Patient engagement using technology-enabled perioperative care pathways has the potential to improve patient outcomes and increase operational efficiency, thereby creating value in health care. In the current standard of care, preoperative evaluation begins after a patient has been scheduled for surgery. While risk stratification is performed during this time period, time constraints limit active management of comorbid medical conditions and patient optimization for surgical readiness. The Perioperative Optimization of Senior Health initiative at Duke University has shifted the focus to interdisciplinary care to optimize older patients prior to surgery (JAMA Surg 2018;153:454-62). Increasingly, insurers are moving to value-based payment models that pay a predetermined fee for surgery and perioperative care (Health Serv Res 2007;42:1443-63). Hence efficient and effective patient optimization in the perioperative period will become increasingly important.

Do we need new technology solutions to improve the patient experience?

  1. It is plausible for a perioperative pathway to become a series of disjointed appointments and cumbersome tasks for patients. Up to 80% of information conveyed to patients is not retained, amounting to $115-$190 billion in preventable expenditures annually (J Gen Intern Med 2012;27:520-6).

  2. Patients often bear the burden of coordinating visits with surgeons, anesthesiologists, and other specialists. They are often frustrated and do not receive optimal care.

  3. Inadequate education and preparation cause cancellation of surgeries that not only delays patient care but also interrupts clinical workflow at significant cost.

So what can technology do?

  1. New technologies have been developed to combine perioperative care pathways with patient experience optimization. These technologies accompany patients and engage them in their care. The focus on patient experience gives patients more control over their care.

  2. Patients who actively manage their care have been shown to have better clinical outcomes compared to those who passively receive care (J Clin Gastroenterol 2019;53:e456-62; asamonitor.pub/3gnxt6n).

  3. Technology-enabled services include scheduling appropriate visits, preparing for surgeries, finding directions to the clinic, and transitioning to a different phase of care. Beyond a patient-friendly experience, it is critical for technologies to fit existing clinical workflows to support process improvements and improve clinical outcomes for patients.

  4. Throughout the perioperative process, there are multiple transition points between one type of provider to another or from one level of care to another (Figure 1). These transition points can introduce friction in the patient experience and may decrease efficiency of the care pathway. When evaluating patient engagement technologies, the capabilities to address these transition points in an automated way can streamline the perioperative process and decrease patient (and often provider) frustration.

Figure 1:

Technology-Enabled Perioperative Pathway Schematic

Figure 1:

Technology-Enabled Perioperative Pathway Schematic

Technologies on the market today offer a wide variety of functionalities that may be useful in delivering an engaging and clinically relevant experiences for patients in the perioperative period.

Some of the popular technology solutions are:

Medumo by Philips: Recently acquired by Philips, Medumo is a software interface that accompanies patients and helps them navigate through each step in their episode of care using automated just-in-time text messages and emails. These messages can include images, videos, instructions, surveys, and other interactive elements to further drive active patient engagement. The software can be implemented for each of the steps in the perioperative process. Beyond a patient-friendly experience, the technology is designed to fit existing clinical workflows to support efficiency improvements and improve clinical outcomes.

This software platform was initially implemented as an automated time-released colonoscopy reminder program to help with colonoscopy preparation quality and decrease rates of canceled procedures. Preparation instructions and appointment reminders delivered via automated time-released text messages and emails resulted in a decrease in the rate of inadequate bowel preparation, from 11.5% to 3.8% (asamonitor.pub/3x6zrxY). The rate of canceled procedures decreased from 6.1% to 4.3% (asamonitor.pub/3x6zrxY).

Expanding the use of the software platform beyond gastroenterology, the program has been implemented for referral conversion for surgical consultations and patient triage with navigation prior to elective surgeries. Messages to remind patients to schedule their surgical consultations resulted in an increase in conversion rate of referrals to appointments within 12 business days from 63.4% to 65.6% (P=0.01) (asamonitor.pub/3gnxt6n). Preoperative triage questionnaires, scheduling reminders, and preparation instructions increased the percent of patients eligible for a remote preoperative evaluation via phone and decreased day-of-surgery cancellation rates from 4.7% to 1.1% (asamonitor.pub/3gmfLQB).

Krames by Staywell: Krames On-Demand is a patient education system that provides clinicians access to comprehensive patient education materials in 37 specialty areas. Krames On-Demand is part of The StayWell Company, a provider of consumer health information products and services such as HealthSheets – patient education sheets with colorful graphics, easy readability levels, and clinician input.

Several large health care institutions have incorporated Krames On-Demand HealthSheets into their websites and blog posts in an effort to increase patient engagement and boost referral conversion. For example, one institution found that over a yearlong period, 3,257 users were referred to the site's “Make an Appointment” page via the health library, and 1,160 appointments were scheduled on the “Make an Appointment” page (asamonitor.pub/3x6zrxY). Another institution found that just one blog post about what to expect during a colonoscopy drove 47 appointment submissions, 358 infographic downloads, and 125 email subscriptions (asamonitor.pub/3gmfLQB).

In an effort to expand StayWell's offering throughout a patient's health care journey, the company has developed Krames on FHIR® (Fast Healthcare Interoperability Resources). This app and solution suite deliver patient education content at the point of care where it has the best chance to help improve patient outcomes. Krames On FHIR integrates into existing EHRs, providing digital, video, and even printed content based on the patient's profile and clinical encounter.

HealthLoop by GetWellNetwork: Recently acquired by the GetWellNetwork, HealthLoop is a digital patient engagement platform designed to actively engage patients at home daily. The service continuously monitors patient progress, assesses risk in real time, and improves patient satisfaction and health outcomes. HealthLoop aims to mimic the intended benefits of telemonitoring as described in randomized controlled trials using remote monitoring of cancer patients (JAMA 2017;318:197-8; J Clin Oncol 2016;34:557-65) to detect emerging complications and minimize the severity of downstream clinical sequelae.

HealthLoop, through its automated digital remote guidance and telemonitoring platform, has shown reductions in costs, readmissions, and complications with increased vigilance from both patients and providers. For example, one institution found a significant reduction in avoidable 90-day costs, a 45.5% reduction in 90-day hospital admissions, and a 54.4% reduction in 90-day complications after hip and knee arthroplasties (J Arthroplasty 2018;33:988-96.e4). Furthermore, the HealthLoop platform was used to successfully measure quality of life after radioembolization for hepatocellular carcinoma (J Vasc Interv Radiol 2020;31:311-4.e1). According to the HealthLoop website, up to 85% of patients report being able to avoid an office visit or phone call by using the program. Programs like HealthLoop can enhance our ability to interact with patients in the latter half of the patient perioperative pathway.

Emmi by Wolters Kluwer Health: Emmi Solutions, a product of Wolters Kluwer Health, provides a multidisciplinary approach to content design and delivery to enhance patient engagement and improve patient outcomes. By enrolling patients in an interactive multimedia Emmi Solutions program, various institutions have increased patient engagement and knowledge for medical procedures while driving increases in medication and procedure adherence.

For colonoscopies, an internet-based program by Emmi Solutions was shown to increase the percent of patients who would arrive for scheduled procedures (asamonitor.pub/3tvUZC1). More recently, a study involving over 2,500 patients undergoing initial screening colonoscopy found that the Emmi program led to an increased rate of satisfactory bowel preparation and lower rate of repeat procedures (Am J Med 2016;129:1219.e1-9). Additionally, compared to traditional mailed preprocedural material, the web-based multimedia program was shown to reduce patient anxiety, leading to significantly decreased State-Trait Anxiety Inventory scores (J Clin Gastroenterol 2018;52:519-23).

In an effort to improve both the patient experience and outcomes, solutions like Emmi can be incorporated into the perioperative pathway once a patient has decided to move forward with a planned procedure.

Twistle: This comprehensive software service connects with patients through multiple channels, including text messaging, a mobile app, and phone calls. The service also works to automate health provider tasks from reminders to information gathering to patient education. Clinicians and patients are able to send and receive HIPAA-compliant messages as well as photos and videos. Twistle integrates with EHRs, registries, and predictive analytics tools to provide real-time insights for team-based care models.

The use of Twistle within Perioperative Surgical Home or Enhanced Recovery After Surgery pathways have resulted in increased savings, decreased length of stay and readmissions, and decreased postoperative complications. For example, the implementation of Twistle within a colorectal ERAS pathway to promote active post-discharge surveillance (APDS) reduced mean length of stay by 2.1 days and reduced readmissions within the first 30 days postoperatively (Surg Endosc 2019;33:3816-27). APDS programs such as Twistle may allow patients to resolve postoperative issues without ER visits or readmissions and may be valuable in establishing a cost-effective and convenient communication channel between patients and their surgical team (Colorectal Dis 2020;22:959-66).

So are these new technologies the future?

Barriers exist to rapid adoption of smartphone technology and mobile health in the perioperative setting. These barriers include lack of necessary equipment, low technology literacy in elderly populations, possible inability to communicate with providers in real time, and language barriers. However, many new solutions are now providing asynchronous communication with health care providers with one- to two-hour response times and automated translation to multiple languages.

Optimizing patient involvement, knowledge, and care during the perioperative period will be an essential component of care delivery. Advances in technology have created an environment in which a seamless navigational experience is expected by patients and can be accomplished by existing health care systems.

When evaluating technology solutions to power the perioperative patient experience, support for each of the transition points in the episode of care should be considered. In addition to HIPAA compliance and a smooth user interface, the ability to automate transitions for patients will be the key differentiator for the technology platforms mentioned above. When optimized and deployed successfully, technology-enabled perioperative care pathways will improve patient outcomes and increase operational efficiency.

Aiden Feng, MD, MBA, Resident Physician, Brigham and Women's Hospital, Boston.

Aiden Feng, MD, MBA, Resident Physician, Brigham and Women's Hospital, Boston.

Daniel Kang, MD, Resident Physician, Brigham and Women's Hospital, Boston.

Daniel Kang, MD, Resident Physician, Brigham and Women's Hospital, Boston.

Lalitha Sundararaman, MD, Clinical Instructor, Department of Anesthesiology and Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston.

Lalitha Sundararaman, MD, Clinical Instructor, Department of Anesthesiology and Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston.