Care integration: the use case of ULSLA

Care integration ULSLA

A take to redesign healthcare based on care journeys

Patient Initiated Follow-up: the use case of CHUdSA

Clinical Pathways: a journey to improve outcomes, efficiency, and predictability in healthcare

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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.   

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? 

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.  

 to know more about ongoing projects and discuss how our solution can address your needs. 

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

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. 

Two strategies to reduce waiting times in the Emergency Department​ 

Operating departments (OR) are hot spots, accountable for the largest part of hospital costs and production. Specifically, ORs contribute to almost two-thirds of a hospital’s total revenue, but also account for about 40% of their total expenses

, including manpower and operating costs.

 is, therefore, a top priority for providers facing an always growing demand of care services, including surgery.

Back to basics: efficiency is not rocket science

When it comes to the future of surgery, medical technology experts often try to predict what’s to come to get ahead of the latest trends. In the last decade, we’ve seen an explosion of new products in a range of high-tech areas: big data, artificial intelligence and machine learning play an increasingly relevant role in treatment planning, decision-making and best practices adoption, while augmented reality, mixed reality and robotics are pointed as essential technologies that impacting surgical devices.

These fancy concepts can sound overwhelming, far away from reality – and quite expensive –, but there is good news: 

the main driver of efficiency improvement is process improvement

. Perhaps not so fancy, but cost-effective.

Efficiency has been described as the capacity of performing things in a way that leads to cost reduction without affecting quality. Other authors define efficiency as the ability of doing the right things, combining productivity and quality

. In turn, quality of care is understood as “the extent to which health care services provided to individuals and patient populations improve desired health outcomes”, being safe, effective, timely, efficient, equitable, and people centered

For the purpose of this blog post, let’s consider efficiency as the ability to increase capacity and quality, while reducing costs.

Top tips to improve surgical journeys through perioperative efficiency.

1. Implement a surgical pathway and keep single source of truth for each professional to improve visibility and collaboration

Perioperative efficiency starts way before the surgery. Missing patient information preceding the surgery can lead to wrong surgical decisions and time lost. This is particularly relevant in complex diseases with multidisciplinary approaches. 

For example, operating a cancer patient without multidisciplinary agreement on the treatment recommendation may lead to poorer clinical outcomes and, thus, extra medical expenditure.

What’s missing? A plan and one source of truth for all professionals to have a shared understanding of the patient status.

Creating an efficient perioperative journey is much like leading an orchestra. There is a pre-defined pathway to be followed – the music staff – a unique source of truth in real time – the conductor – a lot of intricate moving parts – musical instruments. All of them must be in tune, the rhythm succinct. If one instrument is out of tune or loses the beat, it will throw off the entire performance.

As an orchestra, perioperative journeys bring together multiple specialties and professionals working side by side - surgeons, anesthesiologists, diagnostic technicians, among others. There is a care plan to be followed, detailing sequentially framed activities that must be performed and several decisions to be made, considering the patient condition, comorbidities, exams results, etc. But a one and only, real time updated source of truth is still lacking.

This way all professionals to have a shared understanding of the patient status.

2. Stratify patients to avoid cancellations due to unexpected clinical conditions

, surgery cancellation is the leading cause of operating room inefficiencies

. Specifically, day of surgery (DOS) cancellations represent a significant loss of revenue and waste of resources, increasing the already extensive waiting lists that must accommodate the burden of cancelled operations, and most of them are preventable.

For example, admitting a high-risk patient without proper anesthetic risk stratification (ASA) in the OR will surely lead to the surgery being cancelled.

Around 30% of cancellations happen due to clinical reasons

 that could beneficiate from more accurate perioperative evaluation and stratification, including

Preoperative medical assessment has proven its worth to reduce elective case cancellations. In particular, a significant reduction is found in cancellations for medical reasons

3. Automate repetitive tasks to free surgeons and anesthetists’ time

Keeping up with the orchestra metaphor, there are a lot of activities surrounding a live concert which are not performed by musicians to let them focus on their best talent – playing. Our suggestion is about doing the same in your hospital. 

Learn more about how to choose which activities must be automated

From efficiency improvement perspective, automation is useful within two major scopes:

Automation is revolutionizing many industries, including healthcare, enabling hospitals to outsource and offload their most time-consuming work, help relieve administrative burdens and enable healthcare staff to refocus their energy on patients. Such ability looms large when almost half of physicians across all specialties report feeling burned out

 and nearly 60% outline “too many bureaucratic tasks” as the main cause

. Thinking on surgical departments, statistics show that general surgery residents spend at least 30% of their time using the EHR and anesthetists spend almost 20% of their time on administrative work

4. Empower patients and promote evidence-informed behaviors

Going under surgery can be overwhelming and patient education about surgery, anesthesia, intraoperative care, and postoperative pain treatments in the hope of reducing anxiety, improving compliance with pre-surgery recommendations, and facilitating recovery. This improves surgical outcomes and reduces no-shows.

Back to the orchestra, one cannot expect that “ordinary” people assisting to a particular play for the first time will get deep understanding of the several layers presented on a single artistic expression.  Approaches found to overcome those cultural literacy asymmetries range from simple synopsis to cultural mediation programs that offer public a chance to explore the historical, sociological, and artistic background of a particular performance.

A similar method is required to make sure patients feel comfortable proceeding with their surgeries, reduce no shows or low adherence to the pre-surgery treatment plan, making the surgery unfeasible. Did you know that patients not showing up account for 1 out of 5 cancellations

 report increased anxiety levels  due to a lack of communication and information from the practice staff?

Note: to further insights on the importance of having evidence guiding society behaviors read our blog post 

Evidence-informed health: post COVID-19 lessons

Build a continuous improvement culture through a lean management system

In the perioperative setting, every minute wasted erodes quality and financial well-being. Using lean methodologies to address these issues can make an enormous difference in quality, efficiency, and productivity.

The Lean method initially studied at the Massachusetts Institute of Technology to improve efficiency by eliminating "non-value added" activities known as waste. In addition, the method was applied in different settings related to clinical process to remove waste, identify inefficiencies, and improve outcomes.

If you are a Hospital Director looking to opportunity cost optimization, or a Clinical Director who needs to reduce hospital waiting times and prevent readmissions or even a Head of Operating Room striving to reduce no shows and surgery cancellation, 

5 tips to accelerate ORs through perioperative efficiency

Lengthy waiting lists for elective surgery are a daily struggle for patients and a headache for hospital managers. On one hand, they postpone the expected benefits of treatment, while pain and disability remain; on the other hand, delaying the procedures can have a significant impact on a facility’s financial security. In this article, we’ll be exploring the main causes and consequences of this reality in worldwide healthcare systems.

Before going further, there are some facts that we kindly ask you to keep in mind:

If nothing changes, those figures will keep spreading in the upcoming times with some major details pressing ahead: an expected always growing demand contrasting with the health workers shortage are fostering the perfect storm for healthcare systems.

Well, that’s why recruitment and retention efforts are key - but insufficient – drivers to handle such a complex challenge. New productivity enhancing and patient engagement strategies, linked with optimized processes will differentiate those providers able to increase capacity from those who will keep their patients and staff held hostage of lengthy processes and waiting times.

An unprecedented backlog is leading the way…

Long waiting times for elective (non-urgent) surgery have been a longstanding issue, dating back well before the pandemic, but COVID-19 has had a drastic impact on surgical delays, as providers have been forced to prioritize emergency and critical care cases. This shift in resources has resulted in a significant backlog of non-emergency procedures, including surgeries.

A study published in the British Journal of Surgery makes it explicit: 

28 million elective surgeries worldwide have been cancelled or postponed in 2020

 In the same year, surgery waiting times increased by about two months on average.

… and waiting times are turning the spotlights on hospitals (for bad reasons)

Anyone working in a healthcare facility knows that surgical waiting times are a “everyone’s reality”:

And we could keep listing… It is not unique, but it is crucial to understand the leading causes of surgical waiting times and to implement innovative strategies to mitigate them as soon as possible.

Finding the root causes for lengthy waiting lists in surgery 

The root causes of surgical waiting times can be attributed to a variety of factors. Most commonly, it is due to a lack of resources, such as insufficient staff and equipment, poor coordination between different hospital departments and administrative issues can also contribute to waiting times, as well as the sheer number of patients requiring care.

Starting with human resources. It’s well known that health systems are facing a severe shortage of workers due to two major reasons – retirement and turnover – and the second one has been aggravating with growing rates of healthcare workers burned-out. Guess what: perioperative professionals are included in this challenging scenario.

While a current global shortage of 199,000 surgeons and 87,000 anesthesiologists is already reported,

 USA statistics show that, at the present time, more than half of anesthesiologists are 55 years old or older.

a new wave of physician retirements is imminent

At the same time, the world’s population aged 60 years and older is expected to total 2.1 billion in 2050,

 representing an additional risk factor for multiple chronic diseases. The global demand for cancer surgery is expected to increase from 9.1 million to 13.8 million procedures over the next 20 years, and the surgical workforce will need to increase 47%.

Focusing exclusively this reasoning line, sounds obvious that human and technical resources availability are the number one bottleneck for surgical waiting times, but what about the surgeries that are supposed to happen, block hospital facilities and healthcare professionals’ agendas and are cancelled at the last minute?

Cancellations: the hidden face of surgery waiting times

Let’s put it plain: cancellations cost up to €450 million per year…

Evidence reports highly variable elective day of surgery (DOS) cancellation rates from 5% in Finland

It's easy to understand that if an operating room is expected to be working and it changes unexpectedly, there are heavy efficiency losses and waiting times will not reduce – quit the contrary. What is much more difficult to understand is why it happens due to preventable reasons.

…And around 80% of cancellations are preventable

Besides the lack of resources, such as staff or equipment issues previously mentioned as drivers for waiting times, the reasons why a surgery may be canceled include an unforeseen medical issue, such as a sudden infection or complication; the patient's condition not being suitable for the procedure; or the patient not being able to meet the pre-surgery requirements.

In this regard, recent prospective epidemiological study in NHS hospitals states that clinical reasons are responsible for 33% of historical cancellations and 28% of contemporaneous cancellations.

 This include cancellations due to poor preparation or unexpected deterioration in patient health.

Well, what this means in practice is that around 30% of

 cancellations happen due to clinical reasons that could beneficiate from more accurate risk-stratification 

and/or better coordination between different teams and/or care levels.

Once again, it’s not only about having more resources, but also about changing processes to improve the way things are done and make sure that those people are delivering their best.

Last, but not least, increased anxiety levels, often due to a lack of communication and information from the practice staff, are reported by 50% of patients,

resulting in them postponing or canceling the surgery altogether. All in all, preoperative instructions not being followed, lack of OR availability due to administrative issues, or patients simply not showing up, make up 70%

 of surgery cancellations. And all of them are preventable reasons.

patient engagement and navigation enablers’ strategies

, able to reduce either doubts or wrong behaviors that threaten surgery’s viability, 

have their say when it comes to reduce intra-operative cancellations

, consequently reducing – or at least not rising – surgical waiting times.

If you want to keep on top of efficiency tips to increase your OR capacity, read the next blog post. If you prefer to have a conversation about how to reduce cancellations and surgical waiting times, 

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? 

 depends on the suitable and efficient execution of processes, understood as a series of activities aimed to diagnose, treat and prevent diseases and improve a patient’s health. Changes in processes – such as the adherence to the Enhanced Recovery After Surgery protocol 

 or the prompt administration of appropriate antibiotics in the management of patients with sepsis 

 – have proven its worth to improve outcomes.

, executed by different types of professionals, and can vary from one organization to another, according to the resources and infrastructures available. However, reality often deviates from the clinical practice guidelines. That’s why, in this article, we are going to explore process mining - a method for Business Process Management (BPM) and analysis, focused on extracting knowledge from data generated and stored in corporate information systems in order to analyze executed processes – and its applicability in healthcare.

First things first: what does process mining mean and what does this concept brings to healthcare?

Process mining is gaining increasing attention in healthcare. Adopted in the domain of BPM, it is useful to extract knowledge and non-trivial information from the process executions, to discover, monitor, and improve processes. It provides a comprehensive set of tools to return fact-based insights and, thus, to support process and healthcare management improvement.

In short, process mining applied to healthcare involves 3 variables: 

A literature review performed by Rojas et al. identified and classified the most relevant common aspects in which the application of process mining is useful in healthcare. Today, we would like to highlight the following:

Process mining methods to identify different types of hospital processes

 are the clinical processes responsible for managing patients, including tasks ranging from diagnosis to the execution of actions for alleviating each patient.

 focus on the organizational understanding of processes, capturing collaborative information from professionals and their organizational units.

Process mining methods to provide specialists in medical processes the ability to respond to frequently posed questions about these processes

That being so, process mining ensures that not only the healthcare processes are well-understood, but also allows to achieve a high level of process efficiency. Healthcare organizations can 