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Enhancing oncology: automating the invisible work

In the landscape of oncology, the complexities of patient journeys often intersect with a maze of multidisciplinary care, time pressures, and the persistent challenge of information dispersion. Addressing these hurdles becomes pivotal not just for patient prognosis but also for streamlining healthcare workflows and decision-making processes.

Matilde Ferreira

Matilde Ferreira

November 30, 2023 · 7 min read

Cancer presents as a multifaceted condition, often demanding diverse interventions from numerous healthcare professionals over prolonged periods of time. In one UK study, it was found that patients, who had been treated for cancer for less than a one-year period, saw 28 doctors on average, and the minimum number of doctors met was 13.1 A value that mirrors the intricacy of these journeys and the diverse array of professionals involved, even only considering medical doctors.
On the other hand, time stands as a critical factor in the journey of an oncology patient: every month delayed in cancer treatment can raise risk of death by around 10%.2 Thus, swift, and precise interventions significantly impact prognosis, intensifiyng the pressure to orchestrate timely and well-coordinated care.

Care coordination: ongoing hurdles

 The Agency for Healthcare Reasearch and Quality states that:

Care coordination is the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient's care to facilitate the appropriate delivery of health care services. Organizing care involves the marshalling of personnel and other resources needed to carry out all required patient care activities and is often managed by the exchange of information among participants responsible for different aspects of care.3

Despite the widely acknowledged importance of care coordination in care delivery, and the progress that has been made, achieving this coordination remains an ongoing challenge, especially within oncology journeys, which can manifest in different scopes:
  • Communication barriers: different specialties often use distinct terminologies and approaches, leading to communication gaps that can impede effective collaboration.
  • Coordination hurdles: coordinating appointments, treatment plans, and interventions among various specialists and departments can be complex, potentially leading to delays or inconsistencies in care.
  • Differing perspectives: each specialty may have different perspectives or priorities, which could result in conflicting opinions on treatment approaches or care paths.
  • Data integration and sharing: ensuring seamless sharing and integration of patient data across multidisciplinary teams and systems remains a challenge due to diverse platforms and data formats.
  • Decision-making challenges: balancing various opinions and expertise while making critical treatment decisions can be challenging and may sometimes delay timely interventions.
  • Resource allocation: allocating resources - both in terms of personnel and equipment - across multiple specialties in a way that optimizes patient care without causing strain on any one area can be difficult.
In fact, research indicates that patients, caregivers, and clinicians are extensively engaged in significant 'invisible work' to facilitate care coordination. This invisible work involves spending time navigating system barriers such as non-interoperable medical record systems, inadequate decision support, suboptimal communication systems, and expanding panel sizes. These barriers hinder effective coordination among the network of health systems, clinicians, patients, and caregivers responsible for coordinating care collectively. The costs and benefits of this unseen effort on the quality of life, productivity, and other outcomes for patients, clinicians, and health systems have not been thoroughly quantified, but they are likely unsustainable.4
A lack of coordinated care can lead patients getting "lost" in the system and failing to access appropriate services, as well as more unplanned health utilisation.

Intelligent, automated, and evidence-based care journeys guiding care

In a previous article, we delved into the significance of bridging the gaps within healthcare systems and outlined the crucial prerequisites for accomplishing this feat. It all begins by delineating comprehensive and multidisciplinary care journeys. These tools function akin to a map, interlinking multiple system points and directing the course of care. Ultimately, this works like a multidisciplinary consensus ensuring that every patient receives precisely the right care at every juncture.
Moreover, care journeys foster coordination among various levels of care and healthcare professionals, bridging the gaps that often lead to disjointed care, facilitating seamless transitions between care settings, ensuring that vital information and treatments are consistently communicated and executed.
The UpHill Care Journey is a stepwise multidisciplinary care plan guiding patient progression through a sequence of milestones translated from guidelines or evidence into personalized contexts, allowing decision support and digital automation of clinical activities, and aiming to standardize care and improve patient’s outcomes and experience.
Hence, we are referring to a care orchestration system that integrates decision support tools and communication with automation capabilities. This system uses automation to handle administrative or repetitive clinical tasks, enabling healthcare providers to amplify their efforts and focus on specialized tasks, catering to the intricacies of complex patient needs.
Furthermore, it establishes an accessible channel for engaging with, monitoring, and providing care to patients during intervals between standard care interactions. This system utilizes gathered information to automatically update the patient's journey status and promptly alert healthcare professionals about any warning signs.

Interoperable and robust technology ensuring patient traceability

When discussing the necessity of care coordination, it is unavoidable to recall the four levels of care integration outlined by the Nuffield Trust.5
  1. Organizational integration is about policymaking focused on coordinating structures and governance systems across organizations or developing contractual or cooperative arrangements.
  2. Administrative or functional integration involves joining up non-clinical support and back-office functions in order to share data and information systems across organizations. 
  3. Service integration aims to coordinate different services, such as through multidisciplinary teams, create single referral structures, or single clinical assessment processes.
  4. Clinical integration promotes care delivery through a single or coherent process, either across professions or care levels. This could involve developing shared guidelines, protocols or patient journeys across boundaries of care.
Once again, despite noteworthy efforts, a report by the European Commission6 highlights that an interoperable Electronic Health Record (EHR) is not widespread in most of the studied systems. Many patients face challenges in accessing and utilizing their data or transferring it between healthcare providers. The prevalence of interoperable systems between regions or entire countries is not substantial.
Moreover, more critical issues persist regarding service and clinical integration. There is a scarcity of integrated, multidisciplinary, and comprehensive care journeys in place, and the referral criteria lack clarity, leading to disconnected care levels. Additionally, accessing structured health information that is compiled and updated in real-time based on each patient's pathway evolution remains a challenge.
That is why stressing the importance of interoperability in care orchestration software is crucial for optimizing healthcare delivery, namely cancer journeys. Interoperability, like HL7, acts as the bridge, facilitating smooth communication and data exchange among diverse healthcare information systems. In an environment where information is spread across various platforms, interoperability ensures that essential patient data moves effortlessly between systems, promoting teamwork among healthcare professionals. This interconnected system not only simplifies procedures but also improves the precision and speed of decision-making, leading to better patient care.

Key benefits of UpHill’s approach to coordinate oncology journeys

  •  Multidisciplinary visibility: by providing a digital patient journey, updated in real time, UpHill enables a comprehensive view of patient progress for all involved professionals, transcending specialties and institutions, and providing access to the patient's complete medical history.
  • Enhanced patient tracking capabilities: by structuring and automating follow-ups and using such information to update patient status, UpHill enhances patients’ tracking throughout their journeys, ensuring continuity of care and enabling informed decision-making at each stage of treatment.
  • Connected systems: by using interoperability standards, UpHill ensures seamless integration with hospital information systems, automates tasks such as exam requests and appointment scheduling, and centralizes all the information in a single source of truth.
  • Patient education and empowerment: providing a patient portal with detailed information for every step of the journey, UpHill enhances patient navigation and adherence to care plans, thereby empowering patients in their healthcare journey.


  1. Smith SD, Nicol KM, Devereux J, Cornbleet MA. Encounters with doctors: quantity and quality. Palliat Med. 1999 May;13(3):217-23. doi: 10.1191/026921699668267830. PMID: 10474708.
  2. Chapter 2. What is Care Coordination?. Content last reviewed June 2014. Agency for Healthcare Research and Quality, Rockville, MD.
  3. Sallie J Weaver, Paul B Jacobsen, Cancer care coordination: opportunities for healthcare delivery research, Translational Behavioral Medicine, Volume 8, Issue 3, June 2018, Pages 503–508,
  4. Scobie S (2021) Integrated care explained, Nuffield Trust explainer. Available at:  (Accessed: February 22, 2023).
  5. Interoperability of Electronic Health Records in the EU. (2021).  The European Commission. Available at:
    (Accessed: February 22, 2023).
Matilde Ferreira

Matilde Ferreira

Content Strategy & Communication Manager

Graduated in Communication Sciences, early on fell in love with storytelling. Started off as a journalist and then pivoted to the public relations world, she was always driven to craft relevant stories and bring them to the stage.

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