The document discusses creating a digital patient ecosystem called Health Fabric. It describes how Health Fabric allows patients to access and update their medical information, integrate this data with various stakeholders, and create personalized health plans. It provides an overview of the patient journey and how Health Fabric supports integrated care. The document also outlines how Health Fabric can be used by healthcare providers to run health campaigns and remotely monitor patients. It presents a case study on how one GP practice in the UK used Health Fabric to help manage hypertension in patients.

1. Creating a Digital Patient
Eco System
Presented by Satnam Bains, CEO

2. Enabling Patients to
Self Manage their Health
and Wellness

3. Enable Health
Organisations to run
different health campaigns

4. Agenda
The Patient Journey
Integrated Care
Health Fabric overview
Case study around hypertension

5. Understanding
Patient / service user efficacy

6. The Patient Journey
Providing patient access to
their medical information is
not enough
A patient’s digital journey is
an ongoing process
A journey of self awareness
and learning
Enabled by health literacy
Enabled with the right
support

7. Enabling Integrated Care
Provide the information about the
patient to the patient
Allow the patient to update this
information based upon their
personalised needs and goals
Integrate this information into the
various stakeholders that need
this information
Build a cohesive process around
patient needs by understanding
their needs
Develop a preventative,
personalised plan for the patient
Facilitate collaboration around
the patient

8. Getting it right for patients
- service users
Interactive, Intelligent,
Cognitive,
Personalised,
Engaging, Social
Positive Support,
Tribal, Community
Based, Peer to
Peer Support,
Acknowledgement
Patient Information,
Lifestyle Information,
Sensor Information,
Contextual Information,
Location Information,
Correlation Mapping
Fun and Social
Data to
Information
Support and
Community
Marketing,
Product Development,
Understanding user
journeys

9. Healthcare Providers - Running
Different Health Campaigns
Create different plans with daily
or weekly tasks for customer
Embed video, websites and
other content in plans
Commercialise certain plans –
with real time monitoring of
tasks
Patients download
‘MyHealthFabric’ free from app
stores and access the plan
Some plans relate to wellness
Some plans relate to social
needs
Some plans includes clinically
verified plans

10. MyHealthFabric App for
service users
Free - Core application that can be downloaded for
free complemented by a library of care plans
The tasks can be for a variety of uses, and
monitored
Integrated into Withings Devices, Skype, and
Whats App
Can be integrated with clinical systems
Enables patient to create long-term goals,
behaviour change and self management.
Family, carers able to access patient information
and support patient through paid for Friends &
Family app
Drives efficiency, collaboration and facilitates better
care co-ordination at point of care resulting in
better outcomes and cost efficiencies

11. Remotely monitor
service users
Clinician Dashboards - Clinicians
provided with Dashboard (e.g. figure 1)
interface for their patients
Disease specific plans - free Library
of plans
Free Patient App - Patients start to self
manage with download of free
MyHealthFabric App
Skype virtual consultations - With
integrated Health Fabric functionality
Improve Engagement - Change the way
that you engage with patients so that not
all consultations have to be face to face
Patient insight - Get near real time
information about patient and activities
before you see the patient so you can
make an assessment quicker

12. Support behaviour change with
Friends and Family
Friends And Family App – Citizens invite
Friends and Family to download the friends and
family app
Pester Power- Friends and family review all
actions, Glucose readings, Weight Readings,
and communicate with user
Friends and Family Proactively support and
encourage user - Family members support
users to achieve their goals
Friends and Family set awards – Family
members agree awards and incentives based
upon milestones reached
The Friends and Family App

13. Hypertension Case Study – GP Practice
Tamworth
The next set of slides have been created by a set of
GP’s from a medical centre based in the west
midlands as part of their presentation of our pilot
together

14. The need:
There is increasing demand for management
of chronic diseases with less resources and
use of technology may be an option.
Experience so far:
Previous studies using sms for management of
hypertension have proven that technology can
help but with more common use of smart
phones more can be achieved
Apps?
Several apps available
Usually single trick pony
Not comprehensive to cover comorbidity
Many are unreliable
Can an app a day keep the doctor away?
Health Fabric :
Was listed in NHS choices
website,
Sponsor of innovation award 2014
Featured in BBC One
Previously NHS IGT approved
FREE for patient
Can be adapted for individual
needs
Availability of Store for “care
plans”
Integrated into wearables –
‘Withings’

15. Integration:
Has ability to integrate with GP Systems
Dashboard :
Dashboard functionality for doctors/Nurses to mange chronic disease via a central
dashboard
Useful for population monitoring
Customizable :
For other chronic diseases as well
Care plan to suit patient
Can push “care plans”
Can have incident plan for emergencies
Can have list of medications
Feedback available-Friends and family
Ability to invite family to monitor (paid for version)
Built in Skype and WhatsApp communication
Can an app a day keep the doctor away?

16. Experience :
We used Health Fabric app as part of our Tele health component of LES (Locally
Enhanced Scheme) from CCG
Patients with uncomplicated hypertension aged >40 but < 60 yrs were sent a sms
offering this scheme with details posted on our website offering them the options to
download the app to monitor BP (own monitor or loan from surgery) if needed.
Opportunistic advice regarding this app was also mentioned to patients (pre
selected).
Only readings taken in surgery were used for this study
28 of the eligible patients downloaded the app and linked with the surgery
A read code (9NdG) (consent to share information with specified 3rd party) was
added to their notes (July 2015)
Criteria:
Uncomplicated HT aged >40 <60 yrs
Have smart phone and willing to use app
Can an app a day keep the doctor away?

17. Initial Control: July 2015
28 patients signed up- July 2015
4 had BP well controlled at start in previous three readings
24 had a BP reading > 150 systolic or 90 diastolic
Outcome: Jan 2016
All 28 had BP reading of <=150/90 mmHg
24/28 had well controlled BP by May 2016
Limitations:
This is not an clinical trial
28 patients involved were selective list based on age, absence of comorbidity, had an
relatively modern android or iOS phone
Patients were also selected on motivation to use app and wish to improve readings
Difficult to say how many would have improved BP control anyway and whether
improvements can be sustained long term
Some also found it useful to lose weight
Can an app a day keep the doctor away?

18. Satnam Bains
bains@healthfabric.co.uk
www.healthfabric.co.uk