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Monday 26 September 2016
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Patient self-testing and productivity

Insight: IM&T

A patient comes in to see the GP after the practice nurse noted her blood pressure is not well controlled. She is becoming increasingly anxious, which is adding to her woes ("Every time I come to the surgery, I can feel my blood pressure going up").

This is an all-too familiar scenario. The latest blood pressure (BP) guidelines inform GPs that if the clinic BP is 140/90mmHg or higher, we should use ambulatory blood pressure monitoring or home blood pressure measurement to confirm the diagnosis of hypertension and also to continue to monitor treatment effectiveness subsequently.(1)

Our practice, Haughton Thornley Medical Centres (which comprises two surgeries), currently has 11,850 patients – 1,895 of whom are known to have essential hypertension. Many more patients remain undiagnosed with hypertension and are therefore at risk of significant morbidity/mortality.

Traditionally, patients diagnosed with hypertension come along to the surgery, sit in the waiting room before being called in to see a doctor or nurse who would check their BP and then, based on one or two readings, determine an appropriate management plan. Over the last few years we have involved patients in some aspects of this process and we believe we have increased health literacy around hypertension as a result.

Last week we recorded 308 separate BP readings at our practice and, while we do not have accurate data on the number of BP readings carried out by patients, it is likely to be in the region of 70 readings (around 20% of all readings). So, what has changed?

Opportunity to redesign hypertension services
It is our belief that patients, carers and information are the most under-utilised resources the NHS has at its disposal. What does this mean for hypertension services based in general practice?

  • Patients are actually willing to do more for themselves (self-care) if they are supported by their doctor or nurse to do so and are provided with information on what they will need to achieve this.
  • Electronic BP machines, which are now easily available in most high-street pharmacies and electronic shops, give patients the opportunity to check their own BP away from a healthcare professional. Some high-end machines even have the ability to recognise irregular heartbeats.
  • BP machines have been created for use in common waiting-room areas as well as at home.
  • BP readings can be downloaded automatically to personal computers, automatically transferred via wi-fi or Bluetooth to smartphones/tablets/personal health records (for example, Microsoft's HealthVault – see Resources) or the patient can input readings to a smartphone app or to HealthSpace (see Resources).
  • Information is available for patients to understand what their BP readings mean via posters, leaflets, websites (including NHS Choices, Map of Medicine and British Heart Foundation) and web portals that GP practices or others may provide.
  • Clinicians have an important role in helping patients to understand how to check their BP, what the readings mean, what treatments are being offered (lifestyle changes, medications as well as tests and investigations to identify risk factors as well as any existing co-morbidities that may develop/worsen) and the healthy choices that patients can make.
  • Where provided, patients can read what their health professional has informed them of by accessing their electronic health record online and following the personalised instructions written in the record for the management care plan.
  • Links to trusted information sources can also be made available to patients, direct from their electronic health record.

Using technology to support hypertension patients
At Haughton Thornley Medical Centres, we have a BP machine in the waiting room in each surgery. Patients are encouraged to use the machines while they are waiting to see a clinician.

Information leaflets are placed near to the machines to inform patients about what the numbers mean and where to go to learn more. The machine produces an automatic printout of the BP reading and pulse, as well as the time and date, which the patients can retain for themselves or hand in to the receptionist or clinical staff to update their medical record.

Patients who ask to have their BP checked during consultations are asked if they would like to check it themselves using the machine in the waiting room. It may take a couple of minutes more to go to the machine and show the patient how to use it on the first occasion, but once the patient knows how to do it, they are subsequently more likely to check their BP readings themselves.

This saves us a vast amount of time as the patient can get a few readings while they are waiting; the clinician can then continue the consultation from that point onwards, instead of waiting to take another reading. We can also then check the patient's understanding of the reading, supporting an increase in health literacy. In the last week, for example, 15 readings were presented to me in this way.

Once patients become comfortable with checking their own readings, many have also decided to buy their own BP machine themselves. We advise patients to go and talk to the pharmacists about the different machines that are available to buy.

We have also created a specific web page with links to trusted information to help patients and carers understand what hypertension means (see Resources), including a link to a video explaining how to check BP at home, which patients have found very helpful.

There are challenges too: some patients simply do not want to check their own BP, either in the surgery or at home. They may not feel it is their role to do so and some may not be able to afford to buy a machine for themselves. We have invested in a few BP machines we lend out to patients, although this will never be enough for everybody.

Other challenges include ensuring the machines that patients use have the right-sized cuff, are maintained and still function correctly, and that patients are not just making readings up. One way around this is for patients to bring their machine with them so that we can see how they are using them and also compare their readings with our own machines (which are regularly serviced and validated).

Some patients (those on combined oral contraceptive medication, for instance) are now coming into the surgery whenever it is open (from 7am, when we do an early morning surgery, through till 6pm when the surgery closes) to check their BP and weight in the waiting room, handing in the readings if they regard them as 'normal' to the receptionist and then requesting a telephone consultation with the doctor prior to getting their repeat prescription.

They are able to check their records online to see that the readings have been added to their record, review contraceptive options they may have and can review any advice that has been given to them over the phone.

Summary
The interplay of lower cost self-testing technology and online records makes our jobs easier, more enjoyable, more patient-centred, safer, more cost-effective and is a better experience for the patients who opt for this too (see Box 1). The improvement in safety has a corresponding benefit of reducing wastage due to inappropriate prescribing.

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Our experience is that self-monitoring is acceptable for an increasing majority of patients, saving them time and helping them to become less anxious. It also means that
we can deal with more patients, since a telephone consultation lasts five minutes as opposed to a 10-minute face-to-face consultation.

Overall, this improves our productivity and helps us to achieve Quality and Outcomes Framework (QOF) targets, using an innovative initiative to deliver higher-quality care that saves us time and improves our income too!

Dr Amir Hannan is a GP Partner at Haughton Thornley Medical Centres, a self-care champion (www.selfcareforum.org) and member of the Health Informatics Clinical Advisory Team, NHS North-West.

Glen Griffiths is a Patient e-Health Specialist and Vice Chair of the BCS Primary Health Care Specialist Group (www.phcsg.org) who co-created the Haughton Thornley Medical Centres' website (www.htmc.co.uk).

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Reference
1. National Institute for Health and Clinical Excellence. CG127: Hypertension: clinical management of hypertension in adults. London: NICE; 2011. Available from: http://publications.nice.org.uk/hypertension-cg127/guidance

Resources
Thornley House Medical Centre – Hypertension care
www.htmc.co.uk/hypertension

MicroSoft HealthVault
wwww.healthvault.co.uk

NHS HealthSpace
www.healthspace.nhs.uk

Android Market
www.android.com

Apple App Store
www.apple.com/uk/iphone/from-the-app-store