Birmingham Symptom specific Obstetric Triage System (BSOTS) (#3057)

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Idea Description
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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)
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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
WMAHSN priorities and themes addressed: 
Long term conditions: a whole system, person-centred approach / Wellness and prevention of illness / Digital health / Innovation and adoption / Patient and medicines safety / Person centred care
Benefit to NHS:
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.
  • Give mothers control over their data with complete national inter-operability (using industry standard HL7 messaging) allowing her various care providers to access details and include additional information as appropriate.
  • Avoid the need for double entry of data, reducing the administrative burden on clinicians and administrators and thus increasing time for clinical care.
  • Provide high quality data for clinical care as well as for secondary uses, and support evidence based commissioning, service planning and performance monitoring.
  • Increased cost savings because of reduced double entry of data, reduced clinical coding time, reduced litigation costs and reduced clinical time spent on record keeping (a separate cost benefit analysis will be provided).
  • Integrated messaging system between patients and clinicians as well as between clinicians, which reduces unnecessary appointments and enhances quality of care.
Online Discussion Rating
5.86 (7 ratings)
Initial Review Rating
3.80 (1 ratings)
Benefit to WM population:
There are a number of health and weatlth benefits to the West Midlands population, including:
  • Good quality data produced from MiApp will support commissioners to tailor services according to local needs.
  • Individual NHS Trusts can use the data produced to benchmark their services and therefore recognise areas for further improvement. 
  • Clinical risks are greatly recuded through the interoperability, as the West Midlands population will be able to move between healthcare providers with a fully accessible, complete healthcare record.
  • In recognition of the diverse West Midlands population, the record incorporates translation into 18 languages along with information in video format. The aim is that families from all backgrounds and of all capabilities have access to information that they can understand and use appropriately to improve their health.
  • MiApp enables access to the wider health and social care system by highlighting services that are available to all, empoweing women to take control of their own health.
  • Promotes standardised care for the West Midlands population in line with national guidelines.

 
Current and planned activity: 
The Perinatal Institute is a national not-for-profit organisation set up to enhance the safety and quality of maternity care. It is a qualified provider of
maternity support services, including education and training in standardised maternity records, fetal growth assessment and perinatal audit.

The Perinatal Institute has won numerous national awards including most recently the 2016 Queens Award for Enterprise, the 2015 BMJ Award for clinical leaership and the 2015 Patient Safety Award for IT and Technology

The conduct of a quantitative and qualitative evaluation of the MiApp system in comparison to current systems.
What is the intellectual property status of your innovation?:
The intellectual property belongs to the Perinatal Institute
Return on Investment (£ Value): 
high
Return on Investment (Timescale): 
1 year
Ease of scalability: 
Simple
Co-Authors:
Regional Scalability:
The service can be scaled rapidly and efficiently across the region. Our business case means it is likely to be cost-efficent in a very short space of time making it an attractive proposition for commissioners.
 
A robust evaluation of MiApp will establish the feasibility of using this type of solution and provide a measure of it’s transferability to maternity care across the region and ultimately the UK. 

 
Measures:
The project will consist of a quantitative and qualitative evaluation of the MiApp system in comparison to current systems. This evaluation includes a:
  1. Structured survey and semi-structured interviews to explore existing maternity systems with expectant mothers and clinicians.
  2. Structured survey and semi-structured interviews to explore the experience of expectant mothers and clinicians using MiApp. This will include using the principles of user testing to evaluate the mother’s ability to retain and assimilate information held on MiApp.
  3. Economic evaluation of MiApp in relation to time spent on administration in comparison to current systems
Key Deliverables
  • Report on current range of systems available in the West Midlands and their perceived effectiveness in providing mothers and clinicians the information needed for safe maternity care
  • Qualitative and quantitative assessment of user experience of current systems and MiApp.
  • Cost benefit analysis with implications for service delivery in the West Midlands and nationally
  • MiApp is in the process of being rolled out at two sites in the UK but to date there has been no formal evaluation of the effectiveness of MiApp for clinicians and mothers.
  • Proposed outcome measures for women include:
  • Satisfaction with care
  • Retention and assimilation of information
  • Engagement in pregnancy
Inclusion criteria
A number of characteristics can influence the ability to find and understand information in an IT application (including age, educational attainment, inability to speak/read English and deprivation). To help ensure that our cohort reflects this range of characteristics, we will purposively select women from a variety of backgrounds and ensuring the survey is available in multiple languages. 
Adoption target:
The conduct of an evaluation is predicated on the adoption of the device within selected settings. This would be the the first stage of a controlled roll-out, one where we will precisely measure the benefits it provides to encourage its adoption across the region and beyond. 
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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 and enable early interventions. 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 / Innovation and adoption / Person centred care
Benefit to NHS:
Benefits to NHS in line with FYFV:
  • 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%.
 
  • 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.
  • 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.
Initial Review Rating
4.60 (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: 
NHS:
  • North East and North Cumbria AHSN with South Tees NHS Trust to test renal clinic at home funded by Northern Counties Kidney Foundation
  • NeuroResponse social enterprise based at UCL on Multiple Sclerosis pathway
  • Modality and Yorkshire and Humber AHSN to test diabetes/CKD screening model
  • Howbeck Healthcare to test rollout diabetes/hypertension/CKD screening model in South Cheshire and Vale Royal
  • Salford NHS Trust rollout for renal patient management
  • Care UK rollout for uncomplicated UTI management
  • Applied to the Test beds, have been invited to the follow-up meeting for at risk pregnancy, UTI and renal models
 
International:
  • 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
  • Dutch Kidney Foundation and Dutch Health to test population screening for ACR in at risk population compared to other method
  • Rolling out in two HMOs in Israel for at-risk pregnancy model
Return on Investment (£ Value): 
N/A
Return on Investment (Timescale): 
N/A
Ease of scalability: 
Simple
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.
Measures:
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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