copyright holder.

North WestNHS

Date post:	06-Nov-2021
Category:	Documents
Upload:	others
View:	4 times
Download:	0 times

Delivering Benefits for Patients and the NHS in Lancashire ...

Documents