Evidence
The development and implementation of an easily accessible, online patient- operated triage tool could potentially contribute to easing the pressure on health system[s].
Gottliebsen K, Petersson G (2020)
Our journey so far
After initially having the idea as to how more effective clinical triage could take place, we conducted a process of internal validation where we modelled outcomes for fictional patients based on a wide range of scenarios.
This gave us the confidence to move onto externally validating a larger dataset of real-world evidence and again modelling and predicting outcomes.
This then gave us further confidence to build the database and technology which would allow us to gather real world evidence to prove the utility and potential value of our solution.
This was started in 2021 and completed in 2023 and the collation of evidence was finished this year.
Internal Validation
External Validation
Real World Evidence
Proving how the process and technology works
A selection of varied clinical conditions has been shown below to prove how the process and technology works in both simple and complex cases and how the system and technology can be used to both escalate and de-escalate signposting when used alongside accurate and timely clinical reasoning.
“…[digital health] solutions will require evidence to ensure their function in a healthcare setting and their impact on incumbent workflows and how clinicians adopt and interact with such tools.
This is where real world evidence is [key]”
The patients below are a selection of real patients who have contacted ecovery and used our service and technology. The outcomes are real but names and personal details (such as location etc) have been changed to protect their identities.
Mark
Knee
Anterior Cruciate Ligament Rupture
Overview
Suffering from recurrent pain and instability in his right knee after playing rugby a few months previously where his knee twisted and landed awkwardly after jumping for the ball.
Mark then attended his local A+E and his knee was x-rayed, and he was advised that he had suffered no bony injury and was then discharged. His knee then continued to give way while at work and eventually this led him to seek out a course of physiotherapy.
The course of physiotherapy was not successful in providing an accurate diagnosis or alleviating the pain and instability in his knee despite his best efforts and so he sought additional help and completed the online clinical form.
Clinical Reasoning
Mark had several risk factors for a soft tissue knee injury (most likely an anterior cruciate ligament).
He suffered valgus trauma and he had swelling (which settled quickly), instability, clicking and pain which was not improving despite his best efforts.
The algorithm within the form asked these questions once Mark had told us via the form where he was having difficulty with his knee. (Joint Specific Special Questions).
Signposting
Location
Orthopaedics – Knee – Knee (soft tissue)
Given that we knew he had completed a course of appropriate physiotherapy (the form had asked him what exact treatment he had done to date) it was deemed necessary for him to seek the opinion of a knee specialist, specialising in soft tissue knee injuries (not all orthopaedic knee consultants specialise in these).
Mark was advised about three appropriate local specialists in his area after a search of the database.
Outcome
Once he had been assessed and referred for an MRI scan by his specialist of choice it was confirmed that he had suffered a ruptured anterior cruciate ligament injury, and he was offered the choice of surgery (given the type of activities he would like to return to) or conservative rehabilitation.
Gary
Hip
Proximal Hamstring Avulsion / Rupture
Overview
He had been seen by both his GP and a physiotherapist who had provided him with a gentle strengthening programme. Gary completed a clinical form after growing concerned his injury was not improving.
Clinical Reasoning
Two problems remained – there is a six-week window (from injury) to ensure the patient sees the right clinician (because after six weeks it becomes very difficult surgically to repair the tendon) and only a small number of specialists in the country treat this exact problem.
We discussed the case with Gary (due to its complexity) and discussed his options and let him know who all the appropriate specialists where for this exact injury.
Signposting
Location
Orthopaedics – Hip – Hip (Hamstring rupture)
Gary was advised about two local specialists and three other specialists in other locations. Gary chose to see a specialist around 100 miles away because of the time frames of the clinic (as he only had two weeks to see a specialist because if it was ruptured, he would need to have surgery within the six-week time frame).
Outcome
Gary had sustained a proximal hamstring avulsion (rupture) and was operated on within a week.
Feedback
“It’s very humbling to be on the receiving end of such impressive and responsive healthcare. I can’t say how grateful I am for your support and signposting”.
Robert
Shoulder
Rotator Cuff Related Pain Syndrome
Overview
Clinical Reasoning
Signposting
Location
Physiotherapy
Robert was advised to seek out a local physiotherapist and was given guidance on how to find an appropriate clinician.
Outcome
Completed his course of physiotherapy and has had no further issues with his shoulder.
Feedback
“Excellent feedback – detailed, and fast. It saved me a trip to my GP!”.
Leanne
Hip
Greater Trochanteric Pain Syndrome (GTPS) / Tendinopathy
Overview
Clinical Reasoning
Signposting
Sports Medicine
Given she had not improved with physiotherapy but that she was very unlikely to require surgery – signposting to a hip specialist would not have proven helpful, so it was decided to signpost her to her local Sports Medicine Consultant (they run a multi-disciplinary clinic with physiotherapists in attendance).
Outcome
Completed a course of physiotherapy with guidance from the Sports Medicine Consultant and is now symptom free. She required no investigations and no further input from the sports medicine consultant or physiotherapist.
Feedback
“You gave me the opportunity to access specialists I just wouldn’t have known about otherwise and the specialist helped get my hip pain solved”.
Ryan
Hip
Labral Tear / Femoral Acetabular Impingement
Overview
He described an audible clunking, clicking sensation and pain in the hip which at times left him unable to weight bear. He had been investigated with an x-ray by his NHS Orthopaedic team which had showed moderate degenerative changes in both hips, and this was the diagnosis he was given to explain his symptoms.
Ryan was seeking a second opinion because he felt that his progress had plateaued and the clinicians who had seen him to date failed to consider the traumatic nature of his injury.
Clinical Reasoning
Signposting
Orthopaedics – Hip
Hip (Soft Tissue)
Hip (Femoral Acetabular Impingement)
Young Adult
If Ryan was struggling with a sub-acute on chronic injury to his labrum then a hip specialist dealing with both soft tissue problems around the hip and one who also deals with young adult issues was imperative for him to see. He was signposted to four local specialists dealing with femoral acetabular impingement (a group of conditions commonly affecting the rim of the hip joint) and young adult hip problems.
Outcome
Ryan was diagnosed with a labral tear and had surgery to repair the torn labrum.
Feedback
“Thank you for your very rapid response and considered opinion – this has been very helpful”.
Shirley
Ankle
Loose metalwork post fracture (around 10 years prior)
Overview
Clinical Reasoning
She had no other significant medical history (apart from a previous history of breast cancer) and had no red flags or any other worrying signs or symptoms picked up by the clinical forms’ algorithm.
Signposting
Orthopaedics – Foot and Ankle – Foot and Ankle (Trauma)
Sheila was advised on a number of local foot and ankle orthopaedic consultants who had experience dealing with traumatic cases and post traumatic issues. Here the Condition Specific Search function was helpful in narrowing down the search to the correct few specialists.
Outcome
It was deemed likely by the specialist who saw her that the metalwork was indeed the problem, and she was advised it may be best for it to be surgically removed.
Feedback
“Simple to use, the questions allow you to give a thorough explanation of your problem and you receive a prompt reply that clearly states how to take your case forward”.
Christine
Foot
Sesamoiditis
Overview
Clinical Reasoning
Signposting
Orthopaedics – Foot and Ankle – Foot and Ankle (Forefoot)
Considering conservative treatments had not helped then it was deemed appropriate for a referral to a foot and ankle specialist who specialised in treating forefoot disorders.
A simple interrogation of the database using the CRM allowed us to select the correct specialists who treat forefoot disorders by utilising the Condition Specific Search functionality.
Outcome
Referred for ultrasound guided investigation and possible injection which resolved the issue. Patient was also referred for one session of physiotherapy to check her biomechanics.
“Digital triage tools should help people to get to the right place at the right time and should not get in the way of that. Clinicians should be able to override the recommendations from these tools when they think it is in someone’s interest to do so”.
Why keep a clinician in the loop?
- Can be overly risk averse.
- Have an inferior diagnostic accuracy compared with experienced clinicians.
- Have limitations when dealing with incomplete or subjective questioning.
- Limited amount of testing had been performed using real world data
- Struggled to interpret concise information in both triage and diagnosis
Our technology is dependent upon being used by excellent clinicians. The technology, database and automation functionalities have been designed to ensure that clinician time (which is both expensive and valuable) is maximized and protected to ensure maximum efficiency gains for clinicians and their organisations while retaining the inherent advantage of human intelligence and clinical experience.
