Virtual Clinics From Urogynaecology to Pre Operative Assessment

1. Virtual Clinics
From Urogynaecology
to Pre Operative Assessment
Setting up & Running Virtual Clinics
Hallam Conference Centre
London
Stephen Radley MD FRCS FRCOG
Director of R&D, ePAQ Systems Ltd
Consultant Obstetrician & Gynaecologist
Director of Research Jessop Wing, Sheffield Teaching Hospitals

2. Understanding service virtualization: where to start
Case study: Virtual clinics: From Urogynae to Pre Op Assessment
Understanding service virtualization: The theory
Tools and pathways
Where to start? Lessons from our virtual clinics
Developing a web-based ‘Virtual Clinic’ in Urogynaecology
The benefits of virtual clinics for ‘sensitive’ conditions
Practicalities and how the clinic works in practice

3. Understanding service virtualization: The theory
e-Health
Healthcare practice supported by electronic processes and communication.
Cybermedicine / Telemedicine
Use of the Internet / electronic media to deliver medical services, e.g. consultations
& prescriptions. Remote transmission of patient data (images, radiology, test
results & assessments) supporting health care
Cyber Clinician
Medical professional providing consultation via the Internet
Virtual Clinic
Provision of remote or non-face to face medical care. This may utilize different
communications media and interfaces.

4. Tools and pathways
Face to face / Post / Telephone / Internet / Mobile

5. Pathways
NHS England
Technology Enabled Care Services: TECS
Resource for commissioners
‘Maximise value of TECS for patients, carers, clinicians, health economy’
Defined as…
Telehealth, Telecare, Telemedicine, Telecoaching, Self-care
Aiming to…
Improve long-term conditions: convenient, accessible & cost effective
www.england.nhs.uk/ourworld/qual-clin-lead/tecs

6. Where to start?
Lessons from our virtual clinics
Think small!
Consider: patients, clinicians, management
Champions: Staff / Colleagues
Managers / Stakeholders
Funding: Business case / Grants
Industry / Commissioners

7. Bristol female urinary
tract symptoms - Q
Birmingham
bowel & urinary
tract - Q
Sheffield prolapse
symptoms - Q
Female sexual
function index
ICS
Male
Pelvic Floor
Assessment (PAQ)
Questionnaires
Developing a web-based ‘Virtual Clinic’ in Urogynaecology

8. Why an electronic
questionnaire ?
Burden
Value (interactive, simple & easy, help pages)

9. Value / Burden
Appropriate, accessible, practical & acceptable
Use in clinical practice?
Can patients & clinicians use it?
Cost: Patients, providers & society
Use in different settings
How does it impact on patient care?

10. ePAQ – Pelvic Floor
Structure
• Introductory pages
• Questionnaire dimensions (up to 120 items)
Urinary
Bowel
Vaginal
Sexual
• Analysis, summary, printed report
Interactive &
optional
dimensions

11. ePAQ – Pelvic Floor
A questionnaire for clinical use

13. Screen shot: Standard ePAQ item structure

21. ePAQ-PF Summary report

22. Symptoms
Impact
ePAQ Detailed report
(Lower Urinary Tract Symptoms)
QoL

23. Routine clinical care

24. 29 year old, Pakistani, Non-English speaking
Schizophrenia
Not examined
MSU -ve
Solifenacin 5mg

25. The Virtual Clinic

26. 2006 survey of ePAQ users in urogynae clinic
• 80% of under 50s had internet access
• 45% of over 50s had internet access
95% of those with home internet access…
‘Would have liked to have used system
before coming to clinic’

27. Benefits of virtual clinics for sensitive conditions
• Disclosure, discussion & shared decision making 1
• Embedded outcome measures (PROMs & PREMs)2
• Avoiding clinician bias 3
• Engagement, enablement, empowerment 4
1. Schussler-Fiorenza et al. Using an electronic pelvic floor questionnaire to increase
discussion rates of urinary incontinence in primary care: an RCT. (In Press)
2. Black et al Relationship between patient reported experience (PREMs) and
patient reported outcomes (PROMs) in elective surgery. BMJ 2013
3. Black et al. Impact of surgery for stress incontinence on morbidity: cohort study.
BMJ 1997
4. Dua et al: Understanding women’s experiences of electronic interviewing during
the clinical episode in urogynaecology: A qualitative study. IUGA Journal 2013

28. 80.4
71.4
59.3 58.4
39.0
11.1
0%
20%
40%
60%
80%
100%
would
recommend
would
undergo
again
subjective
improvement
or cure
no GSI normal
urodynamic
study
subjective
cure
The ‘Science’ of Outcomes Assessment

29. Symptoms vs Investigations
(BFLUTS): "Does urine leak before you can make it to the toilet?"
0%
20%
40%
60%
80%
100%
Never
(n=6)
Some-
times
(n=20)
Occas-
ional
(n=32)
Most of
time
(n=27)
All the
time
(n=10)
%withdetrusoroveractivity
Ambulatory
Urodynamics
Standard
Urodynamics

30. Patient comments…
I preferred answering the more embarrassing questions via the questionnaire than
face to face
Knowing that an examination was out of the question put me more at ease
Phone consultation excellent, relaxed & stress free
Thorough & informative way of doing things
I didn’t have to worry about childcare
Helped express my problems enormously
Helped focus on urgent and relevant problem
Made me realise the extent of my problem
Helped talk at ease about my problems
It was really easy to use
Good, enjoyable, easy and quick!
Good idea, well done!

31. 0%
10%
20%
30%
40%
50%
Strongly
agree
Mostly agree Neither
agree nor
disagree
Mostly
disagree
Strongly
disagree
'The questionnaire was helpful during my clinic visit'

32. Practicalities
How the clinic works
1) Standard appointments booking system
Patient preference choice, patient information
2) www.epaq-voucher.co.uk
Arranged via OPD / Ward staff / Secretary
3) Monthly clinic: 20 x 10 min appointments
5 – 15 min, supported by correspondence, notes & ePAQ
4) Outcomes
Letter to GP + ePAQ report / ePAQ progress report
Letter to patient
Information leaflets
Follow up
Discharge

33. The Virtual
Clinic
Name Tel Time
Anna Smith AS1234 078212344 14:00
Beryl Jones BJ8765 0114 3098909 14:10
Connie Lewis CL2345 0114 3897890 14:20
Diane Cole DC4567 07989997654 14:30
Edna Rose ER3847 07635668234 14:49
Fiona Groves FG2783 0114 3897890 14:50
Greta Holmes GH1783 0114 3897890 15:00
Heidi Hill HY7896 0114 3897890 15:10
Ida France TA1256 0114 3897890 15:20
Joanne Davies JD3456 0114 3897890 15:30
Kay Somers KS2365 07885668234 15:40
Lisa Tandy LY5698 0757 3897890 16:00
Margaret Smith MS3452 0114 3897890 16:10
Nora Bates NB2344 0114 3897890 16:20
Orla Charles OC3567 07835668234 16:30
Penelope Roper PR5702 07835668234 16:40
Rose Doyle RD5098 07835668234 16:50
Selena Bird SB8090 07835668234 17:00
Tina Moores TM3409 07835668234 17:10
Ursula King PL0987 07835668234 17:20
Violet Bonnett VB0934 07735668239 17:30

35. https://start.epaq.co.uk

36. ‘Dual server technology’
N3
(NHS)
Personalised
Name, DoB, NHS
number, PAS-linked
WWW
(Internet)
Anonymous
Unique Voucher code
& DoB

37. Pre & post BOTOX (Virtual clinic)

38. 0
20
40
60
80
100
U P&S Voiding OAB SUI U QOL
Incontinence surgery: TVT pre and post op mean
ePAQ urinary domain scores (n=54)
pre op mean
post op mean
Effect size: SUI = 2.4 U-QoL = 2.2

39. Mean waiting time between referral & VUC: 28 days
(range 7 - 46)
Primary complaints
Stress incontinence (79%)
Overactive bladder (50%)
Prolapse (27%)
Bowel problems (24%)
Sexual dysfunction (24%)
VUC Outcomes (first 50 patients)

40. 79% Treatment planned or initiated
39% Referred to physiotherapy
44% Scheduled urodynamics
12% Clinic follow-up
8% Referred to another clinic
Virtual Clinic:
First 50 patients

41. Positive aspects (0 = worst, 100 = best possible)
Communication (PEQ)
84 (SD = 16)
Value (QQ-10)
77 (SD 16)
Negative aspects (0 = best, 100 = worst possible)
Barriers (PEQ)
15 (SD = 15)
Burden (QQ-10)
25 (SD = 16)
Virtual Clinic: Satisfaction Data

42. 0%
10%
20%
30%
40%
50%
Strongly
agree
Mostly agree Neither
agree nor
disagree
Mostly
disagree
Strongly
disagree
'The questionnaire was helpful during my clinic visit'

43. 0
20
40
60
80
100
Disagree
completely
Disagree So-so Agree Agree
completely
'I felt taken care of'%

44. Evaluating the impact of a ‘virtual clinic’ on the quality
and cost of patient care in urogynaecology: An RCT
Jones GL, Radley SR, Jacques RM, Wood HJ, Brennan V, Dixon S.
195 Women: New patient referrals to
urogynaecology clinic

45. Resource
Cost per patient
(Intervention) (£)
N = 27
Cost per patient
(control) (£)
N = 30
Mean Difference
(£)
95% CI
Lower
95% CI
Upper
P-value
Cost of
Consultations
Consultation cost1 29.35 69.52 -40.17 - - -
Cost of software 2.40 2.40 0 - - -
Cost of computer N/A 0.25 -.25 - - -
Total consultation
costs per pt
31.75 72.17 40.42 - - -
Direct costs 6/12
GP Visits 41.22 35.33 5.89 -25.29 37.06 .654
Practice nurse 0.94 2.13 -1.18 -3.77 1.41 .063
Appointments 251 188 62.67 -87.02 212.36 .405
Surgery 330 286 44.88 -353.35 442.97 .822
Other professionals
Physio 5 5 .05 -7.58 7.68 .989
Nurse 4.5 2 2.49 -5.48 10.45 .534
Consultant 8 14 -6.35 -23.22 10.51 .454
Total direct costs 641 532 108.37 -346.93 563.67 .635
Indirect costs 6/12
Personal
expenditure (£)
24 16 7.9 -6.04 21.84 .261
Loss of productivity 443 481 -37.81 -847.04 771.42 .926
Total indirect costs 467 497 -29.91 -839.47 779.66 .946
Total costs per pt 1,140 1102 38.04 -1119.34 1196.03 .948
RCT: New patient referrals in urogynaecology

46. Mean difference between groups & 95% CI for post consultation PEQ scores
(positive mean difference indicates that the intervention group has a better score).

47. Summary of RCT Findings
Virtual Clinic does appear to positively improve patients
experience of their consultation, particularly communication
Virtual clinics may prove beneficial in overcoming barriers,
improving emotional wellbeing and enhancing communication
Significant difference between the duration of consultations
(50% shorter in the intervention group) and associated
consultation costs.
Patient selection important factor in cost / benefit

48. An integrated care pathway
N3 + www
1o care
2o care
3o care
ePAQ

49. Home
Internet
Standardisation
Clinical governance
Screening
& Triage
Secondary care
ePAQ: supporting patient centred & integrated healthcare
Clinical assessment
Primary careResearch, Audit
Service evaluation

50. ePAQ – MPH (Menstrual, Pain, Hormonal)

51. ePAQ-Vulva

52. ePAQ-PO
ePAQ-Vascular
(NIHR ScHARR)

53. ePAQ-PO
Summary
Report

54. Users
Manchester
Liverpool
Sheffield
Birmingham
Newcastle
Derby
Leeds
South Tees
Southport
Ormskirk
Scotland (S Ayr)
Italy (Milan)
Ire (Dublin)
Australia
50,000+
Colorectal, Urology, Physiotherapy,
Urogynaecology, Nurse Specialists

55. Thank you

56. References
Computer interviewing in urogynaecology: concept, development and psychometric testing of an electronic
pelvic floor assessment questionnaire (e-PAQ) in primary and secondary care. Radley et al. BJOG, 2006
QQ-10: An instrument to measure face validity and feasibility of questionnaire use in healthcare.
Moores K, Jones G, Radley SC. Int J Quality in Health Care. 2012
Prolapse surgery and sexual function. Dua A, Jha S, Farkas A, Jones GL, Radley SC. International
Urogynecology Journal. (Oct 2011)
Effect of posterior colporrhaphy on anorectal function. Dua A, Jha S, Farkas A, Jones GL, Radley SC.
International Urogynecology Journal. (2011)
Quality of life measurement and electronic assessment in urogynaecology.
Dua A, Radley SC. The Obstetrician & Gynaecologist (Sept 2011).
Factors affecting the outcome of TVT. Jha S, Jones GL, Radley SC, Farkas AG.
European Journal of Obs Gyn Repro Biol (Dec 2008)
Responsiveness of ePAQ-PF. Jones GL, Lumb J, Radley SC, Farkas AG. Int Urogynecol J Pelvic Floor
Dysfunct. (Dec 2008)
Impact of TVT on Sexual function. Jha S, Radley SC, Farkas AG, Jones GL.
Int Urogynecol J Pelvic Floor Dysfunct. (Nov 2008)
Electronic pelvic floor symptoms assessment: tests of data quality of ePAQ-PF. Jones GL, Radley SC,
Lumb J, Jha S. Int Urogynecol J Pelvic Floor Dysfunct. 2008 Jun