Technology and innovation: using virtual clinic follow-up for joint replacement patients

The NHS faces a demographic timebomb and ever-increasing costs of newer tests and treatments. While better treatments and a population that’s living longer are both good news, there’s forecast to be a £30bn year-on-year funding gap between our taxes going in to pay for the service and the costs of running the NHS by the time we reach 2020.

The British population as a whole, therefore, faces a choice between paying more tax, cutting services or what is available on the NHS, or designing a health care service that runs more efficiently.

A significant part of the answer might be provided by a third great revolution to affect human society that we’re currently living through – we’re now in the midst of the information revolution. It has transformed many areas of society – banking, commerce and telecommunications, for example – however health care has largely been left behind. Greater use of innovation and technology has the potential, if used in the right way, to empower patients and health care professionals to produce better value health care for us all.

The challenge of moving from traditional models of care delivery to new services and without leaving anyone behind – either patients or health care staff – should not be underestimated. But the benefits of getting this right could put the NHS on a sustainable footing for many years to come.

At the Royal Cornwall Hospital Trust (RCHT) our orthopaedic team asked whether there was a better, more efficient and complete way to follow up our joint replacement patients.

Hip and knee joint replacements are successful operations that are being performed in increasing numbers each year. In the UK over 150,000 patients underwent hip or knee joint replacement last year, almost double the number performed just over a decade ago. This is a success story that illustrates why the cost of health care is increasing so dramatically in one area.

National guidelines require joint replacements to be monitored at regular intervals; usually at one, five and every subsequent five years following surgery. This follow-up was traditionally carried out via a face-to-face appointment with the surgical team, with questions asked about pain and function and an x-ray film of the joint replacement taken and checked. However, as successful operations we know that between 90-95% of these patients will be doing well at the 10-year point, which means that most patients are brought back to clinic just to tell their surgeon that they’re doing well. That said, as with a lot of chronic conditions in medicine, it’s vitally important to pick up the occasional problem – the joint replacement might need further treatment before it fails, occasionally catastrophically so.

So with the help of funding and expertise from the Health Foundation’s Shine programme, we’re in the process of setting up a virtual clinic to follow up our patients with hip or knee joint replacement.

How does a virtual clinic work? Well, those patients choosing to do so register with the MyClinicalOutcomes web-based system and complete a set of patient reported outcome measures (PROMs). PROMs are short sets of questions developed from clinical research that measure patient symptoms, such as pain and function. A symptom score is generated, allowing patients to compare themselves to other similar patients and to track their health over time looking out for any deterioration or improvement. Patients can consent to share this information with their hospital team, allowing easy monitoring between face-to-face appointments.

Following joint replacement, patients are seen face-to-face at 6 to 8 weeks and then entered, if they prefer, into the virtual clinic pathway. An x-ray film is booked at their local clinic one year after surgery and this is reviewed alongside the patient’s symptom score by the surgical team. A report is emailed and further follow-up arranged as required. The aim is to monitor more patients more regularly within the available clinic time and to target face-to-face clinic capacity to those patients who need it most.

The Health Foundation support will allow RCHT to accurately capture what effects this has and whether virtual clinics could be used elsewhere, both in other parts of the UK and in other chronic health conditions. We’ll let you know how we get on!

Dan is a Consultant Orthopaedic Surgeon at Royal Cornwall Hospital Trust and Co-founder of MyClinicalOutcomes