An Introduction to

Digital Care Pathways

An Introduction to Digital Care Pathways
(DCPs)

Today, care pathways are increasingly digital care pathways. What

does that mean for patients and healthcare providers in the era of
value-based care?

They have been called “clinical pathways,” “care pathways,” “care

maps,” and “patient journeys,” but no matter what term is used, the
meaning is essentially the same: the step-by-step movement of patients
through the healthcare system, starting with the realisation of a problem
or concern and followed by the efforts to address it.

The concept of care pathways was born in the US in the 1980s, a

result of applying documents used in industrial quality management to
improving efficiency in the process of delivering healthcare. Changes
in reimbursement underway at the time were a driving factor. While
reimbursement had traditionally been tied to the volume of care an
organisation delivered, the focus was shifting to outcomes or value-
based care. Establishing pathways based on groups of patients’ shared
conditions, and the consistent and predictable steps that made up their
care, allowed treatments to be standardised based on medical evidence
known to improve outcomes while reducing costs.

“Clinical pathways,” “care pathways,” “care maps,” and “patient

journeys” are all different terms for the same set of events: the
step-by-step movement of specific patient groups through the
healthcare system from start to finish.
 Care Pathways Are Becoming Digital Care
Pathways

Like much else in today’s world, care pathways are increasingly being
digitised. “Digital Care Pathways” (DCPs) employ digital technologies
to follow and support patients through their healthcare journeys. DCPs
present healthcare systems with a way to more deeply understand each
patient’s health and deliver more streamlined, proactive, and patient-
centric care. Ideally, this approach also proves to be the most cost
effective.

The process of digitising care pathways 77%

has been underway for years and is
steadily advancing. Consider these facts: of hospital patients in a US study used
an online search to find their hospital

89% 94%

of physicians use electronic medical of hospitals use EMRs

records (EMRs)

88% 80%

of healthcare leaders from a New of Americans who have access to their

England Journal of Medicine survey electronic protected health information
already use or have plans to implement (ePHI) use it. More than 60% of those
a patient portal for their organisation who do not have access say they want it.
All of the above are examples of the use of digital technology to support
healthcare and patients’ effective interaction with the system. There are
numerous other examples, and more are arriving on the scene almost
every day.

The growth of digital care pathways (DCPs) is good news, because DCPs
offer patients and healthcare providers many benefits. We’ll touch on
several of them in the paragraphs that follow.

The Three Basic Types of Care Pathways

1. The Traditional Analog Care Pathway

The traditional patient journey has no digital component. Every

interaction the patient has with healthcare providers and the
healthcare system is analog.

ý When a healthcare concern arises, the patient calls his or her

healthcare provider (HCP) to schedule an appointment. Appointment
reminders are sent to the patient through the mail, or someone from
the doctor’s office might phone the patient as a reminder.

ý On arriving to his or her appointment, the patient receives a clipboard,

a pen, and a number of paper forms that must be completed. He/she
will need to produce an insurance card. During the exam, the HCP will
also make notes on paper and add them to the patient’s analog file.

ý When the patient returns to the HCP for a follow-up visit, the paper
record will be revisited. Much of the appointment time will be devoted
to the HCP or an assistant asking questions. The patient will answer,
and the answers will be written down on paper.
In the analog scenario, if a piece of paper is lost, that information will be
lost with it. Time and resources are repeatedly sacrificed throughout the
process as all parties wait for paper to move from one locale to another
in order for progress to be made. Capturing and sharing information is
burdensome and uncertain. And, information that could be useful in many
quarters of the system, often doesn’t get there—or doesn’t get there in
time.

2. The Hybrid Care Pathway

Today, in most parts of the world, a patient care pathway is not likely
to be entirely analog. It will almost certainly be a hybrid of analog
and digital systems and practices. There are many forms this can take.
We’ll look at just one possible example.

ý A hospital visit might begin in the traditional way, with a patient

arriving at an Emergency Room feeling ill. There will be several forms
to fill out, all paper-based and so all at risk of being misplaced.

ý The patient will see an ER physician, who will ask a number of

questions and write the answers down on paper. Later, this information
will be typed into the hospital’s electronic medical records system. The
extra step introduces opportunities for error and omission.

ý After leaving the hospital, the patient might receive, via text message
or email, a short survey that asks about his/her disposition, pain or
discomfort, adherence to medication, and adverse side effects, if any.

ý When the patient visits his/her primary care physician for follow up,
that HCP will already have the survey information at hand, having
received it electronically. The hospital’s record of the patient’s ER visit
 will have also been sent to the primary care physician electronically.
As a result, the primary care physician will have far fewer questions
for the patient when they meet. The electronic capture and sharing of
information will have saved time for both the patient and the HCP.

ý If the HCP has the capability, he/she can continue to check in with the
patient electronically, keeping abreast of any changes in the patient’s
condition. This connection improves the HCP’s ability to respond to
the patient and so improves the patient’s likelihood of a successful
outcome.

Introducing digital or electronic elements in this scenario allows for

several improvements in the process versus a traditional, fully analog care
pathway: To begin with, information provided digitally is automatically
and securely stored and readily shared with appropriate stakeholders.
Patients, in turn, can share vital information with healthcare providers via
their own devices from the comfort of their own homes. This touchless,
instantaneous exchange of information saves time for everyone involved,
while keeping all better connected and better informed.

Imagine if the potential of this model were fully realised.

3. An Integrated, Digital Care Pathway

In the not-too-distant future, every possible element of the care

pathway will be digitised and integrated to maximise ease and
efficiency, as well as quality of care. Consider this potential scenario:

ý A patient experiencing symptoms of a mental health concern searches

for an appropriate specialist online.

ý On finding a specialist, the patient creates an account for an online

patient portal, and schedules a tele-consultation with a physician.
ý Via email, the patient receives a screening questionnaire the day
before the meeting with the HCP, followed by a patient-reported
outcome measure (PROM) that is triggered based on the patient’s
responses to the screening form.

ý The HCP reads through the PROM results prior to the consultation
and, during the patient’s visit, addresses the specific health issues the
patient reported. As a result, the patient and physician together agree
on a treatment plan.

ý After visiting with the HCP, the patient receives via email a patient-
reported experience measure (PREM), a short, 5-question survey
asking about their experience with the physician on the telehealth
consultation.

ý Throughout the course of treatment, the patient routinely completes

the PROM surveys from home to report on his/her mental health,
quality of life, and symptoms. By monitoring these outcomes in real-
time, the HCP can see what effect the treatment plan is having and can
adjust each session with the patient to focus on their key issues.

ý The patient experiences worsening physical health and wants to get

back in touch with the HCP.

ý The patient uses the messaging system within the online patient portal
and is able to get questions answered with links to more information.
The HCP decides that bloodwork should be done.

ý Blood analysis suggests the patient has a hormone imbalance likely

caused by diet.

ý The system suggests available times to connect with an

endocrinologist on staff.
ý An auditable trail of patient interactions is created for insurance
purposes.

ý The patient is prescribed a medication and diet-based care plan. The

patient is monitored at home by reporting his/her outcomes weekly
and diet-based education materials are sent automatically to the
patient to improve engagement with the care plan.

ý At a later date, the HCP decides that the patient’s blood pressure
should be monitored weekly and so provides the patient with a
connected blood pressure cuff. The patient enters their weekly
blood pressure values into the HCP’s patient portal via a Bluetooth
connection. If blood pressure measures rise above a preset level,
alerts are sent in real-time to the patient’s care team, allowing for an
immediate response.

ý The patient’s digital care pathway continues over the course of a year.

In this scenario, the relative ease of collecting health information from

patients and making it available to HCPs in real-time facilitates efficient,
shared decision making and more person-centred care. Every stakeholder
across the system benefits.

Some pathways will be far more complex than others, pathways for
cancer treatment, for example, but the efficiencies and benefits are
fundamentally the same: Care improves and is more patient-centric,
healthcare providers and systems gain efficiency, and payers see costs
reduced.
The Benefits of Enabling DCPs
For Patients

While it may seem paradoxical, the digital experience, even when

it’s remote, can enable a deeper relationship between patients and
HCPs. The relative ease and timeliness of virtual encounters reduces
stress and complications. Collecting information directly from patients
at home and making it available to HCPs in real time enables shared
decision making and care that is more personal and person-centred.
Further to that, digital interactions are more frequent and more
detailed than traditional interactions between patients and HCPs
typically are, allowing patients to reasonably feel that their HCPs, and
in fact, the healthcare system as a whole, is more readily accessible to
them, and more interested in the details of their experience.
Also, in this system, proximity, geography, or ability to travel are
not barriers to receiving quality care in a timely fashion. By enabling
healthcare to be monitored and delivered outside traditional care
settings, patients are saved time, money, and energy that would
otherwise be spent unnecessarily accessing health services. But let’s
consider the hard health benefits. For example:

ý Integration of PROMs into the routine care of patients with metastatic

cancer has been associated with reductions in ER visits by 7% and
increased survival of 5 months compared with survival with usual care1.

ý A meta-analysis has shown that telehealth programmes had significant

overall effectiveness in reducing all-cause mortality by 34% among
patients with chronic heart failure.2

ý Web-based monitoring of advanced-stage lung cancer patients was

shown to improve overall survival by more than 50%.3

While it may seem paradoxical, the remote/digital experience

can enable a deeper relationship between patients and HCPs.
For HCPs

HCPs and healthcare systems also benefit when DCPs are enabled.
The efficiencies provided by digitisation give HCPs the ability to
effectively monitor and manage more patients without the need
to invest in more staff. Existing staff can enjoy a reduction in
administrative tasks, and as a result, more time to focus on delivering
care.

Digitisation of standard tasks and information exchange between

patients and HCPs also enhances the quality of care by enabling
alerts to be generated immediately should patients experience
adverse events or deterioration. Early detection and notification of
deterioration gives HCPs the opportunity to act quickly to prevent
hospitalisation, for example. Care improves system-wide over time
as the DCP ecosystem enables ever more precise predictions and
recommendations for HCPs based on big data analysis and machine
learning.

DCPs also lower the cost of care by fostering a more efficient system
that better monitors and manages patients, supporting adherence to
care plans, reducing unnecessary re-admissions, and shortening the
length of hospital stays by providing greater options for remote care.

Finally, DCPs can expand the potential patient population and

encatchment area for a hospital as they make proximity of patients to
services less important.
Patient-generated Health Data, a Foundation of DCPs

As noted above, a key part of the DCP is timely exchange of healthcare

information between patients and HCP—namely, patient-reported and
wearable data. Patient-reported data typically takes one of two forms:
Patient-reported Outcome Measures (PROMs) or Patient-reported
Experience Measures (PREMs). PROMs capture the health outcomes that
matter most to patients, such as quality of life, symptom severity, physical
function, and emotional wellbeing, while PREMs measure a patient’s
experience of healthcare delivery.

PROMs data is critical because it provides HCPs and institutions with

an in-depth understanding of each patient’s unique health status and
concerns. As survival rates for many conditions improve, the focus around
value in healthcare shifts from mortality to morbidity, with PROMs playing
a key role in helping HCPs understand whether treatment plans are
improving the outcomes that patients care most about. For this reason,
PROMs are at the heart of DCPs and value-based care.
Information collected from wearables and connected medical devices
present another key data set that are helping HCPs deliver effective
digital care pathways. Wearables and other medical devices provide
critical objective health outcomes information that are needed to
understand core vitals such as heart rate, weight, blood pressure,
blood glucose concentration, or oxygen saturation. When this data is
incorporated into digital care pathways along with subjective patient-
reported outcomes information, a powerful 360 degrees picture of each
and every patient is developed.

Health information captured directly from patients is the heart of care

pathways, but, until recently we have not had the tools to effectively
capture and measure this data.

The use of PROMs and PREMs is increasingly mandated by governments

transitioning to value-based healthcare systems.

Patient-reported information is the heart of digital care pathways.

 A PROM Sample Question A PREM Sample Question

During the past 4 weeks, how much did During your recent hospital visit, how well
you suffer from anxiety? do you think your care team listened to
you?
ý Very much — 4
ý Quite a bit — 3 ý Very much — 4
ý A little bit — 2 ý Quite a bit — 3
ý Not at all — 1 ý A little bit — 2
ý Not at all — 1

Enabling DCPs
To enable DCPs and net the inherent advantages, organisations
require a complete digital solution that can keep patients engaged,
healthy, and connected to providers even when they are not physically
within a healthcare facility. In fact, digitisation should make location
and proximity irrelevant. It’s a huge goal, but one that’s importance
has been highlighted by the COVID-19 pandemic and the accelerated
shift in care journeys from the healthcare institution to the patient’s
home.

Note that the most effective DCP plays out on a platform that
seamlessly spans and connects the entire healthcare offering. It is not
a series of apps, login screens, portals, and passwords. It is instead a
unified solution that simplifies rather than complicates and engages
users rather than discouraging them.
ZEDOC by The Clinician
The Clinician is a digital health innovator
committed to redefining how healthcare
is measured, delivered, and valued. As a
result, we are proud to offer ZEDOC, our
proprietary platform for building DCPs
and capturing and managing the data
that support them. By coordinating the
entire care journey from patient outreach
through to collection/analysis of key health
information and the delivery of multimedia
educational materials, ZEDOC helps
organisations create streamlined pathways
that enhance outcomes, improve care
delivery, and contain costs.

ZEDOC Capabilities:

ý Capture smart health forms (eConsent, health history,

demographics) and automate risk assessments at the start of every
patient’s journey.

ý Seamlessly collect, analyse, and act on every patient’s individual

PROM information throughout the care continuum.

ý Understand and improve the experience of patients through the

distribution and collection of PREMs information.

ý Integrate wearable and medical device data into the care pathway
for monitoring critical objective health outcomes.

ý Deliver multimedia educational content to patients to help them in

their treatment and recovery.
 Learn More about DCPs
The future of healthcare is one where slow, inefficient, ineffective care
processes are transformed into streamlined care pathways that are
better able to enhance the lives of patients and providers. Digitisation
is the path to this future. We at The Clinician can help you get there.
Let us show you how.

Visit us on the web at Theclinician.com

Email us at [email protected]

References:
1. Basch E, Deal AM, Dueck AC, et al. Overall Survival Results of a Trial Assessing Patient-Reported Outcomes for
Symptom Monitoring During Routine Cancer Treatment. JAMA. 2017;318(2):197–198. doi:10.1001/jama.2017.7156
2. Xiang et al. Metaanalysis and metaregression of telehealth programmes for patients with chronic heart failure. J
Telemed Telecare. (2013)
3. Denis F, Lethrosne C, Pourel N, et al. Randomized trial comparing a web-mediated follow-up with routine
surveillance in lung cancer patients. J Natl Cancer Inst. 2017;109(9). doi:10.1093/jnci/djx029
Case Study: Implementing a DCP
to Support Lung Cancer Treatment
Lung cancer patients undergoing chemotherapy experience a number
of critical symptoms that vary in severity between patients and can be
indicative of forthcoming oncological emergencies. At a tertiary hospital
in Australia, a care pathway was in place to monitor these symptoms for
all patients and deliver timely interventions, but the process was time-
consuming for the oncology team and a blanket approach was applied to
all patients, irrespective of their progress.

The process included a nurse practitioner’s calling patients each week to

ask them about their symptoms, note down the information, transfer it
to the EMR, and then work through any required interventions. For each
patient, the process could take up to 30 minutes.

The ZEDOC Difference

Working with The Clinician and their digital health platform, ZEDOC, the
hospital’s oncology nurses developed and implemented a digitally-enable
care pathway to streamline the collection of symptom information and
enable more personalised, proactive care for patients.

With the new DCP, key symptoms are automatically captured through
a remote digital assessment that patients receive electronically and can
complete on their own devices. The symptom information is then fed
back to the clinical team via a real-time, colour-coded dashboard that
helps the nurse practitioners understand who requires follow up most
urgently.
For symptoms that indicate an oncological emergency, ZEDOC delivers
to the clinical team real-time alerts and advises the patient to immediately
call their nurse or seek medical attention.

Benefits for HCPs

Automated symptom capture and the real-time delivery of actionable

insights are helping the clinical team significantly reduce the time spent
collecting symptom information over the phone, writing notes, and
speaking to patients who don’t require follow up.

By saving up to 30 minutes per patient per week, staff have more time to
focus on delivering timely, high-quality care to those who need it.

The ZEDOC platform is also helping the clinical team to identify serious
deterioration as it happens.

Benefits for Patients

Not only is this a more convenient and user-friendly process for patients,
but it helps them receive the right care more quickly. With symptom
information readily available to the care team, issues can be addressed
as they arise and patients don’t need to unnecessarily visit the hospital if
their chemotherapy is progressing well.

Patients can now report their symptoms simply and easily in real-time,
without fear of judgement or inconveniencing others—a real issue
identified by the nurse practitioners when speaking to patients over the
phone.
In Summary

By using the ZEDOC platform to digitise and transform an existing care

pathway, the oncology team has found a cost effective way to free up staff
from administration while improving both prioritisation of patients and
health outcomes.