Integración asistencial: Alcanza la excelencia con UpHill

Care Continuity: raising the bar with UpHill

ULSAM & UpHill: a journey to achieve CCMM certification

Coordination and automation of cancer journeys: the use case of CHULC

Increase primary care capacity and improve chronic disease management: the use case of ACES Sintra

Primary Care ACES Sintra

Interoperability that works: making healthcare easier

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UpHill enables health teams to improve outcomes and streamline care by applying evidence-based knowledge through stepwise clinical pathways.

UpHill Health

Broadly speaking, all routinely collected data on patient health - outside of controlled clinical trials - are known as Real-World Data (RWD). 

 When we analyze this RWD, we produce real-world evidence (RWE): 

Real-world data have been widely used in research for purposes like tracking drug safety after release and observing patient disease progression over time. With the rapid expansion of healthcare technology—such as electronic systems, biosensors, and mobile and wearable devices—large amounts of RWD are now collected routinely. This wealth of information has immense potential to improve study design and address previously unmet clinical needs.

But could RWD be doing even more? Are there ways to use this information in real-time to improve care rather than only after studies are complete?

Reflecting on UpHill’s participation in the symposium 

, we take a deep dive into how real-world data could be better aligned with the immediate needs of patients, healthcare professionals, and health systems.

To be clear, the value of RWD in assessing a medical product’s benefits in real-world settings is well-documented. The lack of strict eligibility criteria, the ability to track patient behavior in actual healthcare settings, and the potential to support research on high-risk groups - such as pregnant women and children - make it invaluable, especially for research that randomized controlled trials (RCTs) cannot always accommodate.

However, aren’t these approaches working at two very different paces? While RWD may be more cost-effective than an RCT for assessing, for example, the safety of a drug used in heart failure treatment, could this traditional approach fall short of the real impact that the same data could have on managing disease in real-time? Used effectively in day-to-day practice, couldn’t real-world data create a transformative impact on patient care?

Let’s take a step back to address the critical challenge facing healthcare systems worldwide: 

 - driven by an aging population and rising rates of complex chronic diseases - 

while healthcare capacity, regarding available health professionals, remains largely stagnant

. This widening gap leads to familiar issues: long waiting lists for appointments, delays for surgeries, and overcrowded emergency departments.

In this context, healthcare professionals don’t need an overwhelming influx of data that complicates their work;

 they need precise, relevant data to make informed decisions at the right time

. Health systems don’t need to invest in the latest technology for technology’s sake; 

they need to focus on interventions that have demonstrated potential to improve patient outcomes

. And patients don’t need the newest devices on the market; 

they need a healthcare system that’s available when they need it most.

real-world data proves its value when it can influence the course of care for an individual patient while simultaneously streamlining care delivery on a population-wide scale

This journey-based model, fuelled by real-world data, is uniquely equipped to respond to each individual’s unpredictable disease progression, adapting to meet needs as they arise.

A few years ago, while reflecting on the global response to the COVID-19 pandemic, we observed that the future — and increasingly, the present — 

belongs to hybrid models that blend different types of evidence

. Each of them plays a crucial role: scientific evidence should guide care delivery, serving as a map, while real-world data should drive real-time decisions - much like a GPS, offering real-time guidance based on constantly updated information.

This may sound idealistic, but it’s exactly what 

. Believe it or not, all patients need is a mobile phone.

Disclaimer: This article draws on the presentations by Clara Jasmins and Eduardo Freire Rodrigues at the symposium The Impact of RWE on Clinical Pathways.

Real-World Data: can we turn information overload into real-time impact?

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.

 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%.

 Thus, swift, and precise interventions significantly impact prognosis, intensifiyng the pressure to orchestrate timely and well-coordinated care.

The Agency for Healthcare Reasearch and Quality states that: 

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:

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.

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

, 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.

 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.

Once again, despite noteworthy efforts, a report by the European Commission

 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

Enhancing oncology: automating the invisible work

Throughout UpHill’s history, there has been a common denominator: each year surpasses what we had planned for. This is a function of our work — our unique collective force —, as it is a function of how humanity really needs what we are building.

These two elements serve as the key contributors that have brought us to this moment when 

we joyously celebrate our Series A funding round

. Following a remarkable year that showcased 

UpHill's capacity to deliver journey-based care that enhances healthcare capacity and elevates patient outcomes

, and launching Liber — an innovative digital service poised to transform the healthcare landscape — we stand ready to embark on the next chapter by scaling our impact through journey-based care.

Our solid journey to increase healthcare access at scale, steered by evidence, and in compliance with industry standards.

UpHill was founded in 2015 with a clear mission: 

to empower people to provide and receive the best care

. This mission has taken several shapes and, fast forward to today, UpHill stands out as

 the most highly invested care orchestration company in the European Union

. A milestone that attests to the robustness, safety, and efficacy of our technology, as well as our clinical knowledge, setting us apart from other players.

UpHill improves lives with care orchestration software that works both for healthcare teams and patients. During a turbulent period, when the healthcare system grappled with significant challenges in meeting population needs, UpHill was established as the “second brain” behind care provision within major institutions.

Together with the pioneering, dedicated, and talented frontline teams, we are successful in designing, implementing, and delivering novel journeys for the most challenging conditions.

The impact of what we have done together is refreshing:

Throughout our journey, we've come to understand that issues impacting healthcare institutions, such as growing demand and insufficient capacity, are often tied to lacking alternatives that enable individuals to avoid using these services for all and every reason. In essence, healthcare systems are marked by uneven participation from both healthcare professionals and patients.

Healthcare professionals shoulder a heavy load, from diagnosing and treating acute illnesses to managing daily administrative tasks, preventing diseases, and overseeing chronic conditions. Conversely, in most cases, patients find themselves detached from their care journey, lacking information, and without the necessary tools to proactively engage in health promotion, prevention, and disease management.

This is why in 2023 we invented the next-generation care model: 

Liber provides better care, faster, and at a lower price. Liber members can quickly solve acute health issues by interacting immediately with Liber doctors, and enrolling in disease prevention and health promotion programs. All happens at the pace of a high-tech, premium, and personalized service running on the UpHill platform, which accelerates both members and doctors, building on structured medical knowledge.

As I am writing this, people are still awaiting help for hours long in crowded hospitals and primary care centers. From here across the globe, those in need have to wait years for surgeries, many months for appointments, and too many hours for acute care. This is unbearable. This is why UpHill exists, and this is why we are just getting started: our platform is the care orchestration software for the decades to come.

As we continue to solidify our presence in the Iberian market, 

UpHill is set to expand its footprint by opening offices in new locations such as UK and Spain.

With plans to double our team by the end of the year

we are on the hunt for the most talented people with a drive to change healthcare globally

we are in the business of improving life. 

We believe every patient must be on a well-defined, high-quality care journey.

A journey that augments healthcare workers' capacity, enables people’s self-efficacy, and streamlines healthcare systems coordination.

This is how we will achieve access to high-quality care at scale.

UpHill raises €7M to scale journey-based care

Transcribing clinical records by voice, paperless prescriptions, automated scheduling, automatic assistants monitoring patients, or even robotic surgery is not science fiction. There are numerous examples of how technology redesigns the way healthcare reaches, interacts, and treats citizens throughout a relationship that is increasingly continuous, proactive, close, and secure.

One could say that patient-centred care is the way to go. But we at UpHill prefer to think about 

. Why? Because patient-driven care extends beyond placing the patient at the centre of healthcare decision-making and tailoring services to their unique needs. It means dynamically using real-time patient information to adapt and refine each individual's healthcare journey. This approach involves actively and safely leveraging the data received from patients to continuously adjust and optimize their ongoing care, ensuring that every step of the process aligns precisely with their evolving needs, preferences, and values.

The good news is that we now have the tools to make it happen.

Empowering patients with a personalized care journey...

 play a pivotal role in modern healthcare by offering a structured roadmap that guides patients’ care. Standardizing best practices within these care journeys ensures consistency and quality in healthcare delivery, no matter where the patient is. By mapping the ideal path for specific conditions or treatments, healthcare providers can streamline processes, reduce errors, and enhance overall patient outcomes.

Moreover, these journeys foster coordination among various levels of care and healthcare professionals, bridging the gaps that often lead to disjointed care approaches, resulting in suboptimal outcomes and increased healthcare costs. Care journeys serve as a cohesive thread, weaving the different facets of care into a unified narrative. They facilitate seamless transitions between care settings, ensuring that vital information and treatments are consistently communicated and executed.

… and increasing healthcare professionals' efficiency…

 working together with clinical pathways, we have the “best of both worlds”: the scientific knowledge to define processes and the technology to streamline them. 

Care orchestration software combines decision support tools – providing healthcare professionals with a real-time roadmap to ensure standardized and evidence-based care delivery – and communication and automation capabilities – leveraging automation to handle administrative or repetitive tasks and empowering healthcare providers to optimize their efforts and focus on differentiated tasks and more complex patient needs.

The greatest strength lies in the care orchestration solutions' ability to reduce care fragmentation through resolutive digital interactions, providing an open channel for engaging, monitoring, and treating patients between standard care interactions. These systems aid healthcare professionals in 

 actions and attention to patients requiring immediate care or heightened support.

Through comprehensive patient tracking, these technologies enable a panoramic view of each patient’s journey, fostering a proactive approach to healthcare delivery where personalized care is streamlined and resources are allocated effectively to those in most need.

… through interoperable and robust technology.

 capabilities in a care orchestration software is paramount in optimizing healthcare delivery. Interoperability, such as HL7, acts as the connective tissue, enabling seamless communication and data exchange across various healthcare systems. In a landscape where information is scattered across different platforms, interoperability ensures that pertinent patient data flows effortlessly between systems, fostering collaboration among health teams. This interoperable framework not only streamlines processes but also enhances the accuracy and timeliness of decision-making, ultimately resulting in improved patient care. Interoperability is pivotal for creating a unified and efficient healthcare ecosystem, where information is fluid, and collaboration is seamless.

Care orchestration software’s must-haves to promote patient-driven care.

In addition to mapping care journeys, integrating a decision support system, and automating actions, there are other critical features to consider when choosing software in order to ensure a patient-driven approach. A software that allows:

Digitalization strengthening humanization.

The shift towards patient-driven healthcare empowers individuals to actively manage their well-being through a digital connection that bridges the gap between patients and their care, ultimately improving patient outcomes.

Embracing digital health balances healthcare systems, enhancing patient resolution while minimizing resource utilization. It also reshapes the doctor-patient relationship into a continuous through a digitally facilitated connection. 

Embracing digital health balances healthcare systems, enhancing patient resolution while minimizing resource utilization

. It also reshapes the doctor-patient relationship into a continuous through a digitally facilitated connection. As healthcare professionals leverage technology to handle tasks, they are more available to listen, think, and treat their patients, moving from executors to decision-makers and managers.

 this evolving doctor-patient relationship does not lessen the humanity in healthcare. It intensifies it

. Technology, especially automation, allows healthcare professionals to focus on what truly matters: their patients. 

It empowers them to establish profound connections, emphasizing the patient's significance in the healthcare narrative

 Embracing the humanization era in healthcare

Health and environment affect mutually: on one hand, the healthcare sector is a huge responsible for greenhouse gas emissions, which contribute to the deterioration of human health and the planet; on the other hand, health professionals and experts recognized climate change as the greatest threat to human health in the 21st century, with more than 250,000 additional annual deaths to be expected between 2030 and 2050

 – a number that has since been reported as an underestimation.

The impact of care settings, such as hospitals, clinics, and long-term care facilities, on the environment is multifaceted and significant, ranging from energy consumption, to waste generation or transportation emissions:

 poised to increase further if unnecessary processes persist or redundant tasks continue, exacerbating the environmental impact and strain on energy resources.

 Implementing streamlined clinical pathways can significantly enhance efficiency in healthcare settings, reducing unnecessary resource consumption and energy use while maintaining high standards of patient care.

It is common to emphasize the need to tackle the unwarranted waste of resources, such as paper, or to reduce travel for the sake of sustainability and efficiency. However, one often underestimated dimension is the impact of process variations on the predictability of those very processes. And when operations lack consistent standards and suffer unpredictable variations, waste proliferates.

The lack of predictability in healthcare processes can lead to excessive inventory, work duplication, and ultimately, inefficient resource utilization. Therefore, in addition to adopting environmentally conscious practices, it is crucial for organizations to optimize their processes, seeking stability and predictability, in order to minimize resource waste, striking a balance between sustainability and operational efficiency.

There is no sustainability without consistency and predictability.

The process of standardization is a common practice in several industries, ranging from aviation to food handling. Throughout the ages, we’ve seen these industries responding to major safety crises by standardizing processes to reduce variation and ensure consistency among the workforce. This has resulted in a uniformity level that has allowed them to perform their job functions with fewer incidents and more predictable overall results.

Well, the opposite means unpredictability and waste:

The Institute for Healthcare Improvement defines waste as resources expended in services, money, time, and/or personnel that do not add value for the patient, family, or community.

 A clinical pathway is a structured multidisciplinary complex clinical intervention that consists in a care plan describing a sequence of actions or steps, systematically organised around timeframes and criteria-based progression, translated from guidelines or evidence into local structures with the aim of standardizing care and optimizing patient outcomes. It is structured as a normative process diagram or decision tree, detailing interventions - and the actors who perform those interventions, as well as the expected results of these interventions.

translate clinical recommendations into clinical processes of care within the unique culture and environment of the healthcare institution aiming to maximize patient safety and care effectiveness, thus:

And how can UpHill support the transition towards greener hospitals?

UpHill is a clinical pathway software that integrates with existing hospital information systems to automate tasks and bridging gaps in care. With our software orchestrating care, hospitals have a comprehensive view of their patient's status throughout their journeys as individuals and as a population, including past history and expected next steps.

Additionally, UpHill supports health teams by automating tasks such as, scheduling exams and appointments, monitoring patients' signs and symptoms after discharge, intelligently interpretating patients’ answers, presenting the next best actions to be done, and getting records automatically proposed to the Electronic Health Records System.

That is to say, hospitals have optimized and predictable processes, as well as real time visibility on such processes, while healthcare professionals are able to strengthen their focus on high value and impact tasks.

In conclusion, as we stand at the intersection of healthcare and environmental sustainability, it becomes evident that clinical pathways are the cornerstone of a more sustainable future. The intricate relationship between human health and climate change underscores the urgency of adopting practices that not only reduce environmental impact but also enhance patient care. Clinical pathways provide a structured framework to achieve this balance. By standardizing care processes and minimizing unwarranted variations, they can drive consistency, predictability, and ultimately reduce waste in the healthcare sector.

Sustainability is not merely a buzzword; it is a requirement for a resilient healthcare system. 

Clinical pathways, in conjunction with innovative technologies like UpHill, offer a path towards greener hospitals, where resource consumption is minimized, processes are streamlined, and patient outcomes are optimized. In this pivotal moment, embracing clinical pathways is not just a choice but a necessity for building a healthcare system that prioritizes both the well-being of patients and the planet.

Clinical pathways: the cornerstone of a sustainable healthcare future

Much has been said about the impact of the technological revolution on care provision, the infinite advantages of using algorithms to diagnose diseases at an early stage, the ability to personalize treatments, the possibility of blurring the boundaries between the hospital and each person's home. However, less attention has been paid to the redefinition of professional roles that is taking place. And this redefinition is not only desirable, but necessary.  

It's no news that the demographic landscape has changed in recent decades and we are one of the "oldest" countries in the European Union. The average age of the Portuguese population will be 47 in 2022, the second highest among the 27 member states. While increasing longevity is a sign of scientific progress, it is not necessarily synonymous with better living. The increase in chronic diseases is the flipside, forcing the health system to reinvent itself in order to respond to needs that last over time, require multidisciplinary interventions, and whose success also depends on the ability to invest in prevention. 

The fact is that human resources are scarce for so many diverse and demanding needs, and current care processes are not very efficient. To put it simply, there are low-value tasks allocated to extremely differentiated and, incidentally, exhausted professionals. It is therefore only useful to discuss the potential of technology for a healthier, more efficient and more differentiated future if the basis of care provision is also transformed, freeing up medical doctors, nurses and other professionals to focus on high-value, high-impact tasks.   

At stake is the urgent need to promote the intelligent allocation of tasks between teams of healthcare professionals and to take this division to a new level, in which some of them can even dispense with human participation. In a context of scarce human resources, does it make sense for anesthesiologists to spend time filling out pre-surgical questionnaires with data that already exists in information systems? And how many follow-up appointments for stable patients could have been replaced by a moment of asynchronous communication, when general practitioners have lists of up to 2,000 patients? How efficient is the time that nursing teams spend on follow-up calls without any kind of tool to gauge, in advance, which patients are stable and those where their intervention could really make a difference?

In order to reverse this scenario, two fundamental pieces are needed: technology - responsible for carrying out the tasks assigned to it - and care journeys - plans that indicate the route the patient will take from the moment they are diagnosed, linking all points in the healthcare system. The participation of medical doctors and nurses in the design and management of these journeys not only allows these professionals to identify the critical points where the technology is effectively useful, but also to determine the tasks that can be delegated to it, guaranteeing an effective allocation of tasks and greater control and autonomy over the care process.

Like an orchestra, guided by the musical staff, care journeys guide the actions of all the professionals and the technology. Each team "plays its instrument" autonomously and in rhythm. The medical doctor is freed from undifferentiated tasks, moving from the role of executor of any and all tasks to focus on high-value tasks, conceptualization and management - like the composer and conductor of an orchestra.  

Our system already has top musicians - health professionals - and new instruments continue to arrive with promises of intelligence, precision, predictability and security. What's missing? The distribution of musical staffs, which unify different levels of care and multidisciplinary teams and identify exactly which note each instrument should play, in order to increase care predictability, units' differentiation and professionals' specialization.

Staffs and conductors make healthcare work harmoniously. 

In the orchestra that is healthcare, there is a lack of conductors. 

Na orquestra que são os cuidados de saúde, faltam pautas e maestros. 

Integrated care optimizes resource allocation based on patient risk levels, fosters clinical coordination to ensure compliance with best practices, and leverages interoperability to create a seamless system where data flows efficiently across all necessary platforms.

It might seem like a distant prospect, but it's precisely what the HIMSS CCMM model aspires to achieve: optimized data utilization, minimized disruptions in patient care, and leadership and governance structures that support a comprehensive, region-wide approach to addressing local healthcare needs.