Digital Innovation in Outpatient Healthcare Delivery Services:

A Common Methodology to Introduce IoT Technologies in Two Use-cases

Salom

e Azevedo

1,2 a

and Ana Rita Londral

1 b

Value for Health CoLAB, NOVA Medical School, Lisbon, Portugal

Department of Engineering and Management, Instituto Superior T

ecnico, Lisbon, Portugal

Keywords:

eHealth, Healthcare Pathways, Outpatient, IoT, Patient-centered Design.

Abstract:

The introduction of digital innovation in established healthcare pathways needs collaborative work among

technology providers and clinical teams. Further, the involvement of patients is a key-factor as a highly-impact

resource in the design of effective services and sustainable innovation in Healthcare. This paper presents two

use-cases where a common methodology is being applied in two different hospitals, to digitize outpatient

healthcare pathways using IoT technologies for remote monitoring patients at home. The methodology is

driven by principles of user-centered design and focused on outpatient outcomes measurement. It is described

in three steps: ”as-is” process design, process mapping for the new service and deployment strategy. From

context requirements to results evaluation, clinical teams and patients are actively involved in the service

design.

1 INTRODUCTION

In the last decades, the development of digital tech-

nology innovations brought unprecedented opportuni-

ties to outpatient healthcare delivery and to empower

citizens in managing their own health. Sensors, mo-

bile devices, Internet connection and artiﬁcial intelli-

gence algorithms have become more accessible to the

Healthcare systems and to the citizens, and have enor-

mous potential in reducing inpatient costs that have

been continuously increasing, worldwide. However,

these technologies are still a remote reality for most

of the healthcare delivery processes. Among the main

identiﬁed reasons for this slow adoption are factors

that inﬂuence the acceptance of these technologies

and resistance by medical staff and patients. From

previous research, it is known that the strategy used

for managing change is a key indicator of success or

failure (Saﬁ et al., 2018). Interestingly, recent stud-

ies indicate that the role of patients (demand-side) is

limited and that the healthcare providers (supply side)

play a more important role in driving variation and

growth of healthcare utilization and expenditure in ad-

vanced economies (Kr

amer and Schrey

ogg, 2019). If

that is the case, a shift from a single-disciplinary ap-

https://orcid.org/0000-0003-1234-9464

https://orcid.org/0000-0002-8002-6790

proach to a multidisciplinary collaboration, that tack-

les real-world medical challenges and considers the

main expectations, capabilities and priorities of pa-

tients and clinical teams, is needed for scaling-up

digital innovations in Healthcare (Kostkova, 2015)

(Spanakis et al., 2016) (Garavand et al., 2016).

In this paper, we present the methodology em-

ployed in two different healthcare services for the

real-time deployment of IoT technologies in outpa-

tient healthcare pathways: (i) follow-up of patients in

the 1st month post-surgery, from the Cardiothoracic

service in a Portuguese public hospital; and (ii) moni-

toring elderly patients that are enrolled in a Homecare

nursing program, delivered by a Portuguese private

hospital. Both use-cases that are reported in this pa-

per are being deployed in real contexts of healthcare

services and include the collaboration of patients and

clinical teams with technology developers, to incor-

porate the IoT technology in the already established

healthcare pathways.

We describe a patient-centered methodology that

is being proposed to evaluate the value of a new ser-

vice for outpatient healthcare with the use of IoT

devices to collect and monitor clinical and patient-

reported outcomes. This work follows the framework

of Value-Based Healthcare, with a focus on the col-

lection of patient-centered outcomes during the out-

patient period (

Akerman and Stowell, 2015).

Azevedo, S. and Londral, A.

Digital Innovation in Outpatient Healthcare Delivery Services: A Common Methodology to Introduce IoT Technologies in Two Use-cases.

DOI: 10.5220/0009394908210826

In Proceedings of the 13th International Joint Conference on Biomedical Engineering Systems and Technologies (BIOSTEC 2020) - Volume 5: HEALTHINF, pages 821-826

ISBN: 978-989-758-398-8; ISSN: 2184-4305

821

2 USE CASES

This paper describes the implementation of a service

for outpatient outcomes monitoring in two different

hospital contexts:

2.1 Follow-up Service in Cardiothoracic

Surgery Service in a Public Hospital

A pilot is running to monitor patients from home,

in the ﬁrst month after cardiothoracic surgery. The

main objective of this telemonitoring service is to

early detect complications and increase patients ex-

perience of safety. Clinical and patient-reported out-

comes are collected daily by the patient and reported

to the clinical staff that contacts the patient in case

of an alarm event is detected. After running a pilot

with two patients that were exposed to cardiothoracic

surgery, the technology and process design were ad-

justed, based on patients and clinical staff feedback.

The pilot moved now to its second-stage: to follow-

up 80 randomly selected patients that are discharged

in this service.

Outcomes that are collected are: blood pressure,

weight, steps, 5 questions in a mobile app and a self-

picture of the surgical wound.

2.2 Homecare Nursing Service for

Elderly Population in a Private

Hospital

This use case relates to the implementation of a pi-

lot from an European project H2020-ACTIVAGE. A

group of 50 elderly patients (age over 65 years old)

and their caregivers, followed in a homecare nursing

service, were selected to use IoT devices to remotely

monitor outcomes and communicate these with the

nursing team. At current stage, the requirements and

process design were already deﬁned to start the pilot.

Outcomes that will be collected are: glucose level,

blood pressure, weight, steps and simple patient-

reported outcomes that are answered through a mobile

app.

3 METHODOLOGY

As both services were deployed in two real-life pi-

lot sites, we followed a case study approach in order

to identify technical, organizational, and sustainabil-

ity perils and to collect the generated knowledge dur-

ing the deployment of the services, according to (Yin,

1994).

In the healthcare context, the process of creat-

ing or re-engineering a healthcare service that meets

the several needs from the different stakeholders in-

volved poses a high risk in guaranteeing that the end-

user (the patient) is the main beneﬁciary of the ser-

vice. Therefore, we applied the User-centred design

(UCD) methodology to achieve higher levels of ef-

fectiveness, efﬁciency, and satisfaction (Dabbs et al.,

2009;

Arsand et al., 2008). Some key principles

of UCD were applied, such as an iterative and in-

cremental development process, involvement of end-

users, explained design options, real life context eval-

uation and effective multidisciplinary teams develop-

ment process (Gulliksen et al., 2003).

The UCD process was divided in three main

stages:

1. Environment Analysis: Documentary analysis

to collect the information about the as-is situa-

tion of outpatient services in both hospitals. This

stage comprised several activities, such as: iden-

tiﬁcation of stakeholder groups proﬁles, their mo-

tivations and needs, their interests, inﬂuence and

importance.

2. Digitizing the Healthcare Outpatient Pathway:

The following step consisted in transforming

stakeholders’ needs into requirements. Firstly,

the real needs and the perceived and expressed

needs were identiﬁed through semi-structured in-

terviews. Secondly, the listed requirements were

analysed and negotiated. In this negotiation stage,

for each requirement it was discussed the feasibil-

ity to meet the need, regarding time and complex-

ity, and available resources.

3. Deployment Strategy: In both case studies, we

applied the same deployment strategy. Due to the

lack of literature found in discussion of deploy-

ment effects of health-related IoT-based technol-

ogy in real-life settings, this paper reports the ac-

tivities supporting the implementation of the new

outpatient care services.

4 SERVICE DESIGN OF

OUTPATIENT HEALTHCARE

Digitizing the outpatient healthcare pathway is only

possible through collaborative and multidisciplinary

work, where the assessment of the community and its

members experience plays a crucial role in the adop-

tion and evaluation of a new project or program (Eu-

ropean Commission, 1993) (Vermeulen et al., 2014).

This approach was used to enhance participation and

Scale-IT-up 2020 - Workshop on Best Practices for Scaling-Up Digital Innovations in Healthcare

822

transparency through a logically ordered series of ac-

tions designed to solve problems previously identiﬁed

by the involved stakeholders.

The role of the patient in product innovation and

development process has been neglected for most

of the healthcare industry life cycle (Garrido et al.,

2016). However, in the last years, a lot of effort from

academia and patient’s advocates has been conducted

to use the patient as a highly-impact resource in the

design of effective products and services in the health-

care sector. The UCD methodologies are validated

tools to cope with this lapse and empower patients

and their caregivers to be part of this development.

In the context of both use cases described in this pa-

per, the two main characteristics (among the others)

of this systematic methodology are: (i) the participa-

tion of patients, caregivers and the clinical team in the

digitization of the outpatient pathway and (ii) the seek

of consensus among technology providers, healthcare

providers and the patients. Figure 1 illustrates the co-

creation framework that was used for this work.

In this section, we brieﬂy describe the three steps

that were developed to implement the deployment

strategy.

Figure 1: The co-creation framework used for the digital

innovation in outpatient healthcare services.

4.1 Step 1: Design the Process as-is

We ﬁrst selected the following tools to collect enough

information to report the technical requirements:

1. Environmental Analysis through Semi-

structured Individual Interviews. With the

goal of understanding the context of both home

care delivery initiatives, we conducted several

interviews to different stakeholders in order to

understand their needs and motivations, their

relevance and importance in the deﬁnition of

the outpatient pathway. The main relevant

stakeholders identiﬁed were: assisted persons

(patients), formal caregivers (individuals hired

by the assisted persons to provide assistance at

home), informal caregivers (patient’s relatives),

healthcare professionals (nurses and surgeons),

healthcare providers (hospitals), technology

providers (organizations that develop and pro-

vide solutions), technology transfer supporter

(organizations/institutions that guarantee that

the technological intervention adds value to the

healthcare service, satisﬁes the most relevant

needs of the different stakeholders, and is cost-

effective). The group proﬁles were described by

identifying the motivations, goals, and beneﬁts

with the proposed new system. According to

the impact that the solution could have for the

each stakeholder, we classiﬁed each in terms of

importance and inﬂuence.

2. Previous Experience Analysis through Struc-

tured Individual Interviews. For the most rel-

evant stakeholders identiﬁed for each of the use-

cases, we investigated on previous experiences

with technology in their practices (advantages,

disadvantages and opportunities). To gather quali-

tative insights about operational opportunities and

constraints, we interviewed different representa-

tives from each stakeholder group about their atti-

tudes, believes and values of the proposed project.

3. Use Case Scenarios Deﬁnition from Visits to

the Real Life Context. To avoid conﬂicts in de-

sign due to lack of accountability of real-life con-

straints of the system and its actors, the team vis-

ited both hospitals, talked to patients and visited

some homes. The visit to the hospitals enabled

the understanding of the environment in which

the healthcare professionals provide care and how

the interaction with patients occurs. The visit to

patients’ homes enabled the understanding of the

context of how nurses provide care outside hospi-

tal facilities.

Figure 2: Use Case Diagram to identify, clarify, and orga-

nize system requirements.

4. Process Characterization. The output from pre-

vious steps enabled us to create the model of the

current process (”as-is”-model) following existing

best-practice solutions (Im et al., 1997). Visual

Digital Innovation in Outpatient Healthcare Delivery Services: A Common Methodology to Introduce IoT Technologies in Two Use-cases

823

Paradigm software was used to characterize each

step/operation and its dependencies with the rest

of the environment. For each operation, infor-

mation regarding resources, time, cost and clin-

ical constraints was provided by the healthcare

provider and its professionals. Through meeting

with nurses and surgeons several iterations to the

as-is model took place until a consensus to the ﬁ-

nal process was achieved (Figure 3).

Figure 3: Mapped process of the health pathway of a patient

submitted to cardio-thoracic surgery.

4.2 Step 2: Mapping the Process with a

Focus on Patient-centered Care

The design of the technological solution to be inte-

grated in both home care delivery initiatives was de-

veloped with the contributions from both demand and

supply side were involved. To reach a consensus

in the prioritization of the needs to be coped by the

new system we conducted a focus group with clinical

teams. We presented the general process to the stake-

holders in individual meetings and identiﬁed oppor-

tunities to integrate technology that would cope with

the experienced needs.

Transforming the perceived and expressed needs

into retained and speciﬁed needs, we conducted sev-

eral meeting to negotiate the requirements that could

be solved by the service and technology proposed, re-

spect the time and the resources available. The list of

requirements was validated by all stakeholders. Five

different types of requirements were identiﬁed: func-

tional, security, usability and humanity, maintainabil-

ity and support, and performance. The stakeholders’

list and the real needs identiﬁed were used to summa-

rize and describe the different scenarios underlying

the outpatient pathway (Table 1).

The main focus of the ”to-be”-model (Figure 4)

was to enhance the performance of home care service

by improving the patient engagement and experience,

and by informing healthcare professionals with rele-

vant, real-time data on patient’s recovery, health sta-

tus, and quality of life. For this goal, we also worked

on the outcomes reports to provide this information

in an appropriate format so patients and caregivers

get more engaged in the follow-up and recovery pro-

cess. Reporting design is an important issue related to

human-computer interaction that directly affects ac-

ceptance and engagement of both patients and health-

care providers.

Figure 4: Mapped process of the health pathway of a pa-

tient submitted to cardio-thoracic surgery and opportunities

to use IoT-based health-related devices.

4.3 Step 3: Deployment of IoT-based

Technology to Monitor Outpatient

Pathway

The use cases created are being implemented in a pilot

to validate the described methodology. In order to be

able to test the level of adoption of the ”to-be”-model

of outpatient, we selected devices with high usabil-

ity concerns and taking into account the requirements

previously deﬁned. A monitoring web platform al-

lows to control users’ engagement, operational data-

related problems and the outcomes collected by each

monitored patient.

The deployment strategy that is being imple-

mented is iterative: we started to monitor a single pa-

tient with good level of digital literacy for one month,

then incorporated lessons learned and we are now fol-

lowing a group of ﬁve randomly selected patients, be-

fore widely running the pilot.

In the cardiothoracic surgery use case, at the day

of discharge from hospital, patients receive instruc-

tions to use the IoT-based kit. For 30 days, the pa-

tient is instructed to follow the same procedure ev-

ery morning: use a mobile app to follow the tasks of

weighting, measuring blood pressure, taking a picture

of the surgical wound, and answering ﬁve questions

regarding patient reported outcomes. A report with

the collected outcomes from the patient is digitally

sent to the clinical team who contacts the patient in

case of any abnormality detection.

For the referred ﬁrst patient, a weekly con-

tact/meeting with nurses and surgeons was followed

to reﬁne the process. After 1 month, the patient re-

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Table 1: Use Case Scenarios selected for the private Home-

care Nurse Service.

Use Case Scenarios List

Title Description

Daily

activity

monitor-

ing

Nurse needs to monitor activities of

the person’s daily living, such as walk-

ing speed, mobility function, number of

falls and/or risk of fall, ﬁne motor con-

trol, measure hand grip strength, callig-

raphy assessment, ability to speak, and

speech articulation. The nurse evalu-

ates these outcomes when he/she vis-

its the patient. In order to have a

more accurate evaluation of the out-

comes, the nurse asks each stakeholder

(informal and/or formal caregiver and

patient) this information, at different

times throughout the clinical appoint-

ment. Patients usually do not have the

right perception of their level of mobil-

ity function or risk of fall.

Health

parameter

monitor-

ing

Caregivers and patients are told to

ters: blood pressure, pulse/heart rate,

temperature, pain level, weight, gly-

caemia and skin status for preven-

tion and follow-up of disease compli-

cations. When nurse visits the pa-

tient, he/she asks for the records regis-

tered by the informal/formal caregivers

and repeats the record of the patients’

health parameters to validate. When

appropriate, the nurse also takes a pic-

ture of the wound status to have a better

perception of the wound recovery pro-

gression.

Notiﬁcation

of abnor-

mal

situation

Formal and informal caregivers notice

an abnormal activity, including health

parameters monitored that are outside

of normal range and low activity per-

ceived. They contact nurses and report

the situation. When this happens the

Nurse-Chief makes more questions to

better understand the situation and al-

locates an urgent visit from a nurse to

the patient’s house.

turned to the hospital and delivered the equipment.

System Usability Scale (Martins et al., 2015) and

semi-structured interviews to the patient and nurses

were used to test acceptance and optimize the out-

comes reporting tools.

5 DISCUSSION AND

CONCLUSIONS

In this paper, we propose a methodology to design

outpatient healthcare services, by deployment of IoT

technologies. Due to increasing Elderly population

demands in the Healthcare systems and the increased

treatment options, the sustainability of Healthcare is

threatened in the advanced economies. Digital inno-

vation brings opportunities to empower patients to ac-

tively participate in the process of care, to engage in

the process of collecting and reporting outcomes, in

order to prevent healthcare complications that repre-

sent a burden to the Health systems. These opportuni-

ties are being exploited in various studies focused ei-

ther in technology development and clinical services

(Acheampong and Vimarlund, 2016).

The methodology that we present is based on

UCD and takes into account the real-time imple-

mentation of digital innovation, i.e. a new process

is mapped to be successfully integrated in the ex-

istent running process. This work compares with

other recently published studies (e.g. (Hobson et al.,

2018) (Backman et al., 2018), in the way that the

methodology presented brings an innovative perspec-

tive process mapping and service design that is cen-

tered on the patient and its outcomes collection points

and not on hospital resources or technology design.

This patient-outcomes perspective aims at develop-

ing tools to implement value-based healthcare frame-

works considering the real-life challenges.

The two use-cases described are actually running.

Results from the pilots will be published in future

work. Costs driven from this digital innovation will be

integrated in the overall outcomes analysis, as an im-

portant part for the study of scaling-up requirements.

ACKNOWLEDGEMENTS

The devices and 4G transmission for the pilot in Hos-

pital de Santa Marta (Lisbon, Portugal) was supported

by Fraunhofer Portugal and Vodafone Portugal. The

pilot in the CUF Infante Santo hospital (Lisbon, Por-

tugal) was supported by EU project H2020 ACTI-

VAGE ID732679.

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