Oncology Care Journeys: saving time to deliver the best possible outcomes

ULS São José (São José Local Health Unit)

Managing oncology patients involves significant challenges, particularly ensuring multidisciplinary coordination and consistent information. These factors add complexity to an already urgent race against time. Discover how UpHill introduced the country's first digital and automated clinical pathway at ULS São José, transforming patient care.

~1000

Patients enrolled

117

Red flags identified

73%

Patient engagement

Hospital Insights:

9 hospitals and 39 primary care units
+1.8 million patients
~12 thousand chemotherapy sessions (per year)

Oncology care pathways are inherently complex, involving multiple specialties, teams, and facilities, often over extended periods. The fragmentation of information presents significant barriers to effective communication and decision-making, putting both healthcare professionals and patients at a disadvantage in the race against time.

Time is, indeed, a critical factor in oncology care. Despite the existence of well-established guidelines outlining best practices, implementing them remains a major challenge. This can lead to poorer patient outcomes and experiences and increased avoidable costs due to redundant care and preventable health deterioration.

Problem

Lack of real-time visibility into the patient's care journey.
Inability to track patients across different levels of care.
Information scattered across multiple systems
Difficulty managing follow-up processes for a large volume of patients.
Inability to prioritize patients and treatments effectively.
Lack of visibility into key bottlenecks.

Project Goals

Improve patient traceability and visibility throughout the journey.
Enhance coordination among multidisciplinary teams across different healthcare units.
Identify key obstacles in patient navigation.
Optimize waiting times throughout the process.
Identify patient needs at an early stage.
Enhance the patient experience and journey predictability.

Solution

Through a multidisciplinary and digital pathway, UpHill has translated theoretical guidelines into clinical practice, ensuring a personalized and centralized approach for each patient. The solution for oncology care provides complete visibility of the patient's status to the clinical team, while automatically tracking the patient's progress along the journey. Automation is also used for post-surgical follow-ups and oncology treatments.

This pathway ensures:

Mapping of all key stages in the oncology care journey;
Automatic patient enrollment at the first appointment;
Automatic progression of the patient throughout the care journey;
Automated follow-ups after surgery and during chemotherapy treatment;

Multidisciplinary and multi-level care journeys supported by a clinical pathway

The digital care journey for oncology patients at ULS São José is a comprehensive intervention designed to provide continuous and multidisciplinary care. It outlines the actions, decisions, and criteria for diagnosis, treatment, follow-up, and referrals in the management of breast and colorectal cancer patients. UpHill serves as a decision support system, ensuring standardized interventions by teams across different units and helping translate best practices into the local context at ULS São José. This involved thoroughly mapping the key stages of the oncology care journey, including assessment of suspicion, staging and multidisciplinary decision-making, therapeutic decisions, and monitoring of patients in the post-operative phase and/or during treatment.

“Clinical pathways have been in place for a long time, but in practice, they are often only theoretical. This approach turns theory into practice, enabling the patient to be managed in a more personalized and centralized way.”

Pedro Botelho, MD

General Surgeon (Colorectal)

Centralized information for timely and informed decisions

One of the main challenges healthcare teams face is the variety of information systems across different healthcare units, leading to fragmentation. This complicates timely and informed decision-making, potentially leading to treatment delays. With UpHill, information is not only centralized but also contextualized within the patient’s journey. It is automatically updated through interoperability standards, ensuring the patient's status is up-to-date and guiding the next steps in their care.

“Oncological diseases are essentially a race against time. Any improvement we can make in terms of time and treatment effectiveness will, above all, benefit patients.”

Ana Andrade

Hospital Administrator

Automated follow-up to improve patient safety and team efficiency

With automated follow-up mechanisms, UpHill allows ULS São José to monitor patients' health status automatically, both after surgery and chemotherapy sessions, identifying those who need care or intervention. This proactive approach ensures timely interventions, preventing complications from worsening. By quickly alerting healthcare teams to critical changes in a patient's condition, the system helps prioritize and allocate resources effectively, aligning team actions with the actual needs of the patients.

“Automation allows us to ensure a safe transition from hospital to home. Prioritizing patients enables nurses to focus on those who need direct intervention. And, without a doubt, [this project has helped] recognize the value of nursing within the teams.”

Paula Duarte

Nurse Manager

Predictability to optimize processes and allocate resources based on real needs

Real-time monitoring of average response times at each key stage of treatment and follow-up is essential for efficient resource allocation. With UpHill's dashboard, the management team at ULS São José can quickly and accurately identify bottlenecks along the patient journey, allowing them to take swift and targeted action, ensuring a smoother and more timely process.

Solution details and highlights

A care pathway based on the best evidence, customized to the local context.
An omnichannel approach to collect patient information through familiar channels (SMS, phone calls, and email).
No invasive devices or medical procedures.
Use of validated and automated questionnaires.
Smart use of collected data to update the patient's status.
Automatic patient risk stratification.
Interoperability capabilities to connect different systems and reduce task repetition.
Automatic alerts to notify healthcare teams of signs of patient decompensation.
Dashboard with aggregated data for monitoring patient journeys.
Compliance with GDPR and certifications in ISO27001 and ISO13485.

Disclaimer

This data is specific for this use-case in this institution and is presented as an example of how UpHill Route indirectly improves patient management processes in a context in which clinical decision support systems are used. The institution itself collected data. UpHill Route does not claim any direct clinical benefit leading to cost reduction, access increase, unnecessary appointment reduction, or hospitalization reduction.