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Post cancer - Digital Remote Monitoring and Personalised Stratified Follow Up

Checked: 09-09-2024 by Vicky Ryan Next Review: 08-09-2026

Overview

Digital Remote Monitoring and Personalised Stratified Follow Up using My Medical Record website.

My Medical Record (MMR) is a secure website commissioned by NBT and UHBW to support digital remote monitoring as part of Personalised Stratified Follow-Up (PSFU) post cancer treatment.

MMR also provides patients access to their test/scan results, monitoring plan, information about their health condition(s), wellbeing support and information, and the ability to send secure messages to their cancer support team. This supports eligible patients to self-manage following cancer treatment, with help from their clinical team.

Patients who decline interactive access to MMR will be remotely monitored by the clinical team using MMR and supported with telephone calls and letters to confirm results.

The MMR service is offered by clinical teams at NBT (Colorectal, Breast and Prostate) and UHBW (Colorectal, Germ Cell and Ovarian) to eligible patients following cancer treatment.

Clinical Nurse Specialists (CNS), with support from Cancer Support Workers (CSW), monitor and review patients’ test results and symptoms as per an individually clinically assigned protocol.

Results continue to be confirmed to GPs by letter via Connecting Care and to patients via their chosen method (letter in the post or MMR message).

If a patient’s results/scans fall outside of expected ranges, they will be contacted by a CNS/CSW to plan next steps and be suspended on MMR. Patients will be reactivated on MMR if their condition stabilises, and they wish to continue to have personal access.

Discharge

Each remote monitoring agreed clinical protocol outlines eligibility, monitoring plan, monitoring duration and review conditions by treatment undertaken.

Patients will be discharged from cancer services after the agreed follow up duration.

After this time they will not be able to self-refer back into their speciality team but will need GP assessment and referral on an appropriate pathway depending on their presentation.

Please contact the clinical team supporting the patient if you any queries.

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.