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

Reinforcing nursing roles through care journeys

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

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Fragmented care delivery, with limited coordination among providers and healthcare settings, is leading to medical errors

higher affluence to emergency departments across the globe

revenue losses due to surgery cancellations

, and so on. However, recognizing the need for more integrated and patient-centered care, the concept and strategies of care orchestration emerged and refer to the coordination and synchronization of healthcare activities across multiple providers, settings, and time frames to optimize patient outcomes. 

Over time, technological advancements, such as electronic health records (EHRs) and 

, have been playing a crucial role in enabling seamless information sharing and communication among care teams, but care orchestration is not a well stablished reality yet. On the other hand, primary care physicians are increasingly tasked with coordinating services delivered not just by other specialists and hospitals but also by home care professionals and social service agencies, experiencing several gaps when it comes to keep track on patients’ progress.

Can care orchestration be the light at the end of the tunnel for these professionals?

Back to basics: major challenges of being a family physician

Ensuring seamless transitions of care between different healthcare settings, coordinating with specialists, and maintaining effective communication on top of such struggling daily work is quite challenging. 

And that’s why care orchestration must kick in. 

Intelligent, automated, and evidence-based care journeys: increasing autonomy and capacity in primary care

UpHill is a clinical pathway software that integrates with existing information systems to automate tasks and bridging gaps in care. With UpHill orchestrating care, providers 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.

For primary care this means autonomy, capacity, visibility/traceability, prioritization and proximity. 

Decision support system increasing primary care autonomy.

A decision support system plays a vital role in increasing primary care autonomy for diagnosis and treatment while simultaneously upskilling generalist physicians and delivering self-sufficient primary care. By leveraging 

, these systems provide comprehensive and real-time clinical decision support in making accurate diagnoses, choosing appropriate treatment options, and, when empowered with communication tools, monitoring patient progress. Ultimately, decision support systems revolutionize primary care, enabling physicians to deliver efficient, accurate, and patient-centered care independently.

Structured referrals and visibility over patient progress enhancing collaboration.

 Having clear referral criteria, on top of a predefined care journey, ensures that patients are referred to the right specialists or healthcare facilities, minimizing unnecessary referrals and improving the efficiency of the healthcare system. Additionally, interoperability capabilities enhance the accuracy of referrals by considering a wide range of patient-specific factors, such as medical history, symptoms, and test results, which may not always be readily apparent to the referring physician. Finally, it works bilaterally ensuring primary physicians real time visibility over patient progress.  

Task automation increasing primary care capacity.

By automating routine and repetitive tasks, primary care providers can streamline their workflow and focus on delivering essential patient care. Administrative tasks, such as appointment scheduling, patient follow-up, data entry, and documentation, can be automated, freeing up valuable time for physicians to concentrate on direct patient interactions. This increased efficiency allows primary care providers to see more patients within the same time frame, effectively expanding their capacity to deliver care. Moreover, automation can facilitate the management of chronic conditions by automating reminders for medication adherence, scheduling follow-up appointments, and monitoring patient progress.   

Real time monitoring enabling prioritization. 

prioritization is the escape root when demand is great, and resources are limited

. By leveraging advanced technology and real-time data, primary care providers can monitor patients' health status, track key indicators, and identify individuals who require immediate attention or urgent interventions. This proactive approach allows for timely intervention and prevents potential complications, by alerting primary care providers to critical changes in a patient's condition and enabling them to prioritize and allocate resources accordingly.  

To listen more about on how UpHill is helping primary care units to face an always growing demand while conciliating remote monitoring, care prioritization and close patient-doctor relationship, 

Benefits of care orchestration in Primary Care 

Patient care is a complex process that involves multiple healthcare providers, care settings, and interventions. In this respect, care orchestration is an approach that aims to improve the coordination and management of patient care by leveraging technology and data analytics. It is becoming increasingly important in the healthcare industry, as it streamlines clinical workflows, reduces administrative burden, and enables more personalized care, while helping to drive efficiencies and improve the quality of care.

A care orchestrator software is designed to provide multidisciplinary care teams – that can work in different healthcare institutions -, with a single view of a patient's health status, which allows them to make more informed decisions and provide more effective care. It can be defined as:

However, plugging new software in the Hospital Information System (HIS) is not a bed of roses. Limited usefulness, poor usability, challenges with the usage of multiple systems, lack of customizability, siloed data, privacy concerns, and lack of standards are frequently mentioned as barriers for the sustainability of digital health interventions. At stake is the viability of the projects due to lack of engagement and adoption by clinical teams.

Clinical teams’ resistance: that’s all about time and perceived usefulness

When it comes to understand clinical teams’ reluctance to new technologies, resistance to change in established routines, hesitance due to patient safety issues, concerns for the quality of care, opposition to technology itself, tension between standardization and autonomy or independency, are frequently cited on the literature.

As we perceive it, such complex problem, can be wrapped in two words: time and usefulness. Clinical teams are typically very busy and have a lot of demands on their time, so any software that is introduced needs to be user-friendly, seamless, and not add additional stress to their workload.

In other words, any technological solution should present clear benefits when it comes to save time and clearly solve a pre-identified need. There is no room for any doubt or ambiguity, and even less to implement something that adds no value.

Tip: UpHill will hosted a webinar - Interoperability that works: making healthcare easier to deep dive into those topics. 

  to understand how our software overcomes the most common challenges faced by IT teams and allows them to reconcile clinical teams' needs, the best technological practices, and standards, while using the HIS infrastructure.

5 tips to keep in mind when looking for a care orchestration software

1. Real-time data integration and analysis

Care orchestration software should be capable of integrating real-time data from multiple sources, such as Electronic Health Records (EHRs), medical devices, and wearables. The software should be able to analyze this data to provide a comprehensive view of a patient's health status, including medical history, current conditions, and ongoing treatments. By doing so, care teams can make informed decisions and provide more personalized care to patients, according to their needs in real time.

Care orchestration software should facilitate collaborative care coordination among healthcare teams and providers. The software should enable providers to communicate with each other, share information, and coordinate care plans in real-time. This will help to reduce medical errors, anticipate decisions, improve patient outcomes, and increase patient satisfaction.

interoperable with existing hospital infrastructure

. This means that it should be able to integrate with EHRs, medical devices, and other healthcare applications, and be able to:

Interoperability is essential for ensuring that care teams have access to the most up-to-date patient information, without workload duplication, which is critical for providing high-quality care.

Care orchestration software should meet the highest standards of security and compliance. This means that the software should be designed with robust security features to protect patient data from cyber threats, and comply with HIPAA regulations, which set strict standards for the collection, use, and disclosure of patient health information.

Productivity enhancing features and user-friendly interface

Healthcare days are fast paced; clinical teams are often under pressure to manage a large number of patients, handle administrative tasks, and collaborate within more and more complex teams among different providers. A care orchestration software that simplifies and streamlines workflows, while providing tools to enhance clinical teams focus on what matters – highly differentiated tasks and the patients that most need, make a significant difference in hospitals’ capacity and the quality of care provided to patients.

Looking forward to dive deeper on this topic? 

 to discuss how our software overcomes the most common challenges faced by IT teams and allows them to reconcile clinical teams' needs, the best technological practices, and standards, while using the HIS infrastructure.

What to look when you pick a care orchestration software

Nurses play a critical role within healthcare systems as they are essential to delivering safe, high-quality, and patient-centered care. They are often on the front lines of patient care, providing compassionate and holistic care to individuals across the life cycle, from newborns to the elderly. On top of that, they have a distinctive position within the healthcare institutions - due to the wide scope of their work - combining both a 

comprehensive knowledge of patient flows between different settings and departments

, and a stirring role when it comes to build multi-professional and multidisciplinary care plans. 

Nurses are the direct responsibles for deliver holistic patient care; they collaborate with other healthcare professionals to optimize patient outcomes, serving as advocates for patients, ensuring their physical, emotional, and psychosocial needs are met; and also play a pivotal role in health promotion, disease prevention, and patient education.  

invaluable members of the healthcare team

, contributing to the overall health and well-being of patients and their families. 

Taking advantage of the changing landscape of health care  

As the face of health care changes, so do the roles and opportunities for today’s nurses. The major ones include:  

The use of technology in nursing has rapidly advanced over the last decade. This includes the adoption of electronic health records (EHRs), telehealth and telemedicine, remote patient monitoring, and other digital health solutions to improve patient care, streamline workflows, and enhance communication with patients, caregivers, and among healthcare team members

There has been a growing trend towards expanding the scope of practice for nurses in many countries, allowing them to take on more responsibilities and provide a wider range of services. This includes advanced practice roles such as nurse practitioners, nurse anesthetists, and clinical nurse specialists, who can manage patients' health conditions independently.

Evidence-based practice (EBP) has gained traction in nursing, with a growing emphasis on using the best available evidence, along with clinical expertise and patient values, to guide nursing care decisions.

Interdisciplinary collaboration and teamwork have become more prominent in nursing practice, with a growing recognition of the importance of collaboration among healthcare team members to provide safe, efficient, and patient-centered care. This includes improved communication and coordination among nurses, physicians, pharmacists, nutritionists, and other healthcare professionals.

Simultaneously, the challenges of current health systems are there for everyone to see: living longer is a reality, but living better is a challenge given the increased multimorbidity associated with ageing populations, younger generations are increasingly prioritizing health and well-being, and there is also a growing expectation for convenience and accessibility (including for innovative therapeutics and technological solutions), increasing pressure on global systems. 

On the other side, there is an unprecedented critical workforce shortage that has been exacerbated by the COVID-19 pandemic. According to the World Health Organization, by 2030 there will be a shortage of more than 10 million professionals worldwide,

As such, health systems need to adapt to meet the continuously increasing demand, and from a nursing perspective there are, in current practice

, several opportunities for process improvement empowering nurses with greater autonomy, efficiency and efficacy, by redesigning care with digital care journeys

, with a focus on patient safety and patient education and self-care.

Why and how? That’s exactly what we’ve explored in our 

Care journeys design and implementation: nurses' roles in every step of the way 

The role of nurses involves coordinating and managing the care of patients throughout their journey, from admission to discharge, long lasting follow-up, and for every transition to another care setting. 

At UpHill, we define the process of care journeys design, adjustment, implementation and evaluation in 4 stages and, as described below, nurses play a critical role in all of them: 

Nurses playing as gatekeepers of patients’ flow 

Given the deep knowledge hold about the patient's journey through several settings - from inpatient, emergency room, operating room, day hospital, home hospitalization, etc. - and their detailed understanding about the institution structure, nursing teams have a pivotal role in supporting the construction of the care journeys, developing holistic care plans based on evidence-based practice and patient values and expectations, the decisions to be made and by whom, collaborating with other teams to set appropriate goals and interventions for each stage of the care journey.  

Nurses leading change management in healthcare institutions

This step is crucial to fit best practices to the institution's unique context. Nurses play a key role in communicating with other healthcare professionals, hospital managers, IT managers and other staff, and anticipating patients’ needs and values in the wider socio-economic context in which the institution is placed. They ensure that all members of the healthcare team are working together seamlessly, facilitating effective communication, and coordinating services, and resources, as needed. Once again, nurses' knowledge of the institution's functioning is relevant to ensure that it is out of line with reality and to bring all the people (including patients, families, and caregivers) into the project. 

Nurses provide direct patient care, implementing the care plan, administering medications, monitoring patients' condition, participating in referrals, and evaluating the effectiveness of interventions. They also educate patients and families about the care journey, including self-care interventions, managing symptoms, and understanding the goals of care. With a digital care journey, nursing teams have visibility on the patient's progress, accurately identifying the moments when decisions need to be anticipated, therapeutics need to be adjusted, or the patient need to be redirected to another level of care, getting greater autonomy in care provision. Interprofessional collaboration is strengthened by the fact that all have access to the same information, and communication with the patient is also reinforced by the mechanisms of asynchronous communication and regular follow-up.  

, based on clinical criteria - instead of first-in first-out (FIFO) approach - thus driving healthcare institutions to improve allocative efficiency, by deciding which patients should be seen, and whom should be seen first, when demand is great, and resources are limited. 

Nurses as promoters of quality improvement

Nurses are responsible for accurate and timely documentation of patient care, including assessments, interventions, and outcomes. They participate in quality improvement initiatives to continuously evaluate and improve the care journey for patients. Empowered by care journeys, nursing teams access analytical data that allows them to assess compliance with best practices, identifying the most critical points of the journey and areas for improvement, with a special focus on patient safety data. Lastly, such data can be used for research purposes and to inform better health policies to improve patient and health outcomes. 

If interested in going deeper on this subject 

 about concepts, methods, and challenges surrounding care journeys implementation and 

 in which there were shared personal experiences about implemented projects. 

Reinforcing nursing roles through care journeys 

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​ 

Recognizing the need for more integrated and patient-centered care, the concept of care orchestration emerged and encompasses several strategies to drive improvements in healthcare quality, patient experience, and health outcomes. In this webinar, we deep dive into the advantages it provides for solving major challenges that shape primary care.

In this session we cover how care orchestration increases primary care capacity and improves patient stratification. 

UpHill's Projects Preview is a webinar series presenting care automation, care integration and patient monitoring projects being developed by UpHill with top healthcare institutions.