Visionable Improves NHS Stroke Care by Reducing Door-to-Needle Time Using Telemedicine on AWS

The East of England Stroke Telemedicine Partnership, part of the UK National Health Service England (NHSE), built an application to deliver remote, expert stroke care. It was struggling to meet national target times for delivering stroke care, which is time-critical and vital to saving lives, and preventing disabilities caused by strokes. Working with AWS Partner Visionable, it built a secure, video-conferencing application to assess, treat, and support patients remotely. Visionable’s solution was migrated to Amazon Web Services (AWS). Built on Amazon EC2 and Amazon S3, the service has helped the Stroke Telemedicine Partnership reduce door-to-needle time, the time between hospital arrival and treatment.

The East of England Stroke Telemedicine Partnership, part of the UK National Health Service England (NHSE), provides remote diagnosis and treatment for stroke patients using telecommunications technology. A lack of stroke consultants across England and Wales had resulted in less than 1–2 percent of stroke patients receiving thrombolysis—a clot-busting drug for treating the most common type of stroke. The Stroke Telemedicine Partnership wanted to combine resources across hospitals to increase the number of patients receiving thrombolysis to 10 percent.

Successful stroke care is time-critical and precious time was wasted transporting patients between hospitals to access the specialist who could provide them with thrombolysis treatment. Additionally, when thrombolysis treatment is given, patients need specialist observation.

The Stroke Telemedicine Partnership team decided to build a virtual service to increase the number of patients receiving timely care and chose AWS Partner Visionable to help design and develop it. Visionable and the Stroke Telemedicine Partnership were partners from day one after the partnership supported Visionable in its early days by investing in IT hardware and software licenses.

Visionable began designing the virtual service application around the critical functions that the Stroke Telemedicine Partnership needed. The solution was a video platform built specifically for healthcare that later evolved into a full collaboration solution. Working with the Stroke Telemedicine Partnership, Visionable looked at how to improve the interaction between clinicians and patients to build the requirements for the application. The application’s critical functions included dialing in the remote stroke consultant using video for a virtual triage and accessing key patient information from the local stroke teams and anything else needed to help determine care. The solution had to be both scalable and reliable to deliver performance. In addition, it needed to be highly secure to safeguard sensitive patient data.

Built on AWS, the Visionable Collaborator application combines near-real-time communications such as video, messaging, and audio with the Stroke Telemedicine Partnership’s healthcare devices and the relevant clinical information from the local stroke teams to safely treat the patients. The implementation was rolled out in stages to enable Visionable and the local clinical stroke teams to identify and solve issues as they emerged. One challenge was to overcome potential security concerns from NHS IT teams related to new software installation. It was important to identify an IT lead at each hospital so that the team could work with them, and the Information Governance team, to ensure they understood the software and the firewall requirements.

When a new hospital seeks to join the telemedicine service, its IT team often doesn’t understand the purpose of the Visionable application—that it’s a software download onto a PC. This can happen only after the hospital’s Information and Clinical Governance teams are fully briefed and the nature of the application is understood. Visionable designed the service so that hospital IT teams can quickly implement the application onto existing hardware. “Once the IT teams are brought in, they’re happy and surprised at the simplicity of the product,” says Lynda Sibson, telemedicine manager at the Stroke Telemedicine Partnership.

Another challenge was the changing working practices made possible by the remote tool. “First we make the application easy to use to change hearts and minds, then we change habits,” says Miguel Lopes, chief product officer at Visionable.

To make the application user friendly, Visionable focused on the user interface (UI) and user experience (UX) with clinicians and other key users to fine-tune the system. It is important that care providers don’t need to go through multiple screens and interactions to access a patient’s high-resolution images. This in turn helps support easier near-real-time collaboration between care providers. “Our goal is to make healthcare collaboration easier, especially for those hesitant about telemedicine,” says Lopes.

The result for Stroke Telemedicine Partnership care providers is a user interface that lets stroke consultants review radiology images and information quickly and provide a clinical impression to inform the treatment plan. This has enabled stroke care specialists to assess patients more quickly—within the crucial life-saving timeframe. The Stroke Telemedicine Partnership estimates that the service has measurably reduced door-to-needle time. That’s the time from the moment a patient arrives in the emergency ward to the moment that medicine is delivered. From 2019 to 2022, the interquartile range for arrival times—the difference between the 25th and the 75th percentiles—dropped from 38 minutes to 33 minutes.

The Stroke Telemedicine Partnership team also needed to educate and reassure the IT teams that Visionable was not able to access patient data. The application does not store patient data, but it does store user credentials and session details such as duration, dates, and IP addresses. The system must comply with the Digital Technology Assessment Criteria (DTAC)—a set of standards that all new NHS technologies need to meet. It must also meet other local IT policies—such as data storage limits and password and access policies—and be compliant with the EU General Data Protection Regulation (GDPR).

Amazon Simple Storage Service (Amazon S3) plays a major role in achieving this compliance. Amazon S3 gives the Stroke Telemedicine Partnership secure storage that can be detached from the platform—this addresses use cases where the data at rest must reside in the country. In addition, AWS is a trusted cloud provider for the NHS, which was a factor when choosing where to build the solution. “Being on the AWS secure cloud means that the NHS IT teams trust us to provide a secure and reliable service,” says Alan Lowe, chief executive officer (CEO) at Visionable.

To deliver the service, Visionable uses Amazon Route 53, a reliable and cost-effective way to route end users to internet applications. Route 53 enables the application to customize the path for users to manage how they access the platform, ensuring there is no cross-pollination of data and greatly reducing potential security or privacy issues. It also helps set a high-availability option to ensure uptime. The service uses Amazon Elastic Compute Cloud (Amazon EC2), which offers secure and resizable compute capacity for virtually any workload. Amazon EC2 delivers the scalability the Stroke Telemedicine Partnership needs by giving it the flexibility to spin up a new healthcare provider, such as an NHS facility or trust, and enables it to quickly scale or reduce its compute requirements based on workloads.

After the success of the initial project, the Stroke Telemedicine Partnership team worked with a local ambulance service on a feasibility study to explore the role of telemedicine in the pre-hospital management of stroke mimic patients—less serious conditions that have some of the symptoms of a stroke. An estimated 40–50 percent of cases are suspected stroke mimics.

Paramedics were provided with mobile phones and tablets hosting the Visionable software to provide rapid access to stroke consultants to assess suspected stroke mimic patients in a pre-hospital setting. The aim was to avoid unnecessary Emergency Department admissions, as most stroke mimic patients can be safely managed in an outpatient setting or in a doctor’s surgery. The outcome of the feasibility study was positive from a patient and paramedic perspective, with many unnecessary ambulance trips avoided. In addition, the team is trialing the technology with the Welsh Ambulance Service for stroke care.

Demand for telemedicine is growing as the NHS looks for ways to manage staff shortages and improve access to equitable, high-quality patient care. Using AWS, the Stroke Telemedicine Partnership achieves both. “The security and cloud of AWS and Visionable streamlines implementation and keeps everything running smoothly, while delivering time-critical and life-saving stroke care,” says Sibson. “We achieved this by knowing we’ve got a true partnership with them and with our stroke clinical teams—and they continue to work with us as we expand.”