MiApp: A personalised electronic, fully interoperable version of hand-held maternity notes for mothers and clinicians (#1941)

Idea Description
Supplementary Information
Detailed Submission Data
Innovation 'Elevator Pitch':
Good quality maternity information is essential to provide safe care. We will evaluate the Mother’s Information Application (MiApp), a personalised electronic, fully interoperable version of the Perinatal Institute’s hand-held notes. 
Overview of Innovation:
Currently hand-held paper notes are the primary record for maternity. The Perinatal Institute’s maternity notes have become the standard, used in approx 60% of pregnancies in England -https://www.perinatal.org.uk/News/Perinatal_Newsletter_Spring_2016.pdf

The Perinatal Institute have been successful in combining the utility of a standardised, evidence based record for clinicians, with details on the care the mother should expect at the various stages of pregnancy, outlining her choices as well as essential information and key messages to ensure best possible maternal engagement in her care.

The hand-held notes are the master record allowing complete inter-operability with all care providers, but require double or triple entry of data to ensure electronic systems are up to date. With increasing development of information systems, electronic records are starting to become the principal maternity record, which takes information and control away from the mother. Instead they carry either:
  • Print outs of certain aspects of care (being paper heavy and complicated to navigate) or
  • Minimal information in the form of a summary ‘co-op card’ or appointment card.
This results in a lack of routine pregnancy information being given to women, an absence of specific information available to the mother about her own pregnancy, and a lack of inter- operability between the systems used at different facilities meaning other care providers do not have access to the mother’s record if required.
The Mother’s Information Application (MiApp) is a personalised, electronic, fully interoperable version of the Perinatal Institute’s hand-held notes available on smart phones, tablets or desktop computers. It returns control of the health record to the mother, and allows her to make her maternity healthcare record available to her designated care providers, directly or through integration with local information systems.
MiApp is able to:
  • Provide expectant and new mothers with relevant information about their pregnancy, explaining what to expect at each stage and listing options to allow informed choices.
  • Act as the master document for recording and updating details about the care received,
    including results of screening tests, investigations, risk assessments, referrals, and management plans.
Stage of Development:
Close to market - Prototype near completion and final form may require additional validation/evaluation and all CE marking and regulatory requirements are in place
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Innovation 'Elevator Pitch':
We have successfully designed, implemented and evaluated a standardised triage system for use within maternity care.  It is currently used in eight maternity units, with more planned.
Overview of Innovation:
Triage systems are designed to ensure the patient receives the level and quality of care appropriate to their clinical needs and resources available. Triage involves establishing the presenting problem, undertaking a standardised physiological assessment including vital signs and results in a score being assigned based on predictors of urgency which determines the priority of on-going care.
The physiological changes associated with pregnancy mean the standard triage tools may not be applicable. In addition, the underlying good health of the maternity population, which may mask the severity of maternal illness, and no assessment of the condition of the unborn baby reinforce the need for a specific maternity tool. While some informal triaging takes place within maternity care, a national survey showed that women currently wait to be seen in the order in which they arrive and that current prioritisation systems do not use clinical determinants.
Birmingham Symptom specific Obstetric Triage System (BSOTS)
The system was co-produced by clinicians and researchers in Birmingham to prioritise care for women presenting with pregnancy related complications or concerns.  
The BSOTS bundle includes:
  • Completion of a standard clinical triage assessment by a midwife within 15 minutes of the woman’s attendance.  This includes taking a brief maternal history, completion of baseline maternal observations, assessment of pain levels, abdominal palpation and auscultation of the fetal heart rate .
  • This assessment is used to define a category of clinical urgency using a 4-category scale, which guides timing of subsequent assessment and immediate care (by an obstetrician if required) using algorithms.
  • Standardised symptom-specific algorithms are used for allocation of clinical priority and the immediate care and further investigations of the eight commonest reasons for attendance (abdominal pain, antenatal bleeding, hypertension, suspected labour, ruptured membranes, reduced foetal movements, unwell/other, and postnatal concerns). 
  • Documentation is provided to support and standardise completion of the clinical tasks required.
Implementation of BSOTS requires multidisciplinary training of clinicians which takes approximately three hours. The BSOTS training has also been developed and elevated by the team
Stage of Development:
Market ready and adopted - Fully proven, commercially deployable, market ready and already adopted in some areas (in a different region or sector)
WMAHSN priorities and themes addressed: 
Innovation and adoption
Benefit to NHS:
The benefits to the NHS of a dedicated maternity triage system are centred on improving safety for women and their babies by reducing the interval from their attendance to their initial review by a midwife and prioritising urgent care. BSOTS is supported by Royal College of Obstetrics and Gynaecology and Royal College of Midwives for national implementation.
Implementation of BSOTS as the system improves management of the triage department by enabling staff to:
  • See how many women are waiting who have not yet had their initial triage assessment to determine level of clinical urgency
  • See how many women who have had the initial assessment and the level of clinical urgency is known for each women
  • Know when further assessments are due for women in the Department
  • In circumstances where women attend who require urgent treatment it allows women with less clinical urgency to be safely moved out to the waiting area and escalation to occur
  • Facilitate easy handover of the department between shifts using SBAR
  • Use a shared language between clinicians to communicate clinical priority
BSOTS  provides a standardised process to manage emergency attendances and reduces staff safety concerns in maternity triage whilst increasing their resilience and improving handover and communication.
Initial evaluation at BWCNFT demonstrated  that the use of BSOTS increased the numbers of women seen within 15minutes of attendance from 39% to 54% [Relative risk (RR) 1.4 (1.2, 1.7 (95% confidence interval (CI)] and reduced the time to medical review for those who require it. Thus providing a robust pathway for rapid assessment and urgent medical care if required, improving outcomes for mothers and their babies.
Good reliability and validity of the BSOTS bundle were found on the basis of the numbers of women who re-attended and investigation of predefined maternal and neonatal morbidities.  All the midwives reported that BSOTS training had improved their knowledge and confidence and that implementation of the system improved safety for mothers and babies and reduced stress amongst the clinicians.
Intra-rator reliability was excellent both at BWCNFT initially with an Intracluster Correlation Coefficient (ICC) of 0.961 (95% CI 0.91-0.99), and in the additional maternity units where the ICC was 0.971 (0.915-0.996). There was no apparent difference between midwifery band level and amount of triage experience. Showing that the BSOTS tools are reliable and consistent for use amongst varied midwifery staff.
Initial Review Rating
4.60 (2 ratings)
Benefit to WM population:
The West Midlands remains a national outlier for poor rates of perinatal and infant mortality and is committed to the national ambition to halve the number of stillbirths, neonatal and maternal deaths and brain injuries by 2025.
In line with the National Maternity Review (published in February 2016) which set out a clear vision for maternity services across England to become safer and to promote good practice for safer care; the Birmingham Symptom specific Obstetric Triage System (BSOTs) improves the process and clinical prioritisation of care for women presenting with pregnancy related complications or concerns. BSOTs has also been shown to prioritise urgent care for those women who are most unwell or requiring more rapid access to obstetric intervention and emergency treatment.
With increasing use of the Birmingham Symptom specific Obstetric Triage System (BSOTs) across the maternity units within the West Midlands region, women can expect continuity of process and care when they present to units with urgent concerns and that care is standardised across the region. Standardisation of the maternity triage pathway also provides an opportunity to ensure that the midwifery and medical workforce in maternity are able to be trained with the right skills to implement appropriately timed and clinically relevant prioritised of care within all maternity triage departments in which they may work.
Current and planned activity: 
The Birmingham Symptom specific Obstetric Triage System (BSOTs) is currently used in seven units nationally; including half of all maternity units within West Midlands.
A further twelve maternity units have received training for their implementation teams and are due to launch the BSOTs programme in the next six months.
Bespoke training courses for maternity teams are held in Birmingham every two months. This training includes specific training the trainers materials, the BSOTS© maternity algorithms, Triage Assessment Cards and Patient information posters and tips for implementation from other units.

Further development of the Birmingham Symptom specific Obstetric Triage System (BSOTs) with Clevemed systems to transfer the paper based system into an electronic tool with contemporaneous patient record is on-going; due to complete by May 2019. This will enable maternity units currently using the Badgernet Maternity electronic system to use BSOTs digitally and further improve availability.
What is the intellectual property status of your innovation?:
Use is currently protected by signing a Licensing agreement provided by UoB and MidTech.
The schedule within the licensing agreement includes the Birmingham Symptom specific Obstetric Triage System (BSOTs) package for Training and Implementation and is intended to ensure the package is used as intended and that training has been given before implementation
The package is intended to support local training, implementation and on-going use of the (BSOTs) system, in the maternity unit assessing women who attend with unscheduled pregnancy related concerns. This package is set out during the face to face training course, it includes specific training the trainers materials, local training materials, the BSOTS© maternity algorithms, BSOTS© Triage Assessment Cards and BSOTS© Patient information posters. The components of the triage system should be adopted in its entirety, rather than separately.
Return on Investment (£ Value): 
Return on Investment (Timescale): 
0-6 mon
Ease of scalability: 
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Innovation 'Elevator Pitch':
Our online workshop helps women from all backgrounds in all demographic areas to access positive, factual information to support their birth choices using evidence-based information that can be updated as and when new guidance is released.
Overview of Innovation:
The Real Birth Company’s mission statements are ‘to provide relevant, up to date, evidence based antenatal information that is delivered with a positive attitude’ and ‘to impart our knowledge with confidence to empower women and their birth partners at this very special time’.
We have achieved this with our RCM accredited antenatal education training programme that has been developed into an online e-learning antenatal resource for women birthing in the UK & is available in several languages. This e-learning resource is a birth physiology workshop full of important information that supports UK practice & enables women to understand the reasons behind their care, whilst supporting them to make informed choices in labour.

Antenatal education is essential to helping women form opinions & make choices in regard to their pregnancy & birth. There are various types of antenatal education. Hospital accessible antenatal education is dependant on resources, demographics & availability of staff to name a few. Lots of these classes use traditional methods of teaching with limited time to discuss at length the physiology.
The Real Birth online workshop is easily updated & uses evidence-based information from NICE, WHO, RCM, RCOG & others. It is holistic, culturally sensitive & can be accessed from anywhere by computer, tablet or mobile phone.
The innovation of creating a multi-lingual online e-learning workshop came from the positive birth results that were consistent with women & their partners who had attended a specifically designed positive birth workshop.
The workshop was created using techniques that help graduate students revise for exams, this learning technique has been integrated into the imparting of positive birth physiology. The use of non-threatening language & positive birth information helps to normalise birth & reduce fear. When fear is reduced in labour the benefits for both mother & baby are both psychological & physiological.
Barriers to effective antenatal education can include:
  • time pressures for antenatal classes
  • finding midwives who feel comfortable giving antenatal education
  • update & training costs
  • availability of classes
  • limited spaces for face to face classes
  • cost of interpreting services/availability of interpreters
  • birth terminology used
  • women being unable to attend for social or demographic reasons
Our online workshop works to address these barriers to help women from all backgrounds in all demographic areas to access positive, factual information.

Stage of Development:
Market ready and adopted - Fully proven, commercially deployable, market ready and already adopted in some areas (in a different region or sector)
WMAHSN priorities and themes addressed: 
Digital health / Innovation and adoption
Benefit to NHS:
The Real Birth online workshop is an easily accessible form of evidence-based antenatal education (updated as evidence changes) that is interactive, informative & fun to use.
The Better Births Maternity Review says that all women should have access to information to enable them to make an informed, non-bias choice.

Making Normal Birth a Reality states ‘evidence-based information for women about factors that make a normal birth with good outcomes for the mother & baby more or less likely, presented in a format which they understand so that they can plan for the kind of birth they want & make informed decisions’ is an essential part of birth preparation.

WHOs new recommendations on reducing unnecessary births by C-section recommended ‘Health education for women is an essential component of antenatal care’ by using childbirth education workshops that include partners to support women & address fear of birth with methods such as understanding birth physiology, our workshop helps to address unnecessary interventions in labour.

Women with access to antenatal education have a higher chance of normal birth & a more positive birth experience that can help in the postpartum period.
The workshop follows a researched learning technique. Written in a style that enables users to learn & retain the information more effectively leading to confidence & understanding of birth.
Accessed from 25 weeks of pregnancy via a unique coded card issued by the healthcare provider, users work through 1 module at a time before accessing the next to ensure the workshop is comprehensible. Within the modules are questions, diagrams & carefully designed non-threatening animations.
Each language has been translated by first language speakers to ensure the terminology is understandable & animations are culturally respectful whilst explaining a journey of birth. NICE Pregnancy & Complex Social Factors list barriers for women who speak no or little English that include lack of interpreters & knowledge of the maternity service. Our workshop helps address such barriers. NICE also say that with this group of women other methods such as online video clips & audio information should be used.

Our workshop is factually based giving true & correct information & techniques to practice for labour along with the best positions & why. It addresses subjects like the reasoning behind recommendations for skin to skin & looks at how this can help aid mental health for both parents in the postnatal period.
Initial Review Rating
5.00 (1 ratings)
Benefit to WM population:
Antenatal education has a role to play in improving knowledge of, and preparation for parenthood and can lead parents to be, to adopt a range of healthy behaviours that affect pregnancy and birth, improving outcomes and the mother’s experience of birth.
The Real Birth Company is committed to supporting all women to access up to date and evidence-based information relating to their birth. We believe that all women should have access to this information and have produced the e-learning modules in several languages to help tackle health inequalities.
Tackling health inequalities in infant mortality and infant and maternal health, will not just improve health outcomes today, but lay the foundations for sustainable, long-term improvements in health.
At 5.5 deaths per 1,000 live births, the West Midlands has the poorest infant mortality rate in England [2014 data].  The infant mortality rate takes into account the total number of live births and so provides a more accurate indication of trends than just analysing the number of deaths in infancy over time. The West Midlands rates are significantly higher than the England average. (source)
Poorer mothers-to-be often do not attend antenatal classes. Almost three-quarters of pregnant women on low incomes do not attend antenatal classes according to new figures. Nearly half are not even offered them on the NHS. (source)
The Real Birth Workshop was created because we believe that all expectant parents should have access to positive birth information. It is beneficial for pregnant mums and their birth partners to have positive help with their birth preparation. We support all birthing choices because we believe in empowering women with the right information when they need it.
A report by the National Childbirth Trust (NCT) Preparing for birth and parenthood report surveyed 928 expectant parents (first-time mothers and fathers) attending antenatal courses. The research found that while only 3% of women said they felt confident about birth before attending an antenatal course, afterwards 98% said they felt confident or fairly confident. Similarly, among fathers-to-be surveyed, just 1% said they felt confident about birth before their course; afterward 97% felt confident or fairly confident.
The Real Birth Online Workshop provides parents to be with the education they need to manage and reduce maternal anxiety leading to improved coping strategies, greater partner support and a better birth experience.
Current and planned activity: 
We believe the workshop shows decreased admission in the latent phase, decreased use of analgesia & an increase in women having a positive birth experience.

We need champions who can apply for NIHR funding with us to pilot The Real Birth Online Workshop with women using their NHS maternity services.  
A number of languages are currently active, we want to include more to help all women access valuable antenatal education. Being able to access our online workshop provides antenatal education to women who may otherwise be unable to attend classes for various reasons including social, cultural & demographic.
Many proactive measures are being taken to address perinatal mental health. We believe a positive birth experience doesn't depend on mode of birth but choice, understanding & involvement in decision making & empowerment in pregnancy & labour.
Our programme can have a positive effect on women’s birth experiences & her birth partners & assist with informed choice & understanding of birth.  
What is the intellectual property status of your innovation?:
100% IPO The Real Birth Company Limited
Return on Investment (£ Value): 
Return on Investment (Timescale): 
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Innovation 'Elevator Pitch':
Dip.io, a CE approved product turns the smartphone into a clinical grade device enabling lay-users to test urine in their own home, with clinical accuracy and share results electronically with their clinician. 
Overview of Innovation:
42m urine tests a year are undertaken in the NHS to screen for a wide range of conditions. Currently patients collect a sample at home and bring it to the clinic or provide a sample in the clinic where it is either tested on site or sent to a laboratory. This is inefficient, inconvenient for the patient and presents opportunity for improvement in patient experience, clinical quality and cost efficiency.
Healthy.io is the first company to turn the smartphone into a regulatory-approved clinical device. Its first product, Dip.io, uses computer vision and user centric design to turn the smartphone into a urinalysis device. Built around existing semi-quantitative urinalysis dipsticks, Dip.io complements established clinical efforts by empowering patients to test themselves at home with no quality compromise, and securely share results with a clinician.
Healthy.io is empowering patients to take urine testing into their own hands, opening up an immense opportunity to improve preventive efforts, enable early interventions and increase optimisation in the outpatient setting. Key pathways in which digital urinalysis has strong potential to improve patients’ lives and reduce cost to the NHS:
  • Antenatal care: women with hypertension or diabetes in pregnancy have a higher risk of developing pre-eclampsia, a leading cause of maternity morbidity. Dip.io has proven through a usability study at Johns Hopkins to improve women’s experience and could reduce outpatient appointments amongst high risk pregnant women. 
  • Chronic Kidney Disease (CKD): Home-based screening of albumin:creatinine (ACR) for people with diabetes or high blood pressure, to increase adherence to NICE CG 182 and diabetes care process beyond the current level of 50%.
  • Urinary tract infections (UTI): opportunity to improve self-management for patients at risk of admission from UTI (e.g. MS), reduce the 5m GP attendances for UTI in primary care and create digital pathways for pre-op assessment  through using digital urine testing, within existing clinical guidelines.
Stage of Development:
Market ready and adopted - Fully proven, commercially deployable, market ready and already adopted in some areas (in a different region or sector)
WMAHSN priorities and themes addressed: 
Long term conditions: a whole system, person-centred approach / Digital health / Person centred care
Benefit to NHS:
Benefits to NHS in line with FYFV:
  • Primary Care (Diabetes and CKD screening): Smartphone enabled self-testing offers a critical complement to existing population health efforts by shifting testing from primary care to the home. Providing alternatives to face-to-face contact frees up GP resources and nursing time. NICE recommends that every person at increased risk of CKD (people with diabetes or hypertension) needs to annually get their urine tested. However only 50% of people with diabetes and 30% of people with hypertension have a regular urine test reported. Over 1 million cases of CKD remain undetected. Diffusing Dip.io to every at risk patient (8.3m) could improve adherence with no additional overhead, reducing CKD cost by up to £1bn.
  • Maternity Safety (Proteinuria screening): The Maternity Transformation Programme (Better Births) prioritises improvement in maternity safety and provision of consistent quality. This includes halving the rates of stillbirths, neonatal and maternal deaths by 2025. Around 15% of women with hypertension or diabetes in pregnancy have a higher risk of developing pre-eclampsia, a leading cause of maternity morbidity. Automated home-screening for proteinuria in at-risk pregnancies has the potential to early identify pre-eclampsia, save £1,500 for each avoided false negative, save up to £75m by reducing 60% of outpatient appointments (3rd trimester) and reduce antenatal consultation time by 25%.
  • Urgent and Emergency Care (Urinary Tract Infection): Conducting common diagnostic tests at the patient's home supports "improving the ability of patients to self-care for minor illnesses" (UECR).  This includes the need to anticipate recurring conditions such as UTIs. 1-3% of GP visits are UTI related and UTIs accounted for 14% of emergency hospital admissions in MS patients costing the NHS over £43 million. Dip.io offers the opportunity to improve self-management for patients at risk of admission from UTI, reduce the 5m GP attendances for UTI in primary care and create digital pathways for preop assessment within existing clinical guidelines.
  • Harnessing technology and innovation: Our solution leverages existing technology to transform care delivery and supports the drive to digital adoption. We easily integrate into other technologies (integrated with PKB and Allscripts) and make sure interoperability is built in. We are replicating this model for our next product to bring innovation to woundcare management.
Online Discussion Rating
5.50 (2 ratings)
Initial Review Rating
4.20 (1 ratings)
Benefit to WM population:
Our smartphone-enabled digital urinalysis service aims to improve quality and efficiency of existing pathways, driving better patient outcomes and experience.

Main benefits:

Maternity safety: women with hypertension or diabetes in pregnancy have a higher risk of developing pre-eclampsia, a leading cause of maternity morbidity. NICE CG62 recommends dipstick urinalysis during each prenatal visit to screen for proteinuria, an indicator of pre-eclampsia. Increasing testing in between regular pre-natal visits could reduce Pre-eclampsia complications. Women with at-risk pregnancies receive 7-10 Dip.io kits. Following a defined frequency, the women conducts the test at home. The clinician automatically receives the results and is alerted if results are abnormal for immediate follow-up care. This model of care is being rolled out across mayor HMOs in Israel and received more than 90% preference in a Johns Hopkins usability study. Dip.io has proven to improve women’s experience and could reduce outpatient appointments amongst high risk pregnant women.

Diabetes and CKD screening: NICE clinical guidelines recommend people with diabetes/hypertension need to get their urine tested annually but adherence is low e.g. only 51% of people with type 1 diabetes tested. Digital testing could improve adherence and reduce costs. Patients with no recorded albumin reading receive our smartphone urinalysis home-test. Results are immediately available to the clinician and those with abnormal results are invited to a follow-up extensive checkup. This model makes it possible to reach people at risk, who have not received appropriate testing, thus increasing adherence to CKD screening.

Urinary Tract Infection (UTI): opportunity to improve self-management for patients at risk of admission from UTI (e.g.MS), reduce the 5m GP attendances for UTI in primary care and create digital pathways for preop assessment through using digital urine testing, within existing clinical guidelines.
Current and planned activity: 
  • Salford NHS Trust rollout for renal patient management
  • Care UK rollout for uncomplicated UTI management
  • North East and North Cumbria AHSN with South Tees NHS Trust to test renal clinic at home (Northern Counties Kidney Foundation)
  • Modality and Yorkshire and Humber AHSN to test diabetes/CKD screening model
  • Applying to Test beds for at risk pregnancy (Cheshire & Merseyside) and CKD screening (Care City).
  • NeuroResponse social enterprise based at UCL on Multiple Sclerosis pathway

  • Usability study in pregnant women at Johns Hopkins with 92% favourability (soon to be published)
  • US National Kidney Federation and Geisinger Health to improve care for people with hypertension- successful increase in adherence (soon to be published)
  • Dutch Kidney Foundation and Dutch Health to test population screening for ACR in at risk population compared to other method
  • Roll out in two HMOs in Israel for at-risk pregnancy model
Return on Investment (£ Value): 
Return on Investment (Timescale): 
Ease of scalability: 
Regional Scalability:
Our plan is to scale regionally and nationally through a B2B2C business model. We offer several commercial packages that differ in terms of scale, level of integration, agreement timeline and distribution/shipment method. This allows us to partner with different players within the NHS to provide them full digital capabilities through customised, white label kits, a localised application and access to our algorithm in an end-to-end service proposition. Our vision is to serve as the backbone for smartphone enabled, image based medical diagnostics and enable partners to bring our innovation to their existing user base.
Healthy.io and the Dip.io solution work together with healthcare organizations to improve efficiency, value and outcomes by digitizing existing pathways. Measure include:
  • Save outpatient appointment and reduce consultation time to reduce resource pressures.
  • Increase clinical guideline adherence, improving patient safety
  • Improve patient experience (e.g. minimise absence from work and avoid travel expenses)
Adoption target:
Start with a phased roll out to try, test and scale the innovation in a regional NHS organisation. We anticipate that success from this roll out will lead to spreading the implementation of the technology to other specialties within the organisation, other hospitals/GPs within the group and to other providers and partners within the WM area.
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