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THE DIGITAL TRANSFORMATION OF CARE
We will develop and evaluate technologies to ensure health systems globally get the most value from digital innovation. This will encompass new models of care, including more patient-centered and distributed care pathways harnessing mobile health, wearables, remote approaches to consultation, monitoring and consultation, diagnostics and stratified treatments, all of which shifts more power to health consumers.
The MS & HERG Group:
- conduct research on how the digital age is changing health care. They examine how and why people use digital technologies in relation to their health, and how health and care services can harness digital tools to deliver benefits. They also aim to understand why digital tools are sometimes not used, as well as the unintended consequences of their use can be. Recent projects include evaluations of digital triage services and of a national patient portal; studying the regulation and implementation of apps and wearable digital devices; and examining the use and unintended effects of consumer-facing technology, such as AI diagnostic tools. They use a range of social science approaches in this work, with an emphasis on qualitative methods.
- As well as leading the MSc in Applied Digital Health, they host a number of doctoral projects on digital health topics.
- Examples of recent evaluations of two major NHS digital initiatives:
- The wider group has major and sustained impact through hosting the Health Experience Insights website which curates narrative experiences of health and illness collected by researchers in the group and used by the public and by educators.
- Recent publications:
The Nuffield Department of Primary Care Health Science’s Cancer Theme:
- Nuffield Department of Primary Care Health Science’s Cancer Theme co-hosts the NIHR Policy Research Unit (PRU) in Cancer Awareness, Screening and Early Diagnosis. The PRU will utilise national digital datasets including UK Clinical Practice Research Datalink (CPRD), National Cancer Registration and Analysis Service (NCRAS), Hospital Episode Statistics (HES) database, the Office of National Statistics (ONS) and ORCHID to accomplish their aims. Aims include assisting health care professionals in assessing cancer risk and monitoring persistent symptoms, evaluating the accuracy of new screening and diagnostic methods and reducing health inequality.
- The Health Records Data subtheme makes extensive use of national digital databases to conduct their research. BLOTTED is using population-level primary care data to describe patterns in blood testing and identify any trends in blood tests for cancer overall and by cancer site. MAINROUTE uses contemporary data to track changes in presenting patterns, clinical activity and outcomes related to common diseases, including cancer, in the community prior to, during and after lockdown for COVID-19. CANBACK is investigating the risk of cancer diagnosis when clinical features are associated with a new episode of back pain using multiple national digital databases.
- The Clinical Studies subtheme also uses national digital databases and we are specifically interested in the use of digital resources to facilitate remote follow up to reduce burden on both participants and recruiting sites. SYMPLIFY compared cancer outcome data with data collected through national cancer registries to guide the use of remote follow up data in future studies.
- The most impactful studies include:
- Casnet2 in which we evaluated the use of new digital technology. This study evaluated an electronic safety-netting toolkit that provides primary care staff with a way to record safety-netting advice and actions when they think cancer could be causing the patient’s symptoms, and to set reminders to ensure that the patient is followed-up.
- The Suspected CANcer (SCAN) pathway prospective cohort research database collects detailed clinical information from primary and secondary care electronic health record to highly phenotype the patients referred to inform NHS service improvement and research using the SCAN biobank.
- Recent publications:
The IRIHS research group:
- conducts interdisciplinary research on the socio-technical aspects of digital technologies – that is, the human, organisational and societal influences on whether and how technologies are taken up and used, and what happens as a result. Socio-technical studies draw on many disciplines including sociology, anthropology, organisational studies, science and technology studies (STS) and computer supported cooperative work (CSCW). The group includes clinicians, sociologists, psychologists, anthropologists and computer scientists and has an active and diverse group of DPhil students and postdocs.
- Recent and current studies:
- DECIDE (Digitally Enabled Care in Diverse Environments), a rapid evaluation programme of remote monitoring technologies in health and social care
- Remote by Default 2 – the new normal?, an ethnographic study of the wide variety of ways in which UK general practices have introduced, sustained, adapted and withdrawn remote and digital services since 2021
- ModCons (Mode of Consultation):aims to study in which patients are offered which kind of consultation in general practice (telephone, video, e-consultation) and why
- TOGETHER2, a mixed-method study of group consultations (both video and hybrid), a new service model in which there is much policy interest
- SCiP (Supporting Consultations in Remote Physiotherapy), a detailed examination of the talk and body language of patients and practitioners engaged in remote physiotherapy sessions
- IRIHS runs an MSc and DPhil programme in Translational Health Sciences. Modules from the MSc, including Technological Innovation and Digital Health, are available to study as freestanding short courses.
- Recent publications include:
- Rybczynska‐Bunt S, Byng R, Spitters S, et al. The reflexive imperative in the digital age. Sociology of Health and Illness 2024;1:20.
- Greenhalgh T, Payne R, Hemmings N, et al. Training needs for staff providing remote services in general practice: a mixed-methods study. Brit J Gen Pract 2024; 74(738): e17-e26.
- Dakin F, Hemmings N, Kalin A, Greenhalgh T et al. Technostress, techno-suffering, and relational strain: multi-method qualitative study of how remote and digital work affects staff in UK general practice. Brit J Gen Pract 2024, in press.
- Payne R, Dakin F, MacIver E et al. How has quality changed in UK general practice since 2021? A multi-site longitudinal study. Br J Gen Pract 2024, in press (should be out next week).
- The combined RBD2 and ModCons studies will make an excellent impact case study – detailed ethnographic study of how general practice is adapting to the digital world. Major impacts:
- Work already cited in major policy documents on patient safety
- The group's training competencies are influencing national training standards and approaches
- Various organisational development and staff wellbeing initiatives drawing on our work on techno-stress
- Linked with NHS England Primary Care Digital Transformation Team
The Medical Statistics Team:
- focuses on generating the best evidence for diagnosis, prognosis, and monitoring. As part of this, it has developed specific expertise in epidemiology using electronic health records, mainly from primary care in the UK. The group has a strong presence in the NDPCHS NIHR Infrastructure Programmes (ARC and HRC) where it co-leads and leads in Themes 5 and 6 (Digital Health and Methods) for the ARC and leads in Theme 6 (Methods) of the HRC. Besides these, the group leads on separate large trials and other programmes of work delivered through and generating digital solutions.
- Key areas the group supports:
- Direct support to the NIHR Office for Clinical Research Infrastructure (NOCRI) - Theme lead for Methods in the NIHR Oxford HealthTech Research Centre. Methods Lead since 2014, in partnerships with commercial and medical technology developers (e.g. Roche and Abbott Diagnostics) to “speed the development, evaluation, and deployment of diagnostic tests that support health professionals to make better decisions”. Diagnostic evaluation and creation of new methods to improve the use of indirect evidence for evaluating tests. Statistical Lead for the COVID-19 National Diagnostic Research and Evaluation Platform (CONDOR), a national platform created to accelerate the creation and use of COVID-19 Diagnostics (2020-2021).
- Pro-active use of EHRs: Early adopter of using electronic health records for epidemiological research (first paper published in 2010; Khan et al, BMC Family Practice). Delivered research and developed capacity to optimise the use of primary care databases (delivering ten Clinical Practice Dataline (CPRD) studies since 2010), being Chair of QResearch Scientific Committee (2020-2022) and the PrimDISC Committee (2022–2023) and Co-applicant in the creation of OpenSAFELY (2020), thus ensuring faster access to information on risk factors, reducing research expenditure and directly supporting the NHS deliver better care on Multiple Long-Term Conditions (e.g. Chronic Kidney Disease) and infectious diseases (e.g. COVID-19).
- Developing novel methods: Lead of NIHR OxTV ARC Novel Methods to Aid and Evaluate Implementation Theme. Delivering the Oxford City Council evaluation of family safeguarding in Oxfordshire as an example of ‘real world evaluation’. Integrating work with Health Innovation Oxford & Thames Valley to evaluate Stroke Virtual Clinics (2022-2024), ensuring value for money (examining the value of the clinics while minimising research costs).
- Examples of the group’s recent and current awards:
- NIHR, CoMPuTE: Complex Multimorbidity Phenotypes, Trends, and Endpoints. Perera R, Banerjee A, Alvarez Nishio A, Bankhead C, Bennett D, Bhui K, Clegg A, Heneghan C, Pope C, Relton S, Sheehan M, Sheppard J, Steinsaltz D, Taylor P, Tsiachristas A, Zhu T. £2,611,897, Start 01/06/2023, End: 31/05/2028.
- NIHR Applied Research Collaboration. FRD Hobbs, S Ward, S Jebb, R McManus, C Creswell, R Fitzpatrick, J Powell, S Lamb, C Jenkinson, G Fletcher, R Perera (Theme 6 lead). £9,000,000 Start: 01/10/19, End: 30/09/24.
- GRAIL & NHSE Evaluating a Multi-Cancer Early Detection (MCED) Test in symptomatic NHS patients (SYMPLIFY). Project. Middleton & Nicholson & (Co-PI), Pearson, Youdell, Maughan, Hobbs, Butler, Perera (Oxford) £2,513,246, Start: 01/06/2021, End: 31/12/2023.
- The Oxford Martin Programme on the Future of cooling: Cooling down to heat up. R Khosla, M McCulloch, R Perera, C Hepburn, C McElroy, M Allen, C Heaviside, T Hale. £993,440.08 Start: 01/10/19, End: 30/09/22.
- MRC, Open Covid Research PlatformV2. Goldacre B, Curtis H, Walker A, Perera R, Bankhead C. £1,306,409 Start: 29/05/2020, End: 31/12/2021
- Recent publications include:
- Perera R, Stevens R, Aronson JK, Banerjee A, Evans J, Feakins BG, Fleming S, Glasziou P, Heneghan C, Hobbs FDR, Jones L, Kurtinecz M, Lasserson DS, Locock L, McLellan J, Mihaylova B, O’Callaghan CA, Oke JL, Pidduck N, Plüddemann A, Roberts N, Schlackow I, Shine B, Simons CL, Taylor CJ, Taylor KS, Verbakel JY, Bankhead C. Long-term monitoring in primary care for chronic kidney disease and chronic heart failure: a multi-method research programme. Southampton (UK): NIHR Journals Library; 2021 Aug. PMID: 34469090
- Deeks J, Ashby D, Takwoingi Y, Perera R, Evans S, Bird S, Royal Statistical Society Diagnostics Tests Working Group Report, RSS. 2021.
- Perera R, McFadden E, McLellan J, Lung T, Clarke P, Pérez T, Fanshawe T, Dalton A, Farmer A, Glasziou P, Takahashi O, Stevens J, Irwig L, Hirst J, Stevens S, Leslie A, Ohde S, Deshpande G, Urayama K, Shine B, Stevens R. Optimal strategies for monitoring lipid levels in patients at risk or with cardiovascular disease: a systematic review with statistical and cost-effectiveness modelling. Health Technol Assess. 2015 Dec;19(100):1- 401, vii-viii. doi: 10.3310/hta191000.
- Williamson EJ, Walker AJ, Bhaskaran K, Bacon S, Bates C, Morton CE, Curtis HJ, Mehrkar A, Evans D, Inglesby P, Cockburn J, McDonald HI, MacKenna B, Tomlinson L, Douglas IJ, Rentsch CT, Mathur R, Wong AYS, Grieve R, Harrison D, Forbes H, Schultze A, Croker R, Parry J, Hester F, Harper S, Perera R, Evans SJW, Smeeth L, Goldacre B. OpenSAFELY: Factors associated with COVID-19 deaths in 17 million patients. Nature. 2020 Jul 8.
- Hobbs FD, Bankhead C, Mukhtar T, Stevens S, Perera-Salazar R, Holt T, Salisbury C; National Institute for Health Research School for Primary Care Research.. Clinical workload in UK primary care: a retrospective analysis of 100 million consultations in England, 2007-14. Lancet. 2016 Jun 4;387(10035):2323-30.
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INNOVATIVE METHODS IN DIGITAL HEALTH
We will not only lead the world in understanding how to digitally transform health care, and how to derive new knowledge from health datasets, but we will also pioneer new methodological approaches in this field. Our current work includes an innovative agile clinical trials platform built on routine electronic health records. This can radically improve current approaches to randomised trials and the evaluation of interventions, as well as long-term observational studies, at low cost, facilitating faster answers to deliver more rapid benefits to patients.
Our work evaluating digital interventions considers new ways of assessing their usefulness, including the key issues of digital inclusion, and the green impact of digital approaches.
The Oxford Primary Care Trials Unit (PC-CTU):
- has a portfolio of 10 trials on investigation of digital interventions primarily in mental health research, of which five completed and five are currently active. Type of interventions include mobile apps, AI algorithm, devices, online intervention, or automated virtual reality. Level of support varies from design, delivery, to analysis and dissemination. In addition, CTU has also been using digital innovation and healthcare data to conduct two large decentralised platform design clinical trials from recruitment to data capture.
- Some of our most impactful studies include:
- The OASIS trial evaluated whether digital CBT, Sleepio, for insomnia reduced insomnia and reduced paranoia and hallucinations, compared with a usual practice control group. Results of the trial has also contributed to the recommendation by NICE.
- The gameChange trial evaluated a virtual reality (VR) based psychological therapy for people with severe mental health difficulties. Results of the trial has shown a significant reductions in the agoraphobic avoidance of everyday situations and distress. The intervention has been recommended in a NICE Early Value Assessment for use in the NHS for patients diagnosed with psychosis who have severe agoraphobic avoidance.
- Both PRINCIPLE and PANORAMIC trials are two trials conducted during the pandemic that provides rapid initiation of multiple trials evaluating repurposed treatment and antivirals in the community, respectively. Specially, PRINCIPLE trial has provided evidence that the two antibiotics, Azithromycin and Doxycycline, should not be recommended as treatments for COVID-19 infection.
- The CTU was recently awarded the Prix Galien Best Public Sector Innovation Award 2024 for the PRINICPLE and PANORAMIC trials.
- Recent publications:
- Molnupiravir plus usual care versus usual care alone as early treatment for adults with COVID-19 at increased risk of adverse outcomes (PANORAMIC): an open-label, platform-adaptive randomised controlled trial. Lancet. 2022
- PRINCIPLE Trial Collaborative Group. Doxycycline for community treatment of suspected COVID-19 in people at high risk of adverse outcomes in the UK (PRINCIPLE): a randomised, controlled, open-label, adaptive platform trial. Lancet Respir Med. 2021
- Azithromycin for community treatment of suspected COVID-19 in people at increased risk of an adverse clinical course in the UK (PRINCIPLE): a randomised, controlled, open-label, adaptive platform trial. Lancet. 2021
- Automated virtual reality therapy to treat agoraphobic avoidance and distress in patients with psychosis (gameChange): a multicentre, parallel-group, single-blind, randomised, controlled trial in England with mediation and moderation analyses. Lancet Psychiatry. 2022
- The effects of improving sleep on mental health (OASIS): a randomised controlled trial with mediation analysis. Lancet Psychiatry. 2017
ORCHID
- The ORCHID research environment is hosted by the Nuffield Department of Primary Care Health Sciences . ORCHID incorporates the Research Surveillance Centre which has been the primary source for disease surveillance in England for over 60 years.
- Nearly 2000 GP practices and around 19 million patients in England and Wales contribute pseudonymised data for national research and surveillance purposes.
- ORCHID holds data from multiple UK clinical systems (e.g., EMIS and TPP) and which can link primary care data with other health data.
- ORCHID has the potential, with appropriate approvals, for linkage with pseudonymised secondary care e.g. HES, mortality and Cancer Registry data.
- ORCHID consists of three research platforms:
- ORCHID Surveillance enables continuous monitoring of infections and diseases in the community . It is the main source of information for UK Health Security Agency (UKHSA) and helps with prediction and management of flu outbreaks and pandemics.
- ORCHID Epidemiology: a double pseudonymised, research database to facilitate well-designed epidemiological research, with a focus on primary care. ORCHID-E may be used to develop feasibility and sample size calculations for the development and design of trials and other interventional studies.
- ORCHID Trials & Prospective is a future development that will to support our researchers in designing their trials and other interventional studies. As the database is nationally representative, our researchers are able to determine appropriate participant populations by checking feasibility of recruitment, sample size calculations taking into account the inclusion and exclusion criteria. This platform will allow for targeted recruitment of study participants and support long-term follow-up studies in a more efficient, less burdensome and more cost effective way that traditional methods allow.
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