Fragmented health in the era of connectivity: how long will we perpetuate this contradiction? 

Fragmented health in the connectivity era: how long will we perpetuate this contradiction? 

Patient Initiated Follow-up: how it works and why it matters?  

Improving care integration: a way to reduce emergency hospitalizations 

Two strategies to reduce waiting times in the Emergency Department​ 

Time: the challenge sabotaging Emergency Departments

Time: the real challenge sabotaging Emergency Departments 

5 tips to accelerate ORs through perioperative efficiency

How much are hospitals loosing due to inadequate navigation and  cancellations? 

How much are hospitals loosing due to inadequate care navigation and intra-operative cancellations? 

Evidence-informed health: post COVID-19 lessons

Clinical Pathways at the core of Continuous Medical Education activities

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Connectivity, networking, tracking are just three examples of words that have invaded the common discourse and not by coincidence - they mediate the way we live, how we relate, how we interact. Any doubts about the level and potential of what I have just described were cleared up when NASA launched the 

, a tool throughout which anyone could follow, in real time, the path of a telescope. 

Where is it? What happened? Where is it going? When is it supposed to arrive? For all these questions, the most curious minds - scientists or not - found answers. Quickly, updated, just a few clicks away. The same questions can be asked by doctors, nurses, or health managers regarding the thousands of people who, every day, use the health system. And - let's face it - the answer is never easy to find. 

It is curious that we know so much about the universe and very little about where the patients are - often lost between appointments, exams, and waiting hours that are repeated until exhaustion. 

The problem is not new, but despite some promising experiences regarding integrated care models, global health systems remain fragmented, focused on acute and episodic care, unable to meet the needs of today's society. In Portugal, the reality is not different and the discussion has recently gained new impetus with the 

 (Unidades Locais de Saúde) - a clear bet on a model in which primary health care and hospital care work (or should work) in a network. 

On the other hand, new questions also pop up: is this formalization sufficient to ensure the optimization of NHS resources and citizens’ quality of life? 

No. You need to connect all the scattered dots - both for healthcare professionals and citizens – striving for four essential requirements: 

We know that fragmented care is particularly harmful to chronic illness, whose patients complexity requires multidisciplinary care and the articulation of different professionals and levels of care, in the course of a long and continuous relationship with the healthcare system. 

In this context, it is primary to ensure that there is a defined, multidisciplinary and comprehensive care journey that indicates the path that the patient will follow from the moment he or she is diagnosed. A map that connects several points in the system and guides care provision. This is the guarantee that each patient receives the appropriate care at each point in time, regardless of where they are, precisely because the care journey defines all the stages the patients must go through and what happens at each stage. 

Care integration is the engine of a health system with increased responsiveness and higher quality, by allocating each patient to the right professional, maximizing the opportunity cost of each one. To achieve this, it is essential to define clear referral criteria throughout the entire care journey, ensuring that the patient is seen at the correct level of care.  

Taking the care journey as the map that defines the stages a person must pass through and what happens at each stage, the referral criteria act as the traffic rules that dictate when the patient must (or must not) move forward or backward to the next stage or level of care. This point is particularly relevant to optimize the allocative efficiency of the health system and avoid, for example, 

unnecessary overuse of hospital resources

Real time progress monitoring: the navigation 

Given the increasing volume and complexity of patients - associated with several factors, including the increase in average life expectancy -, the scarcity of resources, and the connectivity era in which we live today, it makes no sense to have patient's progress dependent of face-to-face appointments: we can - and should - use the tools that already exist to remotely monitor patients.  

So, just as a navigation system identifies an accident or traffic intensity and adjusts the route, so in healthcare there must be total visibility over the patient's progress, identifying any red flags and adjusting the journey automatically. 

Centralized data and interoperable systems: the GPS satellite network

Ultimately, the success of care integration depends on the ability to overcome the information silos that still persist and find an agile way to obtain structured, compiled and updated health information in real time.  

Like a satellite network that follows the entire journey and ensures that the multiplicity of information systems used in hospitals, primary care centers and other units, communicate with each other, speak the same language, assign a unique and unambiguous meaning to each piece of information they receive or transmit, and guarantee that patients data follow them throughout the health system. 

Even in vertically integrated models designed to work in networks, several challenges remain to make the proclaimed benefits of care integration a reality.   

Health systems are in the spotlight, people have never demanded so much from the health sector, providers are under pressure to better match clinical resources with patient needs and meet evolving customer expectations to thrive in the rapidly changing healthcare landscape. 

The topic that brings us here today is Patient Initiated Follow-up (PIFU) as a strategy to reduce unnecessary appointments, missed or cancelled appointments and preventable hospitalizations. 

Because demand won’t stop, and resources will not follow the same rising trend. 

More patients, less healthcare workers, missed opportunities to improve outcomes and new expectations shaping healthcare systems 

In the background, a continuous growth of the global population fueled by a progressively longer life expectancy grows healthcare needs in volume, which mostly remain unaddressed: 

At the same time, the United Nations and World Health Organization call for action towards effective universal health coverage, health, and well-being for all, 

urging transformative redesign of healthcare systems

 originally designed to deal with acute conditions. The hard truth is that purely time-based, sequential, and standardized approaches are not adequate to meet today's needs concerning chronic diseases management thus leading to inappropriate use of health resources and financial sustainability challenges: 

Finally, new customers’ expectations aligned with Huber et al. definition of health as 

“the ability to adapt and to self-manage, in the face of social, physical and emotional challenges”

 stress the traditional doctor-patient relationship and push providers to try non-traditional strategies and services to improve navigation throughout the system. In fact, recent insights from global market research and consulting companies converge on pointing digital capabilities and ease of navigation as factors increasingly influencing who patients choose as a provider​s.  

Patient Initiated Follow-up: a game changer

Patient Initiated Follow-up is about giving patients the flexibility and convenience to report symptoms exacerbations and arrange their follow-up appointments when they most need them

. It’s about “making appointments more responsive to patient need”.

 An absolutely game changer because, as flawlessly described by the Nuffield Trust:  

As one used to manage chronic diseases – especially those characterized by acute exacerbations – know, acute episodes don't happen at a set date and time. So, the likelihood of patient’s decompensation between two visits scheduled following a fixed follow-up approach is higly variable and unpredictable.

By empowering patients to accurately identify red flags and giving them the ability to report them, safe and conveniently, to the clinical team in charge of their care plan, there is hope that PIFU can help:   

One-million-dollar question: does PIFU work? 

A report by the Nuffield Trust examined the effects of PIFU on service use, costs patient experience and/or clinical outcomes. 

Patient-Initiated follow-up with UpHill: mutual empowerment 

Although the ability to have a patient initiating an appointment when he needs one is intrinsically a good thing – PIFU is not 

First because this strategy may not be appropriate either for all patients nor for all conditions. Secondly, it must be ensured that health teams have all the tools and information needed to effectively reduce care gaps and reduce inefficiencies, while enabling their effectiveness and productivity.  

While many patients frequently self-manage their condition and are on top of their own health status, others might not be sufficiently informed to recognize triggers or changes in their condition. That is to say, PIFU requires supporting patients to self-manage, giving them confidence to act on changes in their symptoms. 

On the other hand, even with PIFU there will always be the need to stratify patients and adjust their care journey according to their risk. That is to say that not all the red flags reported should trigger an in-person appointment. So, healthcare professionals should also be provided with the tools to 

accurately decide how to proceed, preferentially without additional workload

Patient Initiated Follow-up approach enables shared decision-making, reduces unnecessary appointments, and preventable hospitalizations. It is about mutual empowerment since it provides patients with the opportunity to take their health into their own hands, and healthcare professionals with the capacity to provide care to the patients that need the most, with more confidence.  

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Hight affluence combined with inefficient processes makes 

Emergency Departments (ED) absolutely stressful for those who work there and those who need to visit it

. Even conceding that not all the root causes leading to long stays can be addressed from or by the ED, in this blog post we present a new way to shape patient flows during emergency admissions to create time and reduce waits. 

1. Improve process efficiency to save time and resources

In this first block, we’ll be exploring some interventions that will help your Emergency Department save time and resources. 

In the United States of America, overall diagnostic accuracy in the emergency department is high, but some patients – around 6% - receive an incorrect diagnosis.

 Some of these patients suffer an adverse event because of the incorrect diagnosis

 – around 2.0% -, and some of these adverse events are serious

 – around 0.3%. This translates to about 1 in 18 patients receiving an incorrect diagnosis, 1 in 50 suffering an adverse event, and 1 in 350 suffering permanent disability or death. 

Even if those figures are comparable to those seen in primary care and hospital inpatient care, it is relevant to emphasize that the main causes pointed for ED diagnostic errors are cognitive errors linked to the process of bedside diagnosis, which could be avoided by providing - in the time and space in which clinical decision-making happens - 

detailed, updated, multidimensional, and reliable information related to a specific disease

the overuse of healthcare services is widely reported

 and, in the US system, accounts for as much as 30% of all healthcare spending.

 Overuse takes different forms in different specialties. Unnecessary invasive procedures predominate in some, and medications and screening tests in others. In Emergency Departments, overuse of diagnostic testing is the problem. Once again, the implementation of clinical pathways, detailing the actions, decisions, and criteria for the diagnosis, has been shown to reduce resource waste and hospital costs, specially, if clinical pathways are development under a “de-implementing wisely” framework.

Now that we’ve thought about ways to reduce resource waste and improve diagnostic accuracy, let’s focus on saving time, by redefining intra-ER patient flow.  

Usually, it happens in a standardized way covering multiple steps from admission to discharge or hospitalization. Is it absolutely necessary to wait so long in such fragmented moments before having a resolutive interaction with the physician? Long short story: no, it isn’t, as we suggest establishing different flows for emergent and non-emergent patients. 

Physicians will have all the information needed to make accurate decisions the first time they see the patient. Thus, patients will spend less time waiting between interactions and physicians will spend less time in non-resolutive interactions.  

Think of Emergency Department navigation as a journey between a fast, convenient, and agile green lane. Now imagine that it is a slow, fragmented, and lengthy path. Which one would you choose? 

Reduce in-hospitalizations by increasing early discharges safety

Early and accurate identification of patients at low risk of serious illness may improve the flow in the emergency department – as previously described – and by classifying these patients as suitable for discharge. This process represents one of the most vulnerable periods in health care delivery and is described as sometimes being “on the edge”, especially for elderly patients with chronic diseases.

Some challenges remain with discharge effectiveness - ED failure to reconcile medications, patient failure to follow the treatment plan, and patient failure to access post-discharge services are found among the main barriers

 – and can lead to longer-lasting hospitalizations in an attempt to decrease the risk of future readmissions.

On the other hand, evidence found that admission thresholds are higher when the number of emergency inpatients is particularly high, which may indicate that riskier discharge decisions are taken when beds are full.

To face the aforementioned issues, we suggest two approaches:

Reducing emergency department waiting times requires multiple strategies able to reduce admissions, strengthen referrals for other care settings, improve intra-ER efficiency and reduce discharge risks. In this respect, hospital leaders should strive for having efficient patient flow systems in place, such as streamlined registration processes and well-coordinated transfer of patients between departments, as well as speeding up the process of obtaining patient information and test results, improving communication and collaboration between Emergency Department staff and other healthcare providers.  

As umpteen times mentioned, not all the root causes leading to long stays can be addressed from or by the ED, precisely because patient care should not always start and should not finish within the emergency department. The World Health Organization and the OECD have repeatedly pointed out care integration as an unequivocal necessity for today's health systems, creating opportunities for transforming people’s experiences of care from disjointed to coordinated, reactive to proactive, and service-orientated to personalized.  There are found hopeful experiences across systems, but some challenges – to explore in future blogposts - remain.  

 to know more about our Acute Care solution. 