Preface

Welcome to this blogpost that we believe can change everything for the efficiency, and efficacy, of your organisation. Every hospital is focused on one mission: improving outcomes for their patients. Awell Health knows that digital care programs are the key to achieving that mission -- but we also know that building and implementing them hasn’t always been easy.After building 50+ care programs in 15+ care organization, we’ve learned quite a bit about what works, what doesn’t, and the preparations required to ensure success. Now, we want to make sure you’re armed with that same insight -- so you can achieve better patient outcomes, improve efficiency, and reduce costs. Just like our customers did.We created this whitepaper to help you build the perfect care pathways with ease -- and impact thousands of lives. We can’t wait to watch you do it.

What is a care program?

A care program is a structured multidisciplinary care plan that describes essential steps for the care of patients with a specific clinical problem (e.g Omada’s hypertension care program, Carbon Health’s diabetes management program).

The concept of a care programs first appeared in 1985. More than 35 years later, care programs have failed to advance beyond static documents (e.g. paper posters and PDFs), making implementation slow and cumbersome. The legacy formats still in use today are also not unlocking the full potential of what a care pathway can be.

We believe that technology & innovation can facilitate the implementation and use of care pathways into daily practice. Furthermore, technology brings with it the ability to regularly update and improve care programs, while simultaneously allowing patients to be more involved with their own health.

Digital care programs, when built correctly, can facilitate the standardisation of care based on best-available evidence -- and reduce unintended variability of care as a result.

Here are our 7 tips for effective digital care program building:

1. Better a large than too small of a team - Implementing care programs is a team sport

This may seem counterintuitive, given that research tends to favour small teams over larger teams in project development and management. But implementing care programs is actually very much a team sport because it requires collaboration in order to be effective.

"Successful implementation relies heavily on a dedicated project manager and support from the virtual care provider."

Delivering digital care programs requires the continuous involvement of multiple healthcare professionals from the start until the end of care. This ensures there’s cohesion among the care teams, and avoids a top-down approach -- which may lead to resistance from frontline staff.

Plus, since healthcare professionals are oftentimes busy providing patient care, successful implementation relies heavily on a dedicated project manager and support from hospital management.

Moreover, it’s important to remember that “staff having more involvement may attach greater value to incorporating recommending practices into their behaviour.”

“Awell Health has seen implementations fail because too few people are involved. We have not seen implementations fail as a result of larger teams.”
 - Nick Hellemans (Product Lead)

Our recommended set-up for care programs:

Awell Health supports virtual care organisations through the process of creating digital care programs. For the ideal set-up, there are several layers of professionals from the organisation that need to be involved:

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Care program development challenges and opportunities

Care programs facilitate the use of guidelines, provide patients with clear expectations of their care, and deliver them a means of measuring their own progress. However, there are many factors that can help or hinder the implementation of care programs into clinical practice.

Research has identified potential facilitators and barriers which can exist at any stage of development and implementation of care program.



The figure below illustrates how many of the facilitators and barriers are related to staffing, team composition, and support, stressing the importance of forming the right team --- which involves having enough people from the start.

2. Don’t reinvent the wheel - Care programs should be developed based on the best-available evidence

Evidence can be in the form of guidelines, recommendations, scientific literature, protocols, ... These guidelines or recommondations can be international (e.g. from the World Health Organisation) or regional (country specific).

In Tip #1, we highlighted how a top-down approach is not favourable because it can lead to resistance from frontline staff. However, care programs are often developed using the best-available evidence in a top-down manner. That’s because for a given disease in a given context there is usually a scientific consensus on what’s best practice or the best available treatment for a given patient. There is thus a standard set of guidelines health care professionals can align on but more granular adaptations or nuances tailored to the local health services can and will always occur.



That means it’s very important to find the right balance between developing care programs based on best-available evidence and configuring care programs that make sense to the local health services. Local adaptations will always be needed as no two healthcare organisations work in exactly the same way.

“A care program is a vehicle that facilitates standardisation of care and reduces unintended variability of care,” - said Michael Porter, who introduced the concept of Value-Based Healthcare.

3. Go beyond the silos - There are two dimensions to a care program: horizontal and vertical

Horizontal dimension

The horizontal dimension is the length of time forecasted for care programs. In other words: when does it start and when does it end? This is an important consideration to take into account before you begin building. It’s easy to limit the horizontal scope -- or the time of a pathway -- to only include the elements that take place inside a single care setting, like the care provided within a hospital. 


"Considering all possibilities that could occur during treatment will help to give you a broad overview of the potential horizontal dimension for your care program."

Example one


This is a Total Knee Replacement program. Here, it starts at the first consultation with the orthopedic surgeon. Surgery then occurs -- but the pathway shouldn’t end there. If it did, potentially important data like adverse events, patient experience, and other outcomes like pain, swelling, and altered quality of sleep could be missed. In this case, the care program should continue tracking data five years post-operative.

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Example two


Care delivery in breast cancer is typically ongoing, for a long period of time. This makes it impossible to predict when a care program will start and end, so defining the horizontal dimension is much more difficult. Considering all possibilities that could occur during treatment will help to give you a broad overview of the potential horizontal dimension for your care program.

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To conclude, defining the horizontal dimension of a care programs isn’t always easy -- however the International Consortium for Health Outcomes Measurement (ICHOM) offers resources that make it manageable. Their guidelines define standard outcomes, measurement tools, and time points for multiple conditions, including chronic diseases. As Awell Health is a certified ICHOM Technology partner, there’s quick access to ICHOM guidance when using Awell Studio.

Vertical dimension

While the horizontal dimension reflects the beginning and end of a care program, the vertical dimension details the stakeholders or roles involved in the care process. 



The most important consideration should always be the patient. Care programs are intended for a well-defined patient group so think about in- and exclusion criteria for your patient population. It’s also advisable to actively involve patients, for example in a focus group or by conducting interviews. Find out what keeps them awake and what their pains are, and then think about how you can solve them with your care pathway.

In addition, every program must also incorporate each healthcare professional involved in the care journey. This multidisciplinary team should extend beyond the physician and should also include practitioners such as nurses, psychotherapists, dieticians, etc.

4. Standardize your outcome measurements - Care programs can improve quality of care, outcomes and experiences

To improve outcomes, we first need to measure outcomes. This requires engaging with patients to identify the outcomes that matter to them.

Focus on outcomes and not outputs:

• Outputs are a quantitative summary of activity (E.g. the number of patient consultations in a year)
• Outcomes focus on the value that occurs from delivering that activity (E.g. improved patient satisfaction following their consultation)

To identify outcomes that matter to patients, engagement with patients is required.

Types of outcomes:

• Objective outcomes are observable, factual and can be assessed by everyone (E.g. 5 year survival rates)
• Subjective outcomes are those reported by patients and assessable by no one but the patient, and they’re tracked most often using valid questionnaires (E.g. patient feelings and symptoms)

To achieve a more holistic view of a patient it’s important to have a well-defined outcome set that consists of both objective and subjective measurements.

For example, a patient may have a good five year survival rate but by not considering subjective outcomes, we fail to realise that their quality of life is very poor.

On the other hand, a patient may have a very good quality of life but by ignoring objective outcomes, we are unaware of a greater 5 year mortality rate.

5. Data quality should be part of the plan - Facilitate future data analysis by considering data quality during building

With digital care programs, data can be collected easily -- without any intervention from humans -- and it can also be extracted for specific actions (e.g. building dashboards, data analysis). Facilitate these actions by thinking about your data during the building phase.

In computer science, there is a concept of Garbage in, Garbage out (GIGO). Incorrect or poor quality data input will always produce nonsense output -- or "garbage."

Be consistent in naming variables 
(e.g. weight vs Weight vs WEIGHT) , being sure to use the same name for all data.

Metadata is crucial to understanding your data
Metadata is data that describes other data, providing extra context for what’s beingcollected. 
E.g. If we had a weight reading of 80kg, we would want to know when this reading was taken.

Use electronic validations and correct question types to ensure appropriate data collection
For the question ‘What is your weight?’, users can input the same answer in many different formats.

Using electronic validation, rules can be set
All values that are inputted are validated against this rule. In our example, a range of between 10 and 300kg has been set for weight. If a user tries to input 1.7kg, the system will flag this error. Electronic validations help to ensure that data is appropriate and consistent.

6. Start small, launch early - Care programs are vehicles to drive continuous improvement

• A care program is never finished: 
Continuous assessment to ensure that it represents the most up-to-date scientific knowledge, incorporating both clinical experience and patient outcomes is crucial
• Care program are vehicles to drive continuous improvement of care processes: This ultimately improve patient experiences and outcomes
• Starting small also makes it easier for care teams to get used to the approach and understand the value: Beginning the process with a large scope can cause too much change at once, so when the care team is convinced, the care program can extend and grow

"Starting small makes it easier for care teams to get used to the approach and understand the value."

Examples of the “Start small, launch early” principle

Using breast cancer as an example, we can look at some of the common mistakes made when building care program and provide tips for how to improve them.

What we don’t want


For breast cancer and other cancers, there are many treatment modalities such as chemotherapy, surgery, and radiotherapy, which can be administered individually or in combination. The pitfall is trying to incorporate that reality into the care pathway from the start. It is unfeasible to incorporate that level of complexity into the care program from the very beginning, as it results in the scope of the project being too broad -- causing the care program to become too time-consuming to implement. The diagram below shows how a broad scope can result in a project that takes months (or years) to deliver. After months of work, the lack of feedback may mean that what has been built might not be suitable.

What we do want


To mitigate these pitfalls, it’s important to identify a minimal acceptable scope that, most importantly, already delivers value for all stakeholders. If, hypothetically for breast cancer, 90% of patients received surgery or chemotherapy, the care pathway would initially focus on those therapies (as they support a large proportion of patients). With time, additional treatments could be added to increase coverage. By keeping the scope acceptable, implementation timelines can be kept short. The diagram below highlights the benefits of a more focused scope with shorter feedback loops. This allows for a more iterative approach, where learnings can be actioned quickly and decisions can be made faster.

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"By keeping the scope acceptable, implementation timelines can be kept short."

7. Use the right tools to build and implement care programs - For many decades, care programs had failed to move beyond static formats such as posters and PDFs

During the Covid-19 pandemic, all national and international health organisations were publishing guidelines in these static formats.

Even leading organisations like the World Health Organisation, the National Health Service in the United Kingdom, and Sciensano in Belgium were attempting to model care programs for these dynamic times with the same static, unsuitable formats.



These formats fail to harness the full potential of care pathways, which, when digital, allow patients to become active participants in their care journeys.

It’s Awell Health’s mission to fix the broken guideline development lifecycle. No more PDF’s, no more pieces of paper, and no more rigidity.

• Build the care program you need: Don't adapt your way of working to a rigid system. Drag and drop to create flows that are tailored precisely to how you want to deliver care.
• Awell <3 your systems: From your EMR to scheduling and billing tools, create powerful flows that tie disjointed systems together to remove manual work and automate care delivery.
• You run the frontend, we take care of the backend: Stop writing custom code for features that already exist. Our easy to use APIs save time so your engineers can focus on crafting the ultimate care team and patient experience. Awell takes care of the back-end, so you have more time to develop powerful tools and applications for your patients and team.

Conclusion

1. Research shows that getting care programs right means achieving better outcomes and experiences for patients, as well as reducing costs and providing higher quality, more effective services. Not only do patients benefit, but multidisciplinary teams are able to implement best practices and reduce variability in care.
2. Building care programs is a team sport; getting the process right requires both collaboration and knowledge sharing. To set patients and care teams up for success, care pathways must be simple to create and easy to understand. Technology and innovation drives building and implementation, while also allowing for adaptations and improvements based on the latest and best available evidence.
3. Awell Health’s Pathway Studio supports you to transform your care for patients. The no-code platform makes it easy for your clinical team to build, operate and iterate on care programs without needing engineering resources.