A Welsh digital revolution

Thursday, June 9, 2022

Respiratory Futures spoke to Dr Simon Barry, the National Respiratory Lead for Wales, about the implementation of digital innovations he started in support of clinicians and patients.

When did you start thinking about the need to move to a more digital approach to healthcare?

I have been the Respiratory Lead for Wales for about five years. When it came to deciding where to focus the resources we are given by the government I thought we needed to do something innovative and with a real chance to change outcomes.

I had a central question “how do you change the healthcare of the population?” and the response  my colleagues and I came up with, was “if everyone knows, learns and does the things that matter” then that goal will be achieved. We translated that into data on important outcomes, education and quality improvement.

So I chose to focus on digital because it was the most efficient and cost-effective way to scale things up and reach more people with resources and interventions.

Where did it all start?

We started on the path to digital transformation in 2015. We noted that these was considerable variation wherever we looked. This included prescribing patterns, management in primary and secondary care and workforce allocation. Some studies showed that basic levels of care were poor, for example, Asthma UK showed that only a quarter of people with asthma have basic asthma care. We wanted to improve that and it was clear that the solutions would be digital.

The first thing we did was to develop national prescribing guidelines in Wales. Previously each Health Board (there are seven in Wales) had different prescribing pathways for asthma and COPD. We created a strong consensus from clinicians (when asked in a survey 98% were supportive of this endeavour), created the guidelines and had them endorsed by the All Wales Medicines Strategy Group (AWMSG).

The guidelines simplified choice for prescribers, and involved an easy to follow step by step approach. More recently, the COPD and asthma guidelines have been updated to include information on the green agenda in prescribing. Secondly, we created educational packages (National Welsh Standard) to support nurses and other HCP to deliver standardised care to patients with respiratory illnesses.

We work together with a partner organisation, the Institute for Clinical Science and Technology (ICST), based in Cardiff, that specialises in implementing digital solutions, particularly around education.  By having a single digital platform that users sign into, we are able to measure engagement.

You have a strong focus on implementation in your project, can you elaborate on that?

There is evidence that it takes 17 years for a 14% uptake of new information into routine practice. It’s called the “know-do” gap, so everything we have been doing has had a strong focus on implementation, and is underpinned by implementation science.

There are a number of key components to enable good implementation:

  • Alignment of all key stakeholders, and that is from the top to the HCP delivering care
  • A value proposition (what’s in it for me?)
  • Available capacity and readiness to accept the changes
  • Fidelity, so that there is not drift of messaging
  • There must be key enablers in the system who promote uptake

We call these the “Power Layers” and they are vital for successful implementation.

And then the pandemic started.

Yes, and we realised that our platform and approach could be used to host rapid guidance for COVID-19.  In March 2020 in two weeks we developed a COVID digital hospital guideline and made it available on the platform.

This required user registration and meant that we were able to rapidly disseminate to all registrants new information as it became available. We hosted national guidelines such as NICE and BTS as resources, but the predominant mode of delivering updates was through a video format with local experts distilling information into simple key management points. Through this mechanism we were able to measure user engagement.

We also developed a COVID primary care guideline to support GPs diagnosing and referring COVID patients through the same approach. This meant that we had a strategic approach to managing COVID in the community, with GPs referring those with evidence of organ dysfunction to specialist and the rest to multi-disciplinary teams.

Since the log in requires users to declare who they are and where they work and other details, we knew exactly who was accessing and getting the information at any time and what they were looking at. This allowed us to update the guidelines in a targeted way, to focus on what was needed and what the most accessed topics.  

Did the digital approach help in the pandemic?

Yes, it enabled us to rapidly disseminate to the target audience changes in information that would not have been as effective through standard guideline dissemination, and to measure this engagement. During the pandemic, nearly 50% of all consultants of any speciality in Wales were registered on the platform, and nearly 100% of those from the key specialities- respiratory medicine, Intensive care and accident and emergency medicine.

In addition, we received Welsh government support to run a national data collection on COVID-19 patients on the same platform.

It is a retrospective collection, based on case notes and submitted by each hospital. It wasn’t mandatory, but we had the support of the Welsh CMO, who wrote to all medical directors in the country stressing how important and necessary this was. We now have data from three waves of COVID-19.

The data included mortality, comorbidities, vaccination status and other data on patients with COVID-19, including nosocomial infections. Some of the data we collected on the latter was published in Thorax, where we demonstrated that nosocomial COVID-19 infection had higher mortality rates than community acquired cases.

Which other digital projects did you embark on?

While we worked on the Asthma guideline, we began to think how we could use the online platform for Quality Improvement. We created a simple QI tool to facilitate improvements in asthma and COPD care, hosted on the same digital platform. These QI projects can be published and shared to promote best practice.

We also have a patient component to our project. As part of it, we developed three apps on “asthma for parents”, “adult asthma” and “COPD”. All three are now in their second iteration/update.

The apps align to the guidelines, link to videos about how to take the relevant inhaler correctly, address the green agenda and have self-management tools integral to their function. They are free to use and bilingual for those who use Welsh as their first language. The newest iteration of the apps enable a simple survey to be undertaken every month on asthma control. At this stage we are focussed on implementing the apps across the target populations in asthma and COPD, but in time we believe we will have powerful data at a national level on how well controlled Welsh patients with asthma or COPD are.

More recently, we used the app template for Long COVID. The COVID recovery app is a self-support tool, designed by a multi-professional team. Patients can put their parameters in and the recovery goal they want to achieve, and the app directs them to achieve it. We have had 11000 downloads in Wales to date and there continues to be 20 downloads per day on average.

What was the benefit of the shift to digital, and where are you going next in your digital journey?

Overall, what has been described are a series of digital innovations, for HCP and for patients. What will be crucial for success will be implementing these across the whole target population. When we achieve that, then we will transform care in Wales. It is of course self-evident that this structured approach would be equally applicable to any disease area.