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Digital Health Heroes

You’ll remember in a previous blog that I highlighted the fact that clinicians were starting to show real leadership in digital health?  One of the leaders I mentioned at that time was Professor Shahid Ali, and this week I was fortunate to be able to visit his practice and see his work in action.  Consequently, this week’s blog will be a little longer than usual but I hope you will share my excitement at what I found. 

Background to the Phoenix Medical Practice

Professor Ali leads a busy general practice in Bradford, a northern city in England.  It’s a busy and diverse practice stretching across urban and rural areas.  Some eight or so years ago Professor Ali started to look at how the practice could be improved, in particular to improve the lives of patients who seemed to be very regular visitors to the practice.  At that time he felt the practice was pretty much in reactive mode – ‘revolving door syndrome’ as he termed it – whereby patients with multiple long-term conditions would visit for advice on one of their conditions one day, and be back the next day with something else.  He dug into the data and found that 60% of the practice workload was in serving this patient group, but without noticeable improvements in their health outcomes.  Working on an instinct that a more personalised, proactive and immediate care approach could work better, he reviewed the international literature and found good evidence that ‘care plans’ could be effective – although they hadn’t really been deployed in the UK at that time.  From that point he determined to transform the way long-term condition patients would be treated.  When he told his colleagues in the practice they were very sceptical, but nonetheless agreed to a limited trial of 19 patients. 

Getting started

Professor Ali started by conduction cross-stakeholder workshops involving clinicians, patients and local health authority staff.  These were free-form but the message from patients was clear – they wanted more control in their treatment and to feel less ‘medicalised’.  Following these workshops Professor Ali created care plan templates within the electronic health record which consolidated all of the patient history, and devised a system of blue and red clinics to take patients through the process.   Blue clinics were for patients with 1-2 long-term conditions and lasted 30 minutes, whereas red clinics were for patients with more than 2 conditions and lasted 45 minutes.  Goals within the care plan are expressed in the patients’ own terms – some examples Professor Ali gave me were ‘I want to be able to attend the flower show’ or ‘I want to be able to fit into my wetsuit again’.  The first trial (written up in the HSJ here) showed good results in terms of reductions of unplanned GP, out-patient and in-patient visits, which gave Professor Ali confidence to proceed with an ambitious development called Vitrucare™, which turned the paper care plan into a digital format.  Professor Ali even had to form his own software development business called Dynamic Health Systems to do this, as he struggled to find anything on the market that was optimised for general practitioners. 

This system presents an easy to use visual interface for patients to track their goals, create action plans to address, capture patient-reported measurements such as weight and blood pressure and communicate with their GP (currently via secure messaging but real-time video is being added too).  You can see Professor Ali using the system in a remote consultation with a patient below. 

digital health hero

Prof Ali in remote consultation

 All inputs from the patient are immediately visible to their supervising clinician, along with an overall health score.  Other highlights of the Vitrucare™ solution include:

  • Patients were heavily involved in the system design, which is reflected in the ease of use
  • The clinician can use it to provide an information prescription from NHS accredited content.
  • The system works to any internet-enabled device, phone, tablet, smartphone, TV. Interestingly, only 6% of patients lacked broadband internet access and they are now being addressed by these other modes.
  • The system is now integrated both ways with the electronic health record, making the interchange of data much more productive.  
  • Older patients responded well to the system, age was not a barrier to adoption.
  • An additional bonus was that patients on long holidays (such as during the winter months in Spain) could stay in touch remotely. 


As more patients have been added to the system, the benefits have remained consistently good, typically c.40% reduction in resource costs, in fact the more long-term conditions the patient suffered from the greater the benefit.  Currently there are 107 patients using the system, growing to 500 patients across 15 practices with many more interested.  In future Professor Ali would like the system to be available to any patient, to support disease prevention.   A local university will be writing an evaluation paper of the 500 patients experience but the unpublished data indicates valuable improvement in health indicators such as weight, blood pressure, HbA1C for patients who use the digital care planning system, over the paper version.  I fear I haven’t really done this leading implementation of digital health justice but I hope you get a flavour of how comprehensive this approach is. 

So there you have it, my first nomination of a Digital Health Hero.  Who would you nominate?  Please comment below or contact me.


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