A recent HTN Now webinar focused on the potential for technology to help support chronic wound care, focusing on a case study of the Isla digital pathway platform at Birmingham Community Healthcare exploring the utilisation of technology to help detect pressure ulcers in darker skin tones.
We were joined by Kumbi Kariwo, equality and inclusion project lead at Birmingham Community Healthcare NHS Foundation Trust, and Pete Hansell, CEO and co-founder of Isla Health.
With the annual cost of wound care estimated at £5.3 billion in the UK, representing the third highest expense for the NHS after cancer and diabetes, our panel discussed how innovative technology is being used in this space; how it is improving early detection and treatment; and how that translates into improved patient outcomes and increased efficiency.
Using Isla’s digital pathway platform to support care continuity in wound care
Kumbi shared how in 2021 she was appointed as the first chief of nursing fellow in the organisation and briefed to examine inequalities. Her team looked at organisational data as well as what was happening further afield, and in so doing discovered a call to action for research into pressure ulcers in darker skin tones.
For Birmingham’s population, pressure ulcers posed an area of practice that the team needed to focus on. They began to explore how they could reduce the numbers and in particular, looked at patients with darker skin tones to see if there was anything that could be done to reduce the number of pressure ulcers occurring in that patient cohort. They also identified specific issues such as continuity with different colleagues visiting on different days and describing wounds differently, prompting a conversation around what could be utilised to ensure consistency of care.
“Although we had an EPR it wasn’t being used in a way that was conducive to articulating the state of a patient’s pressure ulcer,” Kumbi explained, “so we looked at what was on the market that would allow us to use imagery for a visual record, and that’s when Isla came into play.”
A key benefit of using Isla’s digital pathway platform, Kumbi continued, is that “it allows us to take a visual record, providing a chronology of visual images that people from the same team can look at. We can also use that record to ask questions of specialists. So it helps us identify other groups of clinicians we could work with collaboratively.”
As well as helping the team to better articulate what they were seeing when visiting patients, Kumbi noted that the platform supported the organisation to work in different, smarter ways, such as providing other services where patients weren’t able to leave their homes.
Acknowledging that the process has been a “learning journey”, Kumbi added that the technology has helped overcome the language barrier that exists for some patients in the Birmingham area. “We have 80 commonly-spoken languages, and it was important that that was also built into what we were looking for,” she reflected. “It’s not just a case of addressing one area – tackling pressure wounds for darker skin tones, in this case. A good digital solution, as it unfolds, can look at addressing a number of different challenges.”
Isla’s aims
Pete said that solving this type of challenge was one of the major motivators for Isla’s development, alongside his own experience of growing up with a father with MS, who had “an awful lot of intervention and support from the health service”.
He elaborated: “That gave me a huge amount of appreciation for how valuable the NHS is for families in need of support. It also gave me a sense of how overlapping and convoluted patient pathways can be, and how confusing that can be to somebody who is a recipient of care. So that’s where my interest began.”
The focus for Isla has always been on helping the health system design and implement sophisticated digital pathways as a means of providing more efficient and effective care for a larger number of people. “We like to think we’ve already built the most complete digital pathway platform for the NHS, which means we can support a wide range of clinical specialties because the platform is specialty-agnostic and also agnostic of the points in the pathway where it can be implemented. It can be put in right from referral to post-discharge and to support self-care.”
Wound care is “a huge burden for the NHS”, Pete continued, “and our solution is used now by community trusts and community nurses up and down the country to help offer enhanced visibility of skin health and progression of a variety of conditions whilst patients are at home”.
The approach itself is “quite simple”, he went on, “and starts with the belief that clinicians and clinical teams need to have very good visibility of their patient caseloads; that’s particularly true for wound care because as soon as we begin to see skin breakdown we need to be able to see that and pass that on to the relevant teams.”
In this regard, Pete said, the Isla platform was built to have the flexibility to be used by patients, family members, and clinical teams, offering in-depth insight into the progression of the patient’s condition by supporting a range of different file types including images, PROMs, video, and sound recordings.
“That helps start to solve that problem of a lack of continuity which might occur when you have bank and agency staff coming into community teams without much context, helping enable them to make accurate clinical decisions much more quickly.”
Ensuring inclusivity in chronic wound care
When it comes to ensuring inclusivity in chronic wound care, Kumbi highlighted the importance of having people with lived experience at the table. “When I started this journey I looked at the imagery that we had in our organisation. There were descriptors such as redness, which I knew wouldn’t be applicable to my own skin. That led me to ask how I would know what I’m looking for if I don’t have the imagery for darker skin tones.”
Having that imagery in place is also important when it comes to empowering patients to have autonomy over their own care. “How can I confidently and competently talk them through their care journey, if the imagery isn’t there to show them what their wound journey looks like?”
This realisation led Birmingham Community Healthcare to take a look at things like assessment forms and risk assessments, which “weren’t reflective of our community”. It also became apparent that the organisation “didn’t have consent to share the images that we currently had,” Kumbi continued, “so we started to go to our underserved communities to start to get that consent to share those, for patients and for learning purposes. I think when you are able to visually see what you need to do, it makes that learning journey a lot easier and also safer.”
One of the main outcomes of this work was that it helped the organisation identify that people with darker skin tone are actually at a higher risk. “We put together a paper in 2023 using our data, which showed that people with white or lighter skin tones were more likely to be identified early, whereas in people with darker skin tones it was when the wound was open,” Kumbi shared.
Understanding that changes were not always visible when looking at darker skin tones started to inform how they needed to change practice. There have also been important changes to improve care quality and safety; now, if you present at Birmingham Community Healthcare and you have a darker skin tone you are considered high risk on the trust’s risk assessments. This means that there are additional questions that patients are asked to ensure that clinicians capture information at the first assessment and consider earlier steps to be more preventative.
Using tech to support practice in assessing darker skin tones
The use of tech has helped support practice in a number of ways, according to Kumbi, such as helping care teams visualise wound progression. “In Isla you can have a view of a line of images, so you can start to look at changes; and for those with darker skin tones, you can also have visibility of an assessment questionnaire alongside that.”
Kumbi also identified the potential for this to be further extended with the use of machine learning in the future. “We could start to utilise imagery to detect changes – sometimes there might be changes that can’t be seen by the human eye, but could AI detect those? I also understand that AI is only as good as you build it, so if you build it with bias, it’s going to produce bias; I think we need to be careful with that.”
From her experience, Kumbi highlighted that as a nation there is a tendency to focus on ethnicity data; but using Kumbi herself and one of her cousins as an example, both would be classed as Black African but have different skin tones, with Kumbi’s cousin more prone to redness and blanching. “If you were to assess us both as African you’ve already brought a bias in there. If you look at skin tone you hopefully can get a more accurate diagnosis. Having that imagery there has helped us highlight biases we hadn’t previously identified.”
Whilst “jumping to technology as the solution” is tempting, Pete added, “in practice the most impactful thing we’ve seen is Birmingham as a trust being able to build up a comprehensive image set of wounds across a wide range of skin tones. Because of the consenting model that Kumbi described earlier, there’s now a library where different wounds or locations on the body are tagged and searchable.”
Having that image library in place will help with clinician education, Pete said, “and having that structured dataset in place means there’s a big opportunity to go forward from here to explore computer vision applications and how we might be able to automate part of that assessment. But actually, a large part of the value is already delivered today just by having access to that data.”
Pete also highlighted integration, confirming that it has “always been at the forefront of the way Isla built its digital pathway platform. We’ve built native bidirectional interfaces with both EMIS and SystmOne, and that gives us quite a strong capability to be able to share information back into the EPR records as needed.”
Being cloud native makes the sharing of information easier, Pete added, whilst having a strong user access control model allows patient records to be shared with clinical teams, even from a different trust. The platform also supports information from assessments and questionnaires being put back into EPR systems, which “helps break down this significant problem we have in the NHS whereby information lives in siloes, and it’s difficult to manipulate and bring those datasets together”.
Overcoming challenges around adoption
On some of the challenges that might arise around the adoption of technologies in the management of chronic wound care, Kumbi shared that often clinicians are left out of the discussion tables where a lot of tech is built. “We are the testers, but we’re not the builders – and when it comes to testing, I think we frustrate the builders by telling them everything that it should be doing.”
Unless clinicians and “people who understand the pain points” are included in the building process, she continued, “I don’t think it will ever quite work in the way it was intended”. This is why when starting work with Isla, the trust ensured that there was a list of requirements in place.
“I know it can be expensive to come up with a roadmap, but I think it’s working collaboratively with the people that are ultimately going to be using the product,” Kumbi said. “It has to be very user-friendly, and one of the challenges that we face is that to redesign something that’s already designed takes money and takes time, which makes it more important to start by getting it right at the drawing table.”
It is also important to understand the communities we’re working with, Kumbi went on, “and I know we can’t always build something that works for all, but we need to ensure minimum impact when something is being deployed. If we look back at COVID, all of a sudden we were sending all letters digitally, and overnight people that didn’t have a smartphone or data were excluded from accessing services.”
Getting that coproduction in place and building systems which speak to the patient journey, as well as “having the patient at the heart of things when we are implementing”, is integral to ensuring equality and overcoming challenges with access, Kumbi emphasised.
The Isla technology in place at Birmingham Community Healthcare has helped support patient engagement and communication, Kumbi noted. She cited the example of a patient sending an image through which seemed to show an infection, leading the team to contact the GP; the GP assessed the imagery and within hours antibiotics were sent to the pharmacy of the patient’s choice.
This could have a meaningful impact on reducing A&E admissions, Kumbi considered. “During an ambulance callout, having that information accessible might influence whether that patient needs to be conveyed or not. It’s situations like that where you can see the wider influence, when you are able to make something work for the patient and using technology to reduce pressures on the system.”
Pete agreed with this assessment. “There isn’t going to be sufficient funding to keep delivering care to meet the growing demand in the way we currently do it; we need a different model for healthcare delivery which has to be dramatically more efficient, and technology is at the heart of that for me.”
At Isla, he continued, “we are trying to support that by helping the system move to a model where we’re collecting information continuously and asynchronously from the community, patients, care homes, and flowing that into the system in a structured way. We need to get that to the care team in a way that is useful for them, and then use technology to start to draw out some patterns and insights from that.”
We’d like to thank Kumbi and Pete for taking the time to share their insights with us on this topic.
