25th August, 2016

David_PattersonProfessor David Patterson discusses the importance of education in delivering digital healthcare, his passion for patient activation, and the key challenges he’s faced in delivering innovation to the health and care system.

David Patterson is a Consultant Physician and Cardiologist based at Whittington Health. He is also Emeritus Professor of Cardiovascular Medicine at UCL. He is the only cardiovascular clinician in the UK actively involved in delivering a community-focused anticoagulant and stroke prevention service.

Over recent years, in collaboration with CHIME (UCL Centre for Health Informatics and Multiprofessional Education), David has helped to develop and evaluate clinical information systems culminating in the clinically useful and secure electronic health record (EHR) which forms an important component of the HeliconHeart package.

Here, he deliberates on the importance of education in delivering digital healthcare, highlights how innovation can support patient activation, and discusses the importance of effective clinical governance.

Hi David. Please could you start by introducing HeliconHeart and describing the support it offers to clinicians?

HeliconHeart consists of several inter-related components. Firstly it is a web-based and standards based EHR designed to help practising clinicians wherever they are sited, making sure they have access to the clinical record of the patient together with the right information at the right time. The EHR integrates clinical guidance with advisory systems, and offers a wide range of patient tools. It is not just an electronic health record, it actually provides advice. Secondly, there are innovative eLearning programmes for both Health Care Professionals as well as for patients and their family and/or carers. Thirdly, there are Clinical Governance services together with data analytics.

This innovation places a great deal of emphasis on education, including courses for healthcare professionals and patients. How does this work?

I believe that for any successful digital health strategy to succeed, it must be a socio-technical development rather than simply a technical one. Contained within that statement is an intent to support the person trying to preserve health, as well as the patient being enabled to play a more active part in the management of their conditions(s).

Our approach is to develop two distinct but related eLearning educational modules for each condition or diagnosis. One for the patient and one for the healthcare professional (HCP).

The patient offering has been developed with a great deal of involvement of patients and using language that is understandable to them. It is designed to support their needs and to educate them about their condition. It’s not just words, but graphics, games and tests which are designed to enhance their confidence and their competence.

The eLearning education program for the HCP is designed at CPD level. It is a UCL-accredited programme with assessments of the skills, knowledge and competence of the practitioner.

How important is this ongoing education in delivering digital healthcare?

It’s absolutely vital. One of the difficulties is that people with a rather narrow view of digital healthcare, don’t take the practitioner or the patient with them on this new and innovative journey. The practitioner and the patient have particular needs which are extremely varied, and may be completely at variance with the technology. So both the practitioner and the patient must be continuously supported on their journey with the developing digital healthcare with relevant, flexible and engaging education; and there must be a feedback loop from those being educated back to the educators, so that their needs are continuously addressed.

We understand that you’re a keen advocate for patient activation. Tell us more about this and its links with digital health.

The Patient Activation Measure was developed by Professor Judith Hibbard from the University of Oregon. This involves the patient completing a questionnaire which determines their level of activation (from Level 1 to Level 4). The level of activation appears to be unrelated to literacy skills, educational status, cultural or socio-economic status. A person at Level 4 is able to adopt new behaviours and play an active part in their own health. Someone at Level 1 may not yet grasp that they must play an active part in their own health. They are inclined to be passive recipients of care.

Research shows that only 30% of patients take their Blood Pressure medications if they are in Level 1 compared with 88% in Level 4. Those at Level 1 use healthcare much more than those at Level 4. It is now necessary to develop a portfolio of educational and other forms of support which are specific to each Level and to apply them appropriately. There is a very real opportunity with the rich variety of ‘technology tools’ now available, to engage people in an innovative manner. They will thus become more involved in managing their own health with the appropriate support; this will avoid the very real risk of technology and digital healthcare becoming socially divisive.

I chair The Institute of Sport and Exercise Medicine; a small, independent charity which helped establish the new discipline of Sports and Exercise Medicine. The Institute is now working to draw the very persuasive evidence of the benefits of exercise, activity and dance, into a higher level of consciousness of HCPs, people and patients for both the treatment of illness as well as the preservation of health. Digital health can play a huge role in helping us move this agenda forward at an individual level, a group level and/or a national level. An app that encourages activity or dance for example, could be really attractive to the Level 1 cohort as well as the others. If we can get people at a personal level, engaged with something they enjoy, rather than something they’re told to do, this could really make an impact.

How important is the role of clinical governance in supporting CCGs?

CCGs need to be able to assure the public that it is commissioning care that is good quality and cost-effective. I think is very important that we strive to show real benefit to patients in the form of solid outcome measures rather than just process measures. A lot of services will be moving from a hospital setting into general practice. Increasingly and with the help of apps, patients will become able to self monitor their own conditions. This wider portfolio of possible treatment options will require good clinical governance to support it – the value of digital health in this particular role will be essential if the CCG is to be assured about the safety and cost-effectiveness of the new models of service delivery.

What have been the key challenges for you in terms of delivering your innovation to the health and care system?

Innovation in any healthcare system has become increasingly difficult. It is by its nature disruptive, and therefore challenging and sometimes irritating to others, both clinical and managerial. The benefits with any innovation are not necessarily apparent to others whose natural tendency is to obstruct the further development and revert to the known norm.

There are two other main challenges that we had to face and to overcome. Firstly the NHS and Social Care have become more process orientated – this stifles any new ways of delivering a better service, even though it can be more cost effective and better for the patient. In times of financial pressures the concept of moving a service out from a hospital site into the community and thus reducing the income to one institution, will often not be welcomed.

Secondly, the aftermath of Connecting for Health is still with us; many people remember the huge financial cost without much benefit being apparent to clinicians. With any innovation that involves technology, clinicians are now quite understandably suspicious that there will be few clinical benefits.

Furthermore a lot of people think we already have solved all the IT issues with the use of portals and the very distracting “big data obsession” which has swept through the NHS and Academia.

These factors overlook the fact that the high quality clinical data which forms the basis of the ‘big data’, still needs a lot more developmental work; otherwise we put at risk the opportunity to gain the full benefits of the developing rich longitudinal clinical data which we will be able to explore and integrate with the rapidly developing genomic and proteomic data.

What support needs to be provided to assist clinicians in delivering innovation?

Clinicians, doctors, nurses, pharmacists and other HCPs are by nature, bright people who are full of ideas; but these ideas get ‘squashed’ for a variety of reasons. Job plans and strategic plans mention education, research and innovation but they are rarely defined as protected time and are not valued in the environment.

We used to talk of R&D (Research and Development). An idea is conceived and then tested within a research environment. If it shows a positive outcome and benefit, resources are needed, in the form of people with particular expertise, to help the development part – the ‘D part’ – but it doesn’t exist.

At this level of the development of an idea, it needs nurturing. Particularly when you develop innovations engaging the secondary care sector and community and GP services. Once the innovation has been developed and adopted into a ‘University spin out’ environment or become incorporated into the Academic Health Science Networks (AHSNs) there is much more opportunity for support.

We have been very supported and encouraged by both UCL Business and also UCLPartners. What surprised us was how welcome we have been made to feel around the rest of England by the various Innovation Agencies and AHSNs, with new projects started in the North West Coast and the North East, and our first projects in Scotland and elsewhere in Europe.