Nellie® is an automated SMS-based persona for promoting patient self-care. It is the most researched and effective of its kind in the world.
The underpinning methodology and technology is Simple Telehealth, which was invented in 2008 in the UK. Known there as Florence (or Flo), it is adopted widely across the UK’s National Health Service. Florence has improved the lives of tens of thousands of patients with a range of conditions including asthma, diabetes, COPD, and heart conditions. The outcomes achieved so far are getting unprecedented recognition by key public health and research organisations in the UK. Simple Telehealth is also used by the USA's Veterans' Affairs Department.
The system is clinician led. Using existing or newly-developed shared action plans, doctors and nurses work together on the priorities in their clinics. The action plans shape the development of the technical protocols that manage the sending and receiving of messages. The messages are warm and friendly, enhancing connection with patients and changing outcomes.
In 2016, SEMPHN partnered with the Simple Telehealth organisation to develop an upgraded version of the technology. Nellie is being implemented across South Eastern Melbourne.
The Simple Telehealth website has an extensive library of academic articles and case studies proving the effectiveness of the system. The Health Foundation has a short guide on how to implement support for self-management and why it improves outcomes.
This short video created by the Health Foundation tells the stories of three people who have used Flo:
Case studies from Melbourne
|Case 1: Ruling out hypertension
|Mrs JW is a 50 year-old woman with anxiety, occasional mild depression, domestic stress, and chronic pain resulting from a workplace injury. Blood pressure readings taken at consultation over past few years were erratic and elevated (up to 190 systolic and 110 diastolic). Last one (sitting) was 184/105, pulse 78. Three weeks before intervention patient was due to travel to South East Asia. Stress was high due to worry about blood pressure. Over 2 weeks, Nellie asked for BP readings. At end of period patient again saw GP, who was able to reassure her she did not have hypertension. The experience was stress free for the patient and the GP was not involved during the two weeks. It was easy for them both to see the collected results and Nellie automatically calculated the average.
|Case 2: Medication reminder
|Ms DM is a 64 year-old woman with a history of acquired brain injury (ABI) following 4 x CVAs in 2014. She also has Type 2 Diabetes, Hypertension and Depression. Her ABI affects her short-term memory. She was a new patient to the general practice nurse-led clinic and presented with uncontrolled BP ranging from 150/90 -168/98 and an HbA1c of 8.6%. Nellie was introduced at her care planning session and Ms DM was happy to take up the opportunity for an automated medication reminder from Nellie at 8am every morning to remind her to take her morning medication. She was on this program for several weeks and had only missed her anti-hypertensive medications on two occasions. As a result, her BP had reduced to 130/85, and her fasting BGLs were also beginning to reduce, although she reported that she occasionally forgot to take her evening dose of insulin.
|Case 3: Walking
|Mr CI is a 69 year-old man with a history of CVA 18 months ago. He recovered well, attended a rehab program but had found it difficult to maintain his motivation to keep active. His weight had crept up, as had his blood pressure. Mr CI really liked the idea of being accountable for his daily step measurements and had used Nellie on a daily basis for 3 months to provide motivational messages and to track his daily step count. As a result, he was able to maintain his increased activity at a level of 5-6,000 steps a day and has been discharged from the program.
|Case 4: Walking
- Mr and Mrs S are a retired couple and both have chronic health conditions.
- Mrs S had a knee replacement 3 years ago and has had painful knees since, which limited her capacity for physical activity.
- Mr S was diagnosed with Type 2 diabetes 40 years ago. Diabetes complications included retinopathy leading to partial blindness for which he had surgery. He was treated with 30 units insulin/d. He has a pacemaker.
- In a care planning appointment they both identified weight loss as a goal.
- They commenced a Nellie walking protocol in January 2018 which provided automated daily motivational messages and tracked their daily walking.
- Results 3 months after starting with Nellie:
- Mrs S lost 7kg and is now walking pain-free. Her glucose reduced from 10.7 to 6.5
- Mr S weight reduced from 104kg > 94kg, HbA1c 11.2% > 6.9%, BP 180/95 > 120/65, Insulin dose 30 u/d > 5 u/d with a significant reduction in the frequency of hypos.
|Case 5: Optimising blood pressure
- Ms M is a 70 year-old female with Type 1 diabetes, which was diagnosed at age 30.
- She had presented with microvascular complications and more specifically, deteriorating retinopathy.
- She presented to the diabetes educator, and her main concern was the potential for losing her eye sight.
- Her glycaemic control was excellent (HbA1c 6.5% from 8.0% 12 months previously) and glucose time in range above 90%.
- She had a history of hypertensionand was on anti-hypertensive medication. At the time of her consultation her blood pressure was 145/85 mmHg. Her goal was to reduce microvascular risk factors and she chose to focus on optimising her blood pressure control. It was not clear whether her raised blood pressure was related to sub-optimal control or white coat syndrome so the patient commenced on Nellie with a hypertension protocol. Over the following 4 weeks she measured her BP at home and submitted the results via Nellie. Nellie responded to her raised blood pressure readings to reinforce the target blood pressure range and her anti-hypertensive medication was intensified. This resulted in her systolic BP consistently being less than 130mmHg.
- Using Nellie has enabled Ms M to reduce the risk of further deterioration of her retinopathy (as well as other vascular risk factors) caused by raised blood pressure and has provided her with reassurancethat her BP is now optimally controlled.
Shared Action Plans
Shared action plans often drive the structure of Nellie's messages. Some of the action plans already exist, such as the National Asthma Action Plan. Others are developed specifically for the protocol, though they are generic and can be used with or without Nellie. They are usually handed out to patients when they start on the protocol. Below are sample images of the plans.
- An event was held on 28/11/2017 introducing Nellie to around 70 GPs, care coordinators and managers. Nellie's inventor, Phil O'Connell gave a live demonstration of the system and had an audience member quickly and easily signing up to Nellie, then sending blood pressure readings that Phil displayed in a graph. Dr Geoff Campbell, a clinical lead for Nellie, presented a case study showing how Nellie had saved him time and the reduced patient stress. The talks were professionally recorded and the edited video is published on the web.