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Interoperability Engineer

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

UpHill Health

Transcrição de registos clínicos por voz, receitas sem papel, agendamentos e prescrições automáticas, doentes seguidos por assistentes automáticos ou mesmo cirurgias auxiliadas por robots não são ficção científica. A somar aos anteriores há inúmeros exemplos de como a saúde digital redesenha a forma como a Saúde alcança, interage, previne e trata os cidadãos ao longo de uma relação que se quer cada vez mais contínua, proativa, próxima e segura.

De acordo com os resultados da 2.ª edição do 

, a teleconsulta é a área mais explorada em Portugal - utilizada em 30% das instituições do sistema de saúde – sendo que a gestão do doente crónico (telemonitorização) é apontada como a solução de Inteligência Artificial com maior potencial de implementação por praticamente metade das instituições. A baixa literacia ocupa o lugar cimeiro na lista de barreiras ao desenvolvimento de mais projetos.

Neste artigo, construído com base na apresentação feita no âmbito da sessão “Tecnologias digitais no acesso a tecnologias de saúde”, exploro as oportunidades, as necessidades e os desafios da saúde digital, sob o ângulo das soluções digitais enquanto ferramentas para melhorar a prestação de cuidados de saúde.

Mais doentes, mais tecnologia, mais investimento e sistemas de saúde que gritam por alternativas

Vivemos hoje a tempestade perfeita para o crescimento da saúde digital. Em pano de fundo, o crescimento contínuo da população global, alimentado pela esperança de vida progressivamente mais longa: as estimativas apontam para que a população mundial com 60 anos ou mais atinja o marco dos 2 mil milhões em 2050

, praticamente o dobro dos números atuais, evidenciando-se, assim, a idade como um fator de risco adicional para a multimorbilidade e para a necessidade de articulação de cuidados multidisciplinares, em jornadas de cuidados contínuas.

O volume e necessidades aumentam, mas, na sua maioria, permanecem sem resposta. De facto, para responder ao aumento do número de doentes com múltiplas doenças crónicas seriam precisos mais 40 milhões de profissionais de saúde, a nível mundial, até 2030.

 No entanto, Na Europa, mais de 40% dos médicos irão reformar-se nos próximos 10 anos.

Os sistemas de saúde estão à beira do colapso e o relatório da 

Evolução do Desempenho do Serviço Nacional de Saúde em 2022

, publicado, recentemente, pelo Conselho das Finanças Públicas, reforça a ideia de que é preciso encontrar alternativas. O aumento da atividade já não é suficiente para reverter a situação: em 2022 realizaram-me mais 138 mil consultas hospitalares e mais 95 mil operações cirúrgicas que em 2021, mas as listas de espera – tanto para primeira consulta como para cirurgia – continuaram a aumentar.

Nem tudo é mau: conectividade e digitalização são apenas dois exemplos de palavras que invadiram o discurso comum e não foi por acaso - medeiam a forma como vivemos, como nos relacionamos, como interagimos. Se por um lado, as pessoas têm mais necessidades e exigências – tanto na saúde como na doença – estamos também perante gerações indubitavelmente mais digitais e conectadas que as anteriores.

Numa altura em que o desequilíbrio entre as necessidades da população e a disponibilidade de recursos humanos na saúde enche manchetes e alimenta acesos debates públicos, a saúde digital representa, indubitavelmente, uma janela de oportunidade. Por um lado, permite investir na prevenção e intervenção precoce, reduzindo a necessidade dos doentes serem admitidos num hospital ou outra instituição de saúde; por outro, pode mesmo substituir tarefas de baixo valor que ainda consomem muito tempo de profissionais de saúde altamente qualificados, sem motivo que o justifique.

Adicionalmente, as soluções de digital health estão também a proliferar a uma velocidade sem precedentes e a hegemonia dos EUA enquanto berço destas soluções começa a dar sinais de abrandar: de acordo com os dados da CB Insigths, 25% das empresas tecnológicas mais promissoras da área estão fora dos Estados Unidos,

 o valor mais alto de sempre. Crescem e diversificam-se as soluções e cresce também o investimento, neste caso na ordem dos 3 mil milhões de dólares por trimestre.

editorial publicado na última edição do New England Journal of Medicine

, a saúde digital deve, à semelhança de toda a medicina, ser baseada em evidência e contribuir para gerar evidência. E nesse capítulo há também vantagens já documentadas. Eis alguns exemplos:

Literacia e interoperabilidade: os desafios que permanecem depois da tempestade

 A integração de soluções digitais na prestação de cuidados, que se quer, por motivos de eficácia, eficiência e redução de custos, 

, vai ser cada vez mais difícil quanto mais fragmentadas são as soluções utilizadas. Neste contexto, é fulcral o investimento em 

, o desenvolvimento de sistemas centrais, que sejam pensados numa perspetiva de plataforma e não de produto, bem como desenhados processos assistenciais de cuidados – ainda antes de serem digitalizados.

Por outro lado, é imperativo promover a equidade no acesso a tecnologias de saúde e, neste âmbito, considerar o investimento em literacia em saúde, mas também uma lógica de comparticipação para que aquilo que já está disponível não seja apenas utilizado por quem pode pagar. De facto, o relatório 

Digital Health in the European Region: the ongoing journey to commitment and transformation

 publicado no início do mês pela OMS, aponta o fosso digital no domínio da saúde como um dos principais riscos para o futuro dos sistemas de saúde na era digital.

De acordo com o documento, o fosso está a ser criado devido à implantação e aceitação desiguais das soluções digitais e implica que milhões de pessoas em toda a região da Europa e Ásia Central ainda não podem beneficiar da tecnologia de saúde digital. É urgente resolver esta desigualdade através de investimentos específicos em tecnologia e do desenvolvimento de competências e capacidades dos prestadores de cuidados de saúde, para que todas as pessoas possam aceder e utilizar com confiança as tecnologias de saúde digitais, em especial as mais suscetíveis de beneficiar, no entanto, pouco mais de metade dos países da região desenvolveram políticas para a literacia digital em saúde e implementaram um plano de inclusão digital.

"É uma triste ironia que as pessoas com competências digitais limitadas ou inexistentes sejam frequentemente as que mais beneficiam das ferramentas e intervenções digitais no domínio da saúde, como os idosos ou as comunidades rurais. É necessário resolver este desequilíbrio para a transformação digital do sector da saúde", afirmou Hans Henri P. Kluge, diretor regional da OMS para a Europa, citado em comunicado de imprensa.

Uma nota final para a necessidade de monitorização da evidência associada a estas soluções, tanto pelos fabricantes como pelas autoridades competentes e para a urgência de uma estratégia de dados nacional, assente na adoção de standards e no estabelecimento de requisitos mínimos para os fornecedores de software.

O caminho: saúde digital enquanto enabler de sistemas de saúde mais equilibrados

Os sistemas de saúde caracterizam-se, atualmente, por participações desiguais por parte de profissionais de saúde e utentes.

Aos profissionais de saúde cabe a gestão do doente, burocracias inerentes ao dia-a-dia, prevenção da doença, seguimento – nomeadamente da doença crónica – resultando num volume de tarefas extremamente pesado e variável no que diz respeito à sua complexidade. A título de exemplo, um relatório divulgado pela AMA, revela que um terço dos médicos gasta pelo menos 20 horas por semana em tarefas administrativas, num contexto em que a carga laboral é a principal causa de burnout destes profissionais.

Por outro lado, o utente está, na generalidade dos casos, desconectado do seu percurso de cuidados, desinformado acerca do mesmo, o que justifica a não adesão ao plano terapêutico e a sua baixa eficácia. Além do impacto nos outcomes, esta problemática é também sinónimo de custos acrescidos: no caso das intervenções cirúrgicas, 1 em cada 5 cancelamentos deve-se à falta de comparência dos doentes que poderia ser revertida com maior envolvimento dos pacientes na jornada de cuidados e melhor de navegação.

A saúde digital, alicerçada no redesenho dos processos, em modelos tecnológicos fundacionais e em plataformas generalizadas - disponíveis à generalidade dos cidadãos - equilibra os sistemas de saúde, conferindo mais resolutividade ao utente e reduzindo, simultaneamente, a utilização de recursos.

Porquê? Porque permite aumentar a continuidade e proximidade dos cuidados, sem aumentar o volume. Permite, por exemplo, substituir consultas de seguimento por momentos de comunicação assíncronos e automáticos; aumentar a frequência de seguimento dos doentes após a alta cirúrgica, aumentando, consequentemente, a sua segurança; evitar complicações, identificando-as precocemente e capacitando os doentes sobre os comportamentos a adotar.

Em suma, a saúde digital permite aumentar o perímetro dos modelos de saúde tradicionais para dimensões que são exigidas pelos utentes – doentes e saudáveis.

Saúde digital e os elementos para a tempestade perfeita

In the digital age, where healthcare information is stored electronically and medical devices become smarter by the day, ensuring the security and privacy of patient data is paramount. Cyber threats have been on a relentless rise, with staggering numbers indicating the magnitude of the problem. According to a Norton report

In fact, the healthcare industry has increasingly become a prime target for cybercriminals. These attacks are motivated by the value of medical data on the black market, as well as the potential for disrupting critical healthcare services.

This is just a sample of the cyber-attacks that have already made the news this year. A phenomenon that knows no boundaries, to which not even the most developed health systems have escaped unharmed, and which calls for increasingly robust security requirements.

Today we are proud to announce a significant step in our journey to establishing safety as our primary core value. 

We are now certified with ISO 27001:2022, reinforcing our commitment to protect healthcare information with the utmost care and diligence.

Back to basics: what is ISO 27001 certification?

ISO 27001 is an internationally recognized standard for Information Security Management Systems (ISMS). It provides a systematic approach to managing sensitive information and ensuring its confidentiality, integrity, and availability. 

ISO 27001's best-practice approach ensures that organizations manage their information security by addressing people, organizational, technology and physical aspects.

UpHill is continuously monitoring its overall security posture, with more than 200 distinct controls being actively checked in our assets, that map with the requirements from ISO 27001 and ISO 27002.

What does it mean to be certified under the 27001:2022 version of the standard?

One of the aspects that sets UpHill’s certification apart is that it was achieved using the latest version of the standard - ISO 27001:2022

, a major update of this standard (the previous version was from 2013, with minor changes in 2017).

ISO/IEC 27001:2022 has raised the bar for information security by incorporating a set of important controls that are in line with the current cybersecurity context. These additions cover a wide spectrum of essential domains, including threat intelligence, cloud service security, business continuity preparedness, and robust measures for physical security monitoring. The introduction of controls such as configuration management, information deletion, data masking, data leakage prevention, monitoring activities, web filtering, and secure coding further fortify organizations against modern cybersecurity challenges, ensuring comprehensive protection in today’s digital landscape.

For the last months, we’ve submitted UpHill to a meticulous and structured external audit, covering information systems, data protection, security software, authentication and access control, risk assessment and management, security policies, software development practices, among others. The successful completion of this audit underscores our dedication to adhering to the highest international standards of information security.

The audit was conducted by the British Standards Institution (BSI) – the entity who originally published this standard

. BSI Group supports 84,000 clients in 193 countries worldwide and is the preferred choice of renowned companies. 

Benefits of choosing UpHill as a tech partner

Being ISO 27001 certified is testament to the fact that UpHill prioritizes and ensures data security. But it also ensures the following:

Finally, a message of commitment and appreciation to all healthcare institutions – from hospitals to primary care units – and health professionals that have trusted us and continue to grow with us. We will keep working relentlessly so you all can be at your best.

Spread the good news: UpHill is now ISO 27001 certified by BSI

Spread the good news: UpHill is now ISO 27001 certified by the British Standards Institution

Long-lasting waiting lists for elective surgery, lengthy waiting lists for medical appointments and endless waiting times for medical care at the emergency room. The reality is well-known by worldwide healthcare systems:  

It is agreed that people have never demanded so much from the health sector and if nothing changes, those figures will keep spreading in the upcoming times with much more pressure ahead: an expected always growing demand contrasting with the health workers shortage are fostering the perfect storm for healthcare systems. 

Putting it plain, approximately one out of three adults suffer from multiple chronic conditions often requiring multiple interactions with different providers.

 On the other hand, the available human resources will be lacking - according to the World Health Organization, there will be a shortfall of 10 million healthcare workers by 2030.

Traditional and volume-based strategies (in which higher demand is addressed with more resources) are no longer enough, because there is a foundational shift pressing health systems: 

those systems were originally designed to deal with acute conditions, but today they must deal with an always growing number of chronic patients

, who require a long-term relationship with the healthcare system.  

We are talking about rethinking and redefining healthcare processes to 

, more efficient, and more responsive to today’s needs. 

More than broken services, healthcare systems need to deliver solutions.

The first takeaway that we would kindly ask you to keep in mind is that 

episodic care, planned based on steady timeframes, careless with the dynamic and unpredictable nature of clinical evolution is not adequate to meet the current needs

. Why? Because acute exacerbations of Ambulatory Care Sensitive Conditions don't happen at a set date and time.  

So, providers need to promptly address acute needs when they happen, or even better, anticipate them, especially because evidence shows us that around 25% of acute hospital admissions, could be avoided with timely interventions.

 Which means that resources – human, financial and physical - are being used sub-optimally.  

Allocative efficiency: the ability to do more with the same resources

The core of this subject can be briefly explained as the ability to allocate the right resources to the right patient at the right time, by improving allocative efficiency.  

In a scenario in which health systems must keep up with an exponential growing demand while keeping the same human resources – because they won’t be following the same rising trend - allocative efficiency arises as an essential ability to:  

Following this line of reasoning, allocative efficiency includes prioritizing patient care, by deciding which patients should be seen, and whom should be seen first, when demand is great, and resources are limited.  

Note: this is not about leaving patients unattended or lost on their own, it’s about adjusting the healthcare system answers to each patient, according to his/her risk, taking advantage of the health technologies already in place. 

Prioritization: a word to keep top of mind

Patient prioritization, defined as “the process of ranking referrals in a certain order based on criteria”,

 is one of the possible strategies to improve fairness in waiting list management. This practice differs from a first-in first-out (FIFO) approach that ranks patients on waiting lists chronologically, from triage methods used in emergency departments where patients are sorted into broader categories (e.g. low/moderate/high priority or service/no service). Prioritization is related to non-urgent services involving a broader range of timeframes and patient types.

UpHill approach: prioritization enabled by continuous and automatic monitoring on top of patient-centered care journeys

Care continuity is an unequivocal necessity for today's health systems, creating opportunities for transforming people’s experience of care from disjointed to coordinated, reactive to proactive, and service-orientated to personalized. 

the essential requirements to connect all the scattered dots of healthcare systems

. Long-short story: care journeys are the cornerstone to design a whole new system, without the weight of capital infrastructure, people-tied traditions, and data privacy and security out-of-proportion brakes. 

A multidisciplinary and comprehensive care journey works like a map that indicates the path that the patient will follow from the moment he or she is diagnosed, guiding care provision across different healthcare professionals, teams, departments, providers, and care levels. This is the guarantee that each patient receives the appropriate care at each point in time, regardless of where they are, precisely because all the stages the patients must go through and what happens at each stage were previously defined. 

 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. 

What does it have to do with prioritization? Everything. 

At UpHill, we think on patient prioritization for chronic diseases based on 3 connected dimensions that work on top of care journeys:

The example of two patients with chronic migraine

: currently, in most hospitals, two patients diagnosed with similar severity chronic migraine are followed-up in a sequential rational, based on steady timeframes that does not adapt to the progression of the disease, and for which little to no guidance is found on guidelines and evidence.

Meaning that two patients being followed by the same clinical team wait exactly the same time to be seen by their doctor again, even considering that:

Additionally, there is an information gap about the disease impact, symptoms evolution, etc., between appointments. In other words, by the time they arrive at their next appointment, patients may be stable (and the appointment is unnecessary) or have already experienced acute episodes that warranted their anticipation. Meaning, we usually use evolution-blind follow-ups.

: with a prioritization care approach, the patient's journey is much more adaptative to patient needs, that can be both 

 or identified by the clinical team. Follow-up mechanisms are triggered to assess the frequency, severity, and duration of crisis episodes and, when necessary, in-person appointments are brought forward.

Just like in the previous scenario, these two patients have the same type of migraine, but quite different clinical evolution, requiring different approaches:

Does prioritization work? “Please, show me the numbers.”

A systematic review of patient prioritization tools in non-emergency healthcare services states that “is difficult to assess these findings considering the variance between research settings and the nature of the considered prioritization system, tool, or process used in the studies”.

 However, it points out several studies that conclude that the prioritization process is associated with lower waiting times.

Additionally, feasibility studies show that 70% of follow-up appointments could be managed by telephone or video or did not need to happen at all

 - which indicates a clear room for improvement when it comes to improve allocative efficiency based on patient prioritization – and many others reveal the exorbitant costs of interventions that could be avoided through better risk stratification, care anticipation and patient prioritization.

patient-initiated follow-up use case with a Portuguese University Hospital

 with promising results: 65% of alerts were solved without an in-person visit to the hospital (saving time and resources) and only 22% of patients who triggered the patient-initiated follow-up were referred to the Emergency Department (avoiding unnecessary visits from other patients). 

 to better understand how UpHill can help your hospital improve allocative efficiency and patient prioritization.

Prioritization: when demand is great, and resources are limited 

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

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 

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. 

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