At UpHill you’re able to work wherever you prefer. Feel free to work fully remote, we have team members all over the world!

Remote

Engineering

Interoperability Engineer

Edifício Mythos, Av. Dom João II 42
1990-095 Lisboa

Lisbon

Sales

Sales Development Representative

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

UpHill Health

Associate Professor in Health Management and Leadership at FCS-UBI, ISCTE-IUL, ISCSP-ULisboa

Introduction to eHealth in the context of national and EU challenges

To better understand current trends and directions of eHealth in the European Union (EU) there are three fundamental referential and what are three more specific, yet very relevant, tendencies or lines of work being explored right now. The three fundamental referential documents are:

Although different the lines of focus that these document outline, they obviously intersect with each other in more than one way. They also have relevant differences namely regarding proponents, commitments, and target audiences. All of them, currently condition lines of work in EU funding for research and developments, for interoperability and harmonization efforts, as well as eHealth implementation projects more broadly.

Such conditioning is not just at EU level, like for example cross-border eHealth Digital Services like country-to-country exchange of ePrescriptions, but actually and increasingly, at national level. This is very important trend to analyze as, in the EU, health is a prerogative of member states, ie. it is not part of the treaties that establish the EU. However, thought the fact that there are cross-border movement of goods, services and citizens, there is not just a growing need for harmonization and interoperability, but actually since the publication of the, so called, Cross-border care directive (DIRECTIVE 2011/24/EU), there are also legal imperatives for cooperation.

The Digital Single Market (DSM) also acts as a powerful enabler as communications and digital markets are regulated at EU level and via that way influence and cooperation is needed and justified increasingly in the areas of eHealth and Digital Transformation. Regarding the Digital Single Market Strategy, it is built on three pillars. These have influenced many calls and ongoing support actions. With regards to eHealth it has meant an important energy in standardization work as one of the challenges is the lack of interoperability in the many existing technologies and applications, which limits the “single” digital market, dividing it into language or country markets. The downside of this is larger costs for healthcare providers as they face low competition, severe vendor lock-in and difficulties in switching systems if they so desire.  The MWP 2018-2021, and its support Joint Action (eHAction) have four areas of work of which “overcoming implementation challenges” included efforts related to interoperability, e-skills for professionals, data protection and data security and evaluation, which are highly relevant.

Finally, in 25th April 2018, following a mid-term review of the DSM strategy, the European Commission felt a need to focus some of the aspects and principles of the DSM, into the specificities of modern health and future health and care in the Union. The Communication highlights the importance of advancing the Digital Transformation of Health and Care (DTHC), laying out three priorities to be followed in the coming years. This is very useful document for eHealth and Digital Health strategic planning and its three outlined priorities, to some extents relate directly to the three pillars of the DSM. Of higher relevance to this paper is pilar 1: “Citizens’ secure access to electronic health records (EHRs) and the possibility to share their records across borders, and the use of e-prescriptions”. In sequence we saw the publication of the Recommendation on the European Eletronic Health Record exchange format (EHRxF), based on which the eHealth Network approved important recommendations on the Interoperability ecosystem and funding criteria linking for the first time funding of projects and structural funds to interoperability solutions and harmonization efforts and setting the grounds for conditioning EU funding in the future Multi-Annual Financial Framework (MFF 2021-2027).  The three recent tendencies of focus from the European Commission that trigger action in EU Member States, and which deserve special attention by health leaders are:

These are not isolated items, but rather new focus of attention within the scope of the strategies presented before. These trends are somehow future looking, necessary research and development efforts, but link to interoperability of systems and information in health as they all have two things in common: i) need for large volumes of interoperable datasets, and ii) high quality of the data, with regards to its semantic interoperability and its capacity to be a true capture of health reality.

LOST Interoperability framework, LOST-IIS, and healthcare guide for interoperability

Many years ago, the EU has adopted the famous European Interoperability Framework, which has been further refined and adapted to health into 6 layers, but the famous four, 

LOST) interoperability layers are still the best way to explain interoperability to non-technical people.

Finally, however, I have argued that the famous LOST interoperability framework should be enhanced with two final ‘I’s’ and an ‘S’, which would stand for:

A LOST-IIS approach to digital health is needed at all levels: from Global to National, and from National to local and institutional. Through a holistic global and sustained approach to digital health worldwide, I believe we will see digital health as the only way forward for Universal Health Coverage, for fair and balanced healthcare transformation. Such transformation starts in healthcare organizations but also extends to digital solutions providers who benefit from participating in forums such as, per example, HL7 Chapter Portugal or its equivalents in other countries.

Interoperability challenges and (re)Emerging Technologies

At present, the main ehealth interoperability challenges are:

Interoperability is much more than technical interoperability; the organizational dimensions are perhaps the least appreciated and ill-managed by healthcare organizations. Multidisciplinary boundary-spanning capacities are needed to consult and help healthcare organizations excel in how they integrate with others and integrate their services, value circles and, at the end of the day, deliver or foster better health and care.

Levels of interoperability in healthcare

Efforts to improve healthcare quality and providers’ efficiency have resulted in 

the production of practice guidelines and implementation of clinical pathways

. According to a 2019 European Observatory on Health Systems and Policies’ report, the use of clinical pathways has been growing in Europe since the 1990s, beginning in the United Kingdom, and spreading to most European countries. However, the European Pathways Association (EPA) concluded that, within the last decade, their use was low and mainly in acute care settings. The same document reveals that 

experienced professionals rank improvement of care quality and efficiency among the most important features of clinical pathways.

rapid access to evidence-based resources for professionals to support decision-making, treatment, care planning, referral, and follow-up. 

improve communication and teamwork in multidisciplinary teams

. Last, but not least, clinical pathways have also been reported to 

mitigate risk, be effective in improving patient care outcomes and reduce cognitive overload

A more recent study, conducted within the Department of Pediatrics of the University of Colorado School of Medicine, discloses physicians’ thoughts about clinical pathways’ benefits, covering all the above-mentioned areas. Thus:

Why measure the impact of clinical pathways?

Measuring clinical pathways’ impact provides decision-makers and healthcare teams a means for comparing outcomes resulting from standardized processes implementations within or across organizations, thus, being able to:

Essentially, monitor and measure how reality conforms with the clinical pathway promotes the identification of training needs, the quantification of HCPs' performance and medical processes improvement. Actually, if not properly adhered to, clinical pathways implementation will most likely be unsuccessful in enhancing the quality of the care provided.

How to measure: clinical compliance vs. clinical outcomes

Healthcare organizations that already measure clinical compliance with a pathway usually have an incorrect, not updated, or oversimplified view of the actual conduct in a patient careflow. 

Quality measurement has focused mainly on clinical isolated outcomes of care in specific settings (e.g. length of stay, costs, infection rate, etc.). Although these measurements provide valuable information, the diagnostic and therapeutic actions must be considered as well, that is to say compliance measure.

To achieve all the aforementioned goals, you need more than to look at the results. It is often the case that a hospital measures an outcome, but don’t know which decisions led to that particular result and, by widening the time frame, results fluctuate randomly.

By comparing the collected data with the prevailing clinical pathways, it is possible to identify where the care given has deviated from the expected and quantify the compliance level. 

In practice, hospitals have information systems to capture the treatment behaviors and the details of a patient treatment journey. By comparing such data with the regulations of a clinical pathway, it is possible to assess the compliance of healthcare professionals to the expected course of care and understand the main deviations.

All in all, which actions were missed should be identified and understood, but also the ones executed even though are not recommended, performed in the incorrect order, or within the improper timing.

Our role is to bring actionable clinical pathways to hospitals, making them available for healthcare professionals to train and decide. Therefore, reducing the time it takes for scientific innovation to have an impact in care settings, improving patient outcomes, and making organizations more predictable in terms of costs and results.

Measuring the impact of clinical pathways

The provision of quality hospital services 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 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:

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 

 whether certain practices were really followed, and 

 into resource utilization and performance-related aspects. At this point, we’ve arrived at the three main current types of process mining: 

The first two dimensions mentioned – discovery and conformance checking – can be applied to implement and evaluate clinical pathways compliance. In a first moment to design or redesign processes within a healthcare unit, and after for performance analysis and conformance checking.

This perspective is particularly interesting when it comes to assessing the compliance between a 

 - the term assigned to the evidence-based medical treatment processes of operational nature that healthcare professionals should act in accordance with - and the real medical behaviors.

Clinical pathways provide detailed guidance for each stage in the management of a patient (treatments and interventions), but multiple variances may still unavoidably occur due to individual complexities and subjectivity. 

 Due to the gap observed between what is stated by updated scientific evidence and effective care settings, clinical pathway compliance checking is of utmost importance in the healthcare environment.

For this purpose, when applying process mining techniques and technologies, healthcare organizations are able to compare a given process model with all process executions in reality. The objective is to output a set of compliance metrics to measure the observed deviations. Gathering insights on the actual clinical practice is receiving increasing attention, due to the potential of the information extracted. In the mentioned scenario, clinical pathways compliance analysis is the process of discovering knowledge about how clinical activities impact the patients careﬂow and using the discovered knowledge for: 

Despite the difficulties due to the richer diversity and complexity of medical behaviors over other business processes, discovering process models and analyzing their performance provides relevant opportunities for extracting knowledge out of the abundant information recorded in a hospital’s EHR.

Process mining in healthcare management

Acute Otitis in children

Asthma

Chronic obstructive pulmonary disease (COPD)

Community Acquired Pneumonia

Congenital nasolacrimal duct obstruction 

Conjunctivitis

COPD

Coxarthrosis 

100+ pathways available for your medical teams

Homepage

Heart Failure

Gonarthrosis

Atrial Fibrillation

Coxarthrosis

100+ pathway templates ready to use

Explore some of our use cases for Hilly, the digital assistant designed for health teams that automates care. 

Anesthesia

Surgery follow-ups

Diabetes Mellitus type 2

Rheumatoid Arthritis

Cancer Treatment

Prostate Cancer

Gastroesophageal Reflux Disease

Gastroesophageal reflux disease

Pathways with Hilly

Explore our pathway library with more than 100 templates ready to use, including clinical pathways for acute and chronic diseases. 

Pathway Library

Move towards Patient-Centered care with UpHill

Move Towards

Explore our pathway library with more than 100 templates ready to use, including clinical pathways for acute and chronic diseases.