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Results
Across the three workshops, 51 clinicians from multiple professions and three consumer representatives participated in the codesign process (table 1). After the initial contextual inquiry, the project scope was limited to where health technology can support perioperative care occurring between the initial decision for surgery and admission to the hospital. Improving clinical decisions and practices within this time frame were considered the most important to providing high-quality care to patients waiting for surgery.
Distribution of primary professional roles of participants in the codesign workshops
Workshop 1 and 2 participants worked as a group to iteratively develop seven patient-modelled user personas across a range of perioperative risk profiles.27 Persona descriptions were sufficiently detailed to adequately support clinical decision-making, including personal characteristics (name, photo, gender, social situation and supports, financial status, personal needs and treatment goals), clinical context (contact with healthcare systems, symptoms, pain scores, function, medications, comorbid illnesses) and baseline investigations (blood tests, relevant imaging or investigations). Researchers and participants ensured that the personal and social attributes of the personas were representative of the populations serviced by the participating LHDs. Figure 2 shows an example of persona. Summaries of the persona development exercise were further refined based on consensus feedback from the wider research group. Online supplemental table S1 summarises each persona’s characteristics.
Example of a patient persona. BMI, body mass index. Example of a patient personaa. ASA, American Society of Anesthesiologists Score. BMI, body mass index. BP, blood pressure. DASI, Duke Activity Status Index. eGFR, estimated glomerular filtration rate; HbA1c, haemaglobin A1c; TAD, tobacco, alcohol and drugs.
In the final workshop, participants mapped anticipated perioperative experiences for elective anterior resection for colon cancer or hip arthroplasty, according to each persona. During the initial inquiry and scoping process, these two surgical procedures were chosen as representing different levels of procedural magnitude, clinical urgency and perioperative risk associated with elective surgical procedures. In this workshop, participants worked in small interprofessional groups of five to six people to generate a visual depiction of the perioperative journey for their allocated patient persona, shown in online supplemental figure S1. Journey mapping included reference to key perioperative decisions, person-centred care elements,33 emotions (both patient and clinician), location and access to required clinical information and potential system pitfalls. After reflecting on the journey maps and group summaries, an interactive exercise had participants propose and rank potential solutions where health technology could address identified needs and opportunities (table 2). In this exercise, participants each allocated a limited sum of hypothetical money to their preferred solutions.
Proposed solutions to perioperative challenges, ranked according to participant preferences
Thematic analysis of the project output identified six key design challenges, which were reframed as opportunities to improve current perioperative health systems.
Proactive and preventative perioperative care requires a shift in care processes towards earlier assessment
Currently, most perioperative planning occurs towards the end of the preoperative period, often within weeks of the anticipated surgery date. This gives limited opportunity to implement preventative treatments such as rehabilitation or nutritional therapy.
We currently have a highly labour-intensive process and system. Tasks are often done at the last minute. It’s not optimised.
Improving digital health record integration could provide critical clinical information required for triage and risk assessment at the time of surgical listing and facilitate streamlined preparation, monitoring of clinical status while on the waitlist and planning for hospital services such as intensive care beds.
Clinical records need to support clinicians to make evidence-based yet individualised care decisions
Clinician participants desired autonomy to individualise treatment plans to patient needs and priorities. While participants valued clinical risk scores and algorithms, they wanted flexibility to tailor their preferred tools and avoid over-protocolisation. Some participants were apprehensive about policymakers promoting specific risk scores in clinical algorithms, replacing the role of experienced clinicians in decision-making. All clinicians advocated that better visualisation of clinical parameters in electronic health records could improve decision-making.
A dashboard is an opportunity to get away from manual time-consuming paper-based processes. This gives us an opportunity to identify and triage patients more effectively.
Opportunities for health technology solutions included summarising key perioperative clinical and social variables into visually appealing ways, that provided sufficient data for clinicians to calculate their preferred risk scores.
Communication can be integrated by improving access to clinical information across different healthcare settings
Participants were frustrated by difficulties locating clinical information in electronic medical records, spending considerable time obtaining documentation from private facilities and primary care providers. Different healthcare staff prioritised different aspects of the clinical record, and current processes duplicate information gathering.
Data is buried; different clinical groups use the system in different ways, and there are opportunities for assessments to be done in an interdisciplinary way.
Primary care clinicians wanted access to electronic hospital records to advise patients of waitlist times, and support preventative care and monitoring. Participants also proposed that patients should have input into their perioperative records and information-sharing. There are opportunities to improve access to digital clinical records across different healthcare jurisdictions, between hospital and community and between different members of the perioperative team.
Key transitions in clinical care need to be more streamlined to help with patient and clinician experiences
Transitions in care to different providers and services in the perioperative journey represented potential care fragmentation and uncertainty.
We need better flow systems for how patients come to the surgery and how we optimise and prepare them for that operation.
Participants proposed that the experience of patients and clinicians could be significantly improved through virtual care coordination, especially for high-risk or vulnerable patients or those with additional barriers to care such as rural and remote residence or limited English-language proficiency.
Perioperative organisational structures need to provide an opportunity for shared decision-making and options to pursue non-operative management
Participants reported limited opportunities to redirect patients towards non-operative pathways if surgery is deemed to be of limited benefit, or if treatment goals change. The current demand for complex decision-making support is unknown and proactive referrals are ad hoc. Digital health summaries present opportunities to monitor and stratify subgroups of patients on the surgical waitlist with different perioperative needs and plan health services based on projected requirements.
Partnerships between administrative and clinical staff are required for safe and timely perioperative care
Current systems separate waitlist administration and demand management from clinical services. Participants desired greater partnership between clinicians and administrative staff to manage the waitlist and align clinical needs with efficiency indicators. Participants saw an opportunity to integrate administrative and electronic health records, with the aim of supporting perioperative review and operating theatre demand management and reducing unplanned cancellations.
Twenty digital solutions were suggested, shown in table 2. The highest ranked were a digital clinical support dashboard, virtual care coordination and digitisation of core clinical documents. These three potential solutions also address all six of the key opportunities to improve care.
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