UpHill Notation


A new way to create, read and share clinical pathways

We know that each algorithm is unique. But why does their representation have to be different?

Inconsistencies in the representations raises subjectivity, hinder faster reading and compromises the adoption of clinical pathways.
This is our motivation to create a clinical universal language.
A solution to share and discuss clinical pathways in a clear, simple and consistent way:
  • Actions | Rectangle: activities to be made (requisitions, prescriptions, etc.);
  • Decisions | Diamond: moments of choice according to criteria and decision options;
  • Endings | Circle: Defines the patient's final status on a given path;
  • Connections | Arrows: to express the relationship and sequence between actions/decisions/ends.

With this notation I can represent algorithms in less than 2 hours. Rethinking the process and aligning the steps we make every day is a valuable asset.

Camila Pereira

Psychiatric Intern, Centro Hospitalar Psiquiátrico de Lisboa

How to begin?

Step by step guide to design a clinical pathway

Representing algorithms can be quite challenging. Expressing the complexity of the relations between each moment of decision, evaluation and even reflection is not always linear. That is why we have created UpHill Notation.
To start representing an algorithm, it is important to know the initial moment. Does the patient have a confirmed diagnosis? Or does he arrive with a suspicion? What are the inclusion and exclusion criteria? Defining this initial moment is crucial for a correct representation of the algorithm.

What should I do next?

After understanding the context of the algorithm to be represented, each moment must be sequentially framed. The purpose is to be able to express the relationship between actions, be it temporal or causal.


Activities to be made

Actions are all moments on the algorithm where an activity must be done. This category includes objective examinations, prescription of drugs and other therapeutic attitudes or the request for additional diagnostic tests.

How to put into practice

Let's consider the HFpEF algorithm:
“If the patient shows signs and symptoms of congestion, a Diuretic should be prescribed along with a Beta-Blocker and a ACE inhibitor/ARB”
“If the patient does not show signs and symptoms of congestion, only a Beta-Blocker and a ACE inhibitor/ARB should be prescribded”


Choosing moments

Decisions are all moments when a choice has to be made according to a criterion, whether is the patient's condition, signs and symptoms or clinical results.
Decision moments can have one or more options.
The maximum number of paths that can be followed is defined by the number inside the diamond shape. For example, if this number is “1” then only one of the paths can be choosed.
If the number is joined by a “+” it means that one or more paths can be taken.
In these moments of decision, a criterion can sometimes be applied, usually in the form of a question in which the answer to that criterion defines the path to be followed.
If there is no criterion, then the path is defined by itself.

How to put into practice

Let's consider the HFpEF algorithm
“If the patient has K +> 5.5 , still symptomatic and with LVEF <35%, an MRA must be prescribed. If the patient is not symptomatic and has LVEF <35%, then he is under control.”


Completion of a path

Endings are all moments of completion of a path of the algorithm. An end is not necessarily the moment of completion of the algorithm itself but be the end of one path.
All elements of the pathway, actions or decisions, can finish with an ending. When this occurs, the circle must be followed by the patient's final state for the respective path.
Several actions or decisions can have the same ending.
The same ending can be shared by different actions or decisions, even if they occur at different times or phases.


Connections between elements

Connections are all the relations expressed between elements. These relationships should mirror the sequence, temporal and / or casual between actions, decisions and ends.

Tip from UpHill

To help with the reading, the arrows should always follow the same direction: from left to right or from top to bottom.

Whenever there are repeated actions as a cycle, such as drug titrations, these paths must be represented by a dashed line.
For example, if among actions there is a time criterion to be applied, it must be described above the connection arrow.

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