Many healthcare organizations today are focusing on understanding the patient journey, as they operate in a competitive landscape that is driven by Meaningful Use policies and regulations that focus on demonstrating effective use of technology to improve patient care, satisfaction and experience.
At the same time, the inherent fragmentation of care, further magnified by the rapid proliferation and popularity of urgent care clinics, can diminish the return on investments for quality improvement projects. In part this is because transforming raw patient care data into contextual, accurate and reliable medical information is extremely difficult.
It is not sufficient to rely on “Big Data” alone due to several limiting factors:
- Lack of interoperability
- The need to recognize and filter out mistakes, errors and other ‘noise’ in the data
- Patients and providers are continuously adding data to the mix in exponential rates thanks to the proliferation of devices and apps.
The resulting massive swell of fragmented data is difficult to integrate meaningfully with subjective manifestations of human behavior and into a unified framework of continuity management. The result: information overload, combined with poor usability, overwhelms patients and providers.
Journey mapping is a decision support tool well-suited to address the complexity associated with continuity of care which the American Academy of Family Physicians defines this as “the quality of care over time.”
By mapping the patient journey, qualitative and quantitative data can be organized, blended and analyzed using a unified system that is designed to contextualize relationships across a chronology. And more importantly, the “human scale”—the range of individual experiences that is critical to healthcare—is preserved at high fidelity.
In this blog post, I’ll use a case study to demonstrate a continuity of care journey mapping methodology, that is optimized for improving the patient journey, as well as overall patient and provider experience.
Applying Journey Mapping to the Patient Experience
Journey Mappring is a data-driven methodology for developing a continuous and holistic view of how well an organization is performing at each and across its touch-points with a patient, relative to the patient’s expectations and concerns.
Capturing the varying perspectives of all relevant stakeholders, journey mapping offers a multidisciplinary framework for streamlining and improving processes. By plotting the flow across touch-points and information systems, journey mapping helps identify interoperability gaps and optimization opportunities. Finally, since journey mapping is domain agnostic, patient experience and continuity of care models in the context of healthcare are compatible with and extensible to other domains.
In the healthcare context, a patient journey captures phases of an episode that correspond to it’s progression from outset to closing. At each phase, the patient and relevant providers share various touchpoints, such as appointment scheduling, office visits, and lab work. At each touchpoint captured in the journey, action and information flows between people, devices and systems are synthesized. The result is a visualization. This helps identify inter and cross-organizational gaps in areas such as data flow, compliance, availability of relevant information at points of intervention, and medication synchronization, to name just a few.
Journey mapping begins with a baselining step intended to capture the ‘current state’ patient experience from multiple perspectives, as well as interactions within the clinical environment. Each perspective—patients, practitioners, administrators and so on, is represented by a persona. Persona is a modeling abstraction that aggregates subjective facets, such as emotions or thoughts, and integrates them with concrete goals, tasks, and actions.
Subjective indicators of personas, including perception, motivation, and satisfaction are supported by qualitative research methods such as surveys, interviews, contextual inquiry, and observations. This type of research is cost effective; data can be quickly processed and made available. It also has a proven ability to help identify the onset of shifts in patient needs and expectations.
Each persona’s interactions with relevant systems such as EMRs, CRMs and CMSes are also mapped. Stress points, disconnects, information loss and many other difficulties along the journey, which have direct impact on continuity of care, become apparent.
A Case Study for Mapping the Patient Journey
Illustrating this article is a detailed example of urinary tract infection, a serious condition that affects the health of millions of people annually worldwide.
According to the American Urologist Association:
Urinary tract infections are a significant health problem, both in community and hospital-based settings. It is estimated that 150 million UTIs occur yearly worldwide, accounting for $6 billion in health care expenditures.
The epidemiology of a UTI suggests that this infection is very common among adult women. In the United States, approximately 25-40% of women ages 20 to 40 years old have had a UTI.
In other words, UTIs are a serious health problem. Many women, regardless of where they live or their socio-economic status, require treatment for UTI episodes throughout their life. This particular journey, therefore, is likely to resonate with many readers based on personal experience. On a broader level, it provides a good example of the role that journey mapping methodology can play in improving patient experience and continuity of care for a wide population.
In this patient journey, we follow a 50-year-old female who has recently experienced two UTI episodes within four weeks of each other. The journey reflects conditions in a large metropolitan area with a high density of providers such as medical centers and urgent care clinics; patients have a wide choice of care options.
Determining the Scope of the Patient Journey
One of the first action items is determining the scope of the journey. In the case of UTI, the widest scope would cover the patient’s entire adult life, and the narrowest scope, a single episode. Clearly, with such a wide range, scoping the breadth of the journey requires practical objectives.
Starting with a narrower scope is the faster, more practical approach because data is more readily available. The narrow scope it is preferred because it serves as a spot check. Spot-checking is well-accepted industry-agnostic methodology for quality assurance in systems of any size. So the next question is, how narrow?
Modeling a single episode might amplify an outlier and have limited continuity issues, since it presents an isolated instance. I decided to look at a slightly wider scope that includes a recurrent UTI.
Consequently, the journey covers two recent adjacent UTI episodes (Figure 1, A and B). Additionally, the patient’s recent medical history includes a UTI episode that took place about 5 months prior to the start of the journey (Figure 1, C). That episode progressed from UTI to sepsis, a life threatening blood infection, and it provides an additional layer of context to continuity of care considerations.
Identify the Persona Taking the Journey
Assuming multiple persona classes were developed for patients and providers, the next step is to determine which patient persona should be used for this journey.
The journey spans about two months in the life of the patient, during which she experienced two UTI episodes about a month apart. Most likely, the antibiotics prescribed during the first episode were not potent enough for the bacteria that caused the UTI. The patient’s emotional state and actions, specifically, her decision to use an urgent care clinic instead of scheduling an appointment with her regular doctor. This decision is related to the life threatening UTI episode that preceded the journey by several months, and it resulted in introducing new providers and new challenges to continuity of care mix.
Table 1 below lists a core set of the primary persona’s attributes. They are organized around 5 basic categories: demographics, technographics, chronic conditions, recent medical history, and providers.
Table 1: Persona Attributes
Determine a Structured Narrative
A patient journey map is a form of data aggregation and visualization that uses narrative to instantiate the experience of an individual, from the onset of a medical episode to its closure. Narratives, in general, are notoriously inefficient when it comes to consistency in authoring, translation, classification and patterns analysis. Ideally, journey map narratives could be of tremendous value if map authors used some sort of a standardized structure. This makes the narrative information sharable and usable in other analytical settings.
The continuity narrative of the patient journey should focus on information transmission. Communication breakdowns between patient and provider, and among providers, tend to disrupt the continuity of care. The points of transmission in healthcare journeys are touchpoints that involve contact with providers, such as clinic visits, labs, phone calls, email exchanges, or dealing with insurance. The fidelity of the patient’s ‘story’ should be preserved as it passes through the touchpoints, or accessed from another journey. Spots of deviation should be easily identified and the roots of the failure—systemic or incidental—can be explored and addressed.
As you consider a pragmatic and easy methodology to create structured journey mapping narratives that are interoperable with clinical document architectures, one approach I suggest focuses on a high degree of human readability, and some degree of machine processing. After gathering information, you can parse touchpoint events into sets of factual statements, where each statement captures a single aspect of the event.
First, let’s scope which type of content left out of the narrative:
- Emotional state: When used in ‘general purpose’ domains such as ecommerce, standard journey mapping practice relies heavily on capturing the user’s emotional state at various points of a purchase process. For example, in a journey map that follows the purchase process of healthcare insurance online, confusion and frustration as part of the digital experience can be often attributed to the user interface. In healthcare, the patient’s emotional state may be associated with factors that are not directly related to the experience quality of a specific journey (such as side effects of medications or mental illness). Capturing the patient’s emotional state is an open area for further work in the continuity framework.
- Informal touchpoints: These include research the patient may conduct on the Internet, conversations with family members, and so on. These touchpoints influence the journey experience directly and indirectly. They are, however, beyond the scope of the framework presented here.
Below is a sample patient journey map used in our UTI journey, click to view the full image.
How to Discern Visualization Patterns
My considerations of how best to present the narrative information and visualize continuity of care, I focus on three objectives:
- The patient journey must visualize the shifts in the patient’s condition at any touchpoint with providers. The patient’s assessment of her health condition guides her actions and eventually sets in motion a flow of cascading events throughout touchpoints.
- The patient journey must visualize the interactions between the patient and providers at any touchpoint.
- The patient journey must be clean and easy to follow.
Layer 1: Self Assessment and Plotting the Patient’s Condition
The base layer of the journey is a visualization of the patient’s condition throughout. The transition from healthy state to ill state can be gradual, with symptoms advancing gradually from mild to severe, or it can be sudden. In cases of unfamiliar symptoms, people increasingly turn to online symptom checkers to research these conditions. In cases of reoccurring illness, such as the flu, people may recognize from past experiences the onset of a new episode.
Self-assessment is very subjective, but it plays a major role in influencing the patient’s emotional state and guiding her actions and interactions with providers throughout the journey. The primary graph charts the patient’s self-assessment of her condition at each of the journey’s 68 days (Figure 2). Each day the patient self-evaluates her condition based responses to the question: ‘How do you feel about the severity your present condition?’ The 10-scale answer is on the range of 1(mild) to 10 (severe).
Layer 2: Principal Journey Parties
Next, I layered in the principal entities involved in the journey, as horizontal bars parallel to the timeline (Figure 3):
- The patient
- The patient’s primacy care physician
- The patient’s specialist treating her auto-immune chronic illness
- The urgent care clinic the patient visited in order to get treatment
This modular arrangement makes it easy to extend the model to include additional parties to the journey. On the patient’s side, these can include parents/caregivers for pediatric use cases, spouses and children for geriatric use cases, and self-monitoring apps and devices that capture physiological data points. On the provider’s side, additional providers, insurers, or systems.
Layer 3: Touchpoints
The next layer captures touchpoints, the most important ingredient in a patient journey map. Visually, the touchpoint slices across the horizontal bars that represent the parties, on days in which a relevant interaction occurred.
A closer look at the visual representation of individual touchpoints (Figure 5, below) reveals an iconographic treatment serving two key objectives:
- The visualization should be ‘clean’ and easy to read, since the primary use of journey maps is as communication tools.
- Develop a set of repeatable visual vocabulary elements, which can be used consistently across other journeys, to facilitate interoperability when comparing relevant patient journeys.
Icons and directional arrows represent two properties of a touchpoint, origination and type (Figure 6):
- Directionality: The arrow originates at the originating party row, and ends at the destination party row.
- Engagement Type: direct and indirect. A solid arrow represents a direct touchpoint, meaning that a Human-to-Human interaction took place. Examples include an office visit, a lab test or a phone conversation between a patient and a physician. A dotted line represents an indirect touchpoint in which the Human-to-Human communication has been facilitated via an interaction with a portal, fax or email.
Layer 4: Touchpoint Utility Bar
Just above the X-axis of the journey is the alert bar (Figure 7). Icons placed along the timeline and aligned with relevant touchpoints indicate such information such as the start and end of the journey, time-sensitive events or Alerts. The stars indicate opportunities for improvement.
Layer 5: Touchpoint Capsules
The space below the X-axis is reserved for brief descriptive snapshots of the touchpoints (Figure 8). Plan ahead the journey’s layout and space allocation: The details of each touchpoint are essential to understanding the journey. However, condensing the essence of an interaction or communication is challenging, especially when the frequency of touchpoints is high.
When possible, featured insights or questions should be added to this bar. For example, in this patient journey, we could highlight canned email subjects limitation in communicating tine-sensitive issues. Visual treatment helps differentiate the capsules by type of touchpoint. For example, all emails are set in yellow round-corner box. The featured question is in a blue oval.
Despite obvious limitations imposed by the scope of this post, it is easy to identity several key continuity of care issues that impact the patient experience:
- E-mail, facilitated via the patient portal website, plays a key role in patient-provider communications (~60% of touchpoints), but its implementation introduces inefficiencies for provider and patient alike.
- Abnormal lab results do not trigger notifications or alerts.
- When the systems used by the Urgent Care Clinic and the patient’s primary care physician are not integrated, data points relevant to continuity of care, such as the visit to the clinic, lab results and medication administered there, are not added to the patient’s electronic medical record.
- Where available, patients are increasingly likely to seek treatment at Urgent Care Clinics since the experience these facilities provide is superior to that of the emergency room, which used to be the only option available outside regular work hours.
These issues, and many others that surface, can in turn be prioritized and addressed, their impact measured and implementation refined.