Automated Digital Pathways to Improve Outcomes

According to the Beryl Institute, patient experience is “the sum of all interactions, shaped by an organization’s culture, that influence patient perceptions across the continuum of care.”1 Journey maps depict the path (interactions) taken by patients as they navigate the healthcare system; integration across departments may be necessary. During the patient journey, insights are generated, expectations defined, processes assessed, and steps taken to enhance the patient experience.

More specifically, journey maps have been used to increase customer satisfaction, develop new products or services, identify gaps in communication touchpoints (and service), identify clinical gaps in care and prioritize customer-centric initiatives.2 Increased brand awareness and patient retention should result. Journey maps may be developed internally or, more often, via the use of an external vendor such as a consultant or research firm.3

In this article, limitations associated with the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) are discussed, Enhanced Recovery after Surgery protocols are highlighted, and the importance of the patient discharge journey emphasized.

HCAHPS as a starting point

The HCAHPS is a standardized national survey of a patient’s hospital experience and an indicator of care quality.? Results are incorporated into the patient survey star rating (to facilitate informed decision-making) and the Value-based Purchasing program administered by the Centers for Medicare & Medicaid Services (CMS).

The survey is composed of 19 core questions, 29 in total, focused on several areas: “communication with nurses and doctors, the responsiveness of hospital staff, the cleanliness and quietness of the hospital environment, communication about medicines, discharge information, overall rating of hospital, and would they recommend the hospital.”? Questions about transitions to post-hospital care, admission through the emergency room, and mental/emotional health were added in 2013.? The survey is administered between two days and six weeks after discharge.?

A report issued by the American Hospital Association, Federation of American Hospitals, America’s Essential Hospitals, Association of American Medical Colleges and Catholic Health Association of the United States in 2019 recommended updating the survey instrument, re-evaluating literacy requirements, considering social determinants of health and including a digital option for survey completion.?

Among the suggested topics for inclusion include care transitions and post-discharge experience, efficiency and teamwork of the care team, fulfillment and comprehension of the patient’s care plan, and sense of emotional and physical safety.? HCAHPS results are not timely, requiring nine to 21 months post-submission for posting by CMS to the Hospital Compare website.10

Surgical patient journey begins and ends at home

Prior to surgery, patients schedule a date and prepare themselves both physically and mentally for surgery. Surgery is a fearful and anxiety-producing prospect. Patients should have a complete understanding of the risks, benefits and potential outcomes, including length of rehabilitation, potential long-term biological changes and loss of function/use, before consent. Dietary restrictions (solids, liquids) are mandated just prior to surgery, and medication routines may be disrupted. Digital tools have been used to facilitate these parts of the patient journey, though with somewhat limited success. ?

Reduce Lengths of Stay While Improving Clinical Outcomes

Enhanced Recovery after Surgery (ERAS) protocols extend from the pre-hospital and pre-operative phases to the intra-operative, post-operative and post-discharge phases, i.e., the entire episode of care.1?-11 They have been shown to reduce hospital length of stay while improving clinical outcomes and the experience of care.12 ERAS requires an engaged patient (and caregiver) and care team to facilitate early mobility and recovery. Post-operative focus areas include, but are not limited to: ?

·????????Pain management – opioids-sparing, multimodal analgesia

·????????Fluid management – adequate fluid and volume therapy

·????????Wound management – infection avoidance

·????????Nutrition – early nutrition (excluding 10-20% of patients with adynamic ileus)

·????????Mobility – early ambulation desirable to avoid blood clots, pressure ulcers and potential for pneumonia

Enhanced Recovery After Surgery Protocols

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Source: https://www.aana.com/practice/clinical-practice-resources/enhanced-recovery-after-surgery

Complementing ERAS: The patient digital experience

During the pre-operative, intra-operative and post-operative phases, the patient journey is largely driven by the care team with family communications and updates potentially given intra-operatively. However, digital opportunities do exist during the pre- and post-operative phases to “empower patients and families to be active participants in their care,” “proactively guide patients through personalized pathways” and “allow patients to order meals and control their environment” (i.e., lights, temperature, entertainment).13

The objectives of a consumer-based digital experience are to provide end-user convenience, usability and autonomy through the application of technology. Emerging technologies in healthcare continue to focus on the experience and engagement of the patient. Clinical automation prepares patients for their medical event and helps them feel supported as they recover from that event. Allowing the patient to control when, where and how they respond to communications from a care provider can ensure a strong adherence to the protocols for clinical best practices and make the patient feel empowered through their clinical journey.

The importance of the patient discharge journey

Patient discharge from the hospital is a critical step in the patient journey. A physician authorizes discharge, and the multi-disciplinary care team generates details of the discharge plan, a complex process with multiple touch points. The discussion needs to include consideration of the patient’s physical condition, needs and type of care required, and the discharge destination, activities, medication reconciliation, diet and required equipment (e.g., commode, oxygen).1? Discharge plans may include warning signs and symptoms for common problems faced by surgical patients after discharge. Discharge instructions provide a sense of security and represent a source of empowerment.1? Caregivers need to be part of the discharge planning process. Effective discharge planning should avoid an unnecessary prolonged length of stay and result in fewer re-admissions and emergency department visits.1?

Discharged, post-operative patients may be asked to:

?????????????????????Closely monitor symptoms and changes in health

?????????????????????Respond with appropriate and timely actions (contact staff, schedule a doctor visit) when symptom levels indicate a problem

?????????????????????Adhere to medication regimens, some of which are inconvenient or produce side effects

?????????????????????Ambulate and undertake breathing exercises

?????????????????????Make office visits for lab tests, physical exams, and clinician consultations

Digital tools exist to engage and educate patients, track symptoms and recovery milestones, and monitor patients using alerts and dashboards.1? Electronic medical record (EMR) integration exists.

Bottom line

Opportunities exist to augment ERAS protocols with digital tools to accelerate recovery and improve the patient experience. Patient engagement is required for medical education, condition optimization, protocol compliance and post-operative rehabilitation. Narrowing the information gap of the patient and caregiver (family) remains paramount.

Connect with the authors:

Josh Sol provides a deep understanding of the influences digital innovation and technology can make on an institution and to consumer experience. With his experience in healthcare information technology, he has been a trailblazing thought leader in the digital/clinical innovation and application space. He is passionate about enabling technologies and is focused on improving the digital experience for patients and clinicians.

Nathan Cooperman , M.D. is an integral part of the Digital Health Transformation and Strategy practice within Health Solutions. Dr. Cooperman has served in leadership roles as both a consultant and physician for more than 20 years and possesses a unique skillset that empowers healthcare organizations to develop and implement meaningful technologies that enhance the patient experience while maximizing quality, safety and provider satisfaction.

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The views expressed herein are those of the author(s) and not necessarily the views of FTI Consulting, Inc., its management, its subsidiaries, its affiliates, or its other professionals.

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FTI Consulting, Inc., including its subsidiaries and affiliates, is a consulting firm and is not a certified public accounting firm or a law firm.

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FTI Consulting is an independent global business advisory firm dedicated to helping organizations manage change, mitigate risk and resolve disputes: financial, legal, operational, political & regulatory, reputational and transactional. FTI Consulting professionals, located in all major business centers throughout the world, work closely with clients to anticipate, illuminate and overcome complex business challenges and opportunities. ?2022 FTI Consulting, Inc. All rights reserved. www.fticonsulting.com

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[1] “Defining Patient Experience.” The Beryl Institute (last visited July 3, 2022). https://www.theberylinstitute.org/page/DefiningPatientExp .

[2] “The State of Mapping the Customer Journey.” Hanover Research (2019). https://cdn2.hubspot.net/hubfs/3409306/The-State-of-Customer-Journey-Mapping_final.pdf .

[3] Ibid.

[4] “HCAHPS: Patients' Perspectives of Care Survey.” Centers for Medicare & Medicaid Services (page last modified December 1, 2021). https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/HospitalHCAHPS .

[5] Ibid.

[6] “HCAHPS Fact Sheet.” Centers for Medicare & Medicaid Services (March 2021). https://hcahpsonline.org/globalassets/hcahps/facts/hcahps_fact_sheet_march_2021.pdf .

[7] “HCAHPS: Patients' Perspectives of Care Survey.” Centers for Medicare & Medicaid Services (page last modified December 1, 2021). https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/HospitalHCAHPS .

[8] Claudia A. Salzberg, PhD, Charles N. Kahn III, et al. “Modernizing the HCAHPS Survey: Recommendations from Patient Experience Leaders.” Federation of American Hospitals (2019). https://www.aha.org/system/files/media/file/2019/07/FAH-White-Paper-Report-v18-FINAL.pdf .

[9] Ibid.

[10] Ibid.

[11] “Enhanced Recovery after Surgery.” American Association of Nurse Anesthesiology (AANA) (last visited June 23, 2022). https://www.aana.com/practice/clinical-practice-resources/enhanced-recovery-after-surgery .

[12] Ibid.

[13] ?Get Well Network Homepage.?GetWellNetwork, Inc. (last visited June 29, 2022). https://www.getwellnetwork.com/getwell-inpatient/ .

[14] “Hospital Discharge Planning: A Guide for Families and Caregivers.” Family Caregiver Alliance (last visited June 13, 2022). https://www.caregiver.org/resource/hospital-discharge-planning-guide-families-and-caregivers/ .

[15] Molly J. Horstman, et al. “Patient experience with discharge instructions in post discharge recovery: a qualitative study.” BMJ Open 7(2) (February 20, 2017). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5337662/ .

[16] “Hospital Discharge Planning: A Guide for Families and Caregivers.” Family Caregiver Alliance (last visited June 13, 2022). https://www.caregiver.org/resource/hospital-discharge-planning-guide-families-and-caregivers/ .

[17] SeamlessMD Homepage. Seamless MD (last visited June 23, 2022). https://seamless.md/product/product-overview .