Project Name: Cardiovascular Disease (CVD) Case Finding in Primary Care  - Penguin Patient Management System

Project Summary:

The Project aims to provide and implement a Cardiovascular Disease (CVD) screening, assessment and review program, across the Didsbury, Chorlton Park and Burnage Primary Care Network (PCN).

The project will use blood pressure (BP) readings, as a leading indicator of risk to then determine priority for assessment and clinical review.

Evergreen Limited (“Evergreen”) have developed a disease-agnostic, web-based application, with application programming interface (API), to record Patient Reported Outcome Measures (PROMs), with interfaces for both clinician and patient (“Penguin System”). 

Novartis and Evergreen have developed a bespoke BP clinical template which will be accessible via the Penguin System.

In this Project, Evergreen (on behalf of Novartis), will complete the configuration of the bespoke BP clinical template by determining the clinical data to be collected including PROMs, patient pathway, clinical data to be imported from other systems (e.g. blood test result systems) and the configuration of the clinician’s and patient’s dashboard.  Following configuration, the Penguin system will then be implemented within the PCN’s system.

Any Patient over 40 years of age, or with a raised BP reading of 140/90 in the prior 5 years (excluding patients with previously diagnosed Hypertension), will be asked to input an up-to-date BP reading, at which point, the Penguin System will auto triage patients into the relevant clinical pathway.

Implementation of the project in the PCN aims to;

  • Empower patients to own their disease and consider risk factors.

  • Improve the identification and prioritisation of CVD patients.

  • Flag to clinicians patients who report outcome measures that are outside of the clinically-determined tolerance levels, or whose scores are on a consistent increasing trend.  These real-time rapid alerts of patients not achieving optimal outcomes will enable their care to be reviewed and optimised more quickly than if the patient had to wait for a scheduled appointment;

  • Support the move to a needs-based care model, keeping well-managed patients with minimal disease impact at home and managed through other means such as virtual consultations, recycling capacity to manage those patients who are not achieving optimal outcomes;

  • Support clinicians to make a confident and informed decision about a patient’s treatment plan, virtually or face to face, based on patient reported outcomes; and

  • Enable clinicians to prioritise new patient referrals and the backlog of patients caused by unanticipated workload e.g. COVID-19, based on assessment of patient need using a single indicator of Blood Pressure

Planned Milestones:

  • Project kick-off meeting

  • Preliminary Paperwork/Sign off

  • PDS IT interfacing work completed

  • Pathway Mapping

  • Local Training & Configuration of Local Test Platform

  • Live System Set-up

  • Start of 12-month license, hosting and support

  • Business Case, Write-Up and Project Close

Expected Benefits:

  • Empower patients to own their disease through provision of educational resources and ability to track progress through validated PROMs and clinician touchpoints over time.

  • Better management of their disease via the clinician’s specifications to the Penguin software solution (including the clinical template).

  • A digital platform to record their PROMs at home between appointments, freeing up appointment time to discuss results and patient health factors identified via the PROM questionnaires.

  • Reducing the number of hospital appointments for patients who are feeling well and achieving optimal outcomes – saving patients time, reducing time off work and the associated financial outlay with travel to hospital appointments

  • Ability to access to clinical data, including PROMs, for individual patients in one digital platform.

  • Flagging to clinicians the patients who report outcome measures that are outside of the clinically determined tolerance levels, or whose scores are on a consistent downward trend.  These real-time rapid alerts of patients not achieving optimal outcomes will enable their care to be reviewed and optimised more quickly than if the patient had to wait for a scheduled appointment.

  • Support the PCN to move to a needs-based care model, keeping well-managed patients with minimal disease impact out of secondary care and managed through virtual consultations at reduced frequency, recycling capacity to manage those patients who are not achieving optimal outcomes or who are on waiting lists for initial review.

  • Support clinicians to make a confident and informed decision about a patient’s treatment plan, virtually or face to face, based on patient outcomes.

  • Enabling clinicians to prioritise new patient referrals and the backlog of patients caused by COVID-19 based on assessment of patient need using the validated PROM

  • Increased opportunities for digital innovation and engagement across the PCN, aligning to the Novartis strategic priority: driving the use of data and going digital.

  • Creation and real-world use of the Novartis clinical template in the Penguin system for Patient PROMs.

  • Baseline, non-patient identifiable, aggregated PCN data in baseline reports.

  • Improved reputation through collaborative working with the PCN to collect BP and PROMs via a robust online system.

  • Aligns with Novartis focus of innovating to address the most significant unmet needs of patients in the UK.

Start Date & Duration: Aug 2022 – 24 Months

UK2207299873 

Project Name: Cardiovascular Disease (CVD) Case Finding in Primary Care - Penguin Patient Management System

Completion Date: November-2022

Outcomes Summary:

This project was a pilot to initially determine if the PCN could collate patient blood pressure (BP) measurements in a quick and simple manner using the Penguin Patient Management System.

This pilot did not engage a large enough section of the target patient population as quickly as hoped. Therefore, the project was closed early so that the PCN could pursue alternative solutions to collect BPs.

Outcomes:

Evergreen Limited (on behalf of Novartis), completed the configuration of the bespoke clinical template to initially collect patient BPs and the configuration of the clinician’s and patient’s dashboard.  Following configuration, the Penguin system was implemented within the PCN’s system.

304 patients were invited to report their blood pressure via the Penguin system, however only 62 (20 %) patients responded. The PCN needed to increase their hypertension register by 25 – 50 % in order to achieve the targets for the Investment and Impact Fund requirements to receive financial funding from the NHS by 31-March-2023. It was determined after a month of using the system that Penguin system was not returning the volume of patient responses required to meet the PCN’s target.

Conclusion:

The PCN uses the Accurx platform which allows patients and healthcare professionals to communicate. After the early closure of the Pengiun pilot, the PCN switched to using the Accurx platform to request and receive patient BP readings. As a result,  the patient response increased. The PCN has now reached a 41.6 % increase in their hypertension register numbers.

UK2303305350