Embedding the Pillars of Quality in Health Information Technology Solutions Using “Integrated Patient Journey Mapping” (IPJM): Case Study

Abstract

Background
Health information technology (HIT) and associated data analytics offer significant opportunities for tackling some of the more complex challenges currently facing the health care sector. However, to deliver robust health care service improvements, it is essential that HIT solutions be designed by parallelly considering the 3 core pillars of health care quality: clinical effectiveness, patient safety, and patient experience. This requires multidisciplinary teams to design interventions that both adhere to medical protocols and achieve the tripartite goals of effectiveness, safety, and experience.
Objective
In this paper, we present a design tool called Integrated Patient Journey Mapping (IPJM) that was developed to assist multidisciplinary teams in designing effective HIT solutions to address the 3 core pillars of health care quality. IPJM is intended to support the analysis of requirements as well as to promote empathy and the emergence of shared commitment and understanding among multidisciplinary teams.
MethodsA 6-month, in-depth case study was conducted to derive findings on the use of IPJM during Learning to Evaluate Blood Pressure at Home (LEANBH), a connected health project that developed an HIT solution for the perinatal health context. Data were collected from over 700 hours of participant observations and 10 semistructured interviews.
ResultsThe findings indicate that IPJM offered a constructive tool for multidisciplinary teams to work together in designing an HIT solution, through mapping the physical and emotional journey of patients for both the current service and the proposed connected health service. This allowed team members to consider the goals, tasks, constraints, and actors involved in the delivery of this journey and to capture requirements for the digital touchpoints of the connected health service.
Conclusions
Overall, IPJM facilitates the design and implementation of complex HITs that require multidisciplinary participation.

Full text

Original Paper
Embedding the Pillars of Quality in Health Information Technology
Solutions Using “Integrated Patient Journey Mapping” (IPJM):
Case Study
Stephen McCarthy1, PhD; Paidi O'Raghallaigh1, PhD; Simon Woodworth1, PhD; Yoke Yin Lim2, MD; Louise C
Kenny3, PhD; Frédéric Adam1,4, PhD
1Department of Business Information Systems, Cork University Business School, University College Cork, Cork, Ireland
2Cork University Maternity Hospital, Cork, Ireland
3Dept. of Women’s and Children’s Health, Institute of Life Course & Medical Sciences, University of Liverpool, Liverpool, United Kingdom
4INFANT SFI Centre, University College Cork, Cork, Ireland
Corresponding Author:
Stephen McCarthy, PhD
Department of Business Information Systems
Cork University Business School
University College Cork
Western Road
Cork, T12 K8AF
Ireland
Phone: 353 21 490 ext 3214
Email: stephen.mccarthy@ucc.ie
Abstract
Background: Health information technology (HIT) and associated data analytics offer significant opportunities for tackling
some of the more complex challenges currently facing the health care sector. However, to deliver robust health care service
improvements, it is essential that HIT solutions be designed by parallelly considering the 3 core pillars of health care quality:
clinical effectiveness, patient safety, and patient experience. This requires multidisciplinary teams to design interventions that
both adhere to medical protocols and achieve the tripartite goals of effectiveness, safety, and experience.
Objective: In this paper, we present a design tool called Integrated Patient Journey Mapping (IPJM) that was developed to
assist multidisciplinary teams in designing effective HIT solutions to address the 3 core pillars of health care quality. IPJM is
intended to support the analysis of requirements as well as to promote empathy and the emergence of shared commitment and
understanding among multidisciplinary teams.
Methods: A 6-month, in-depth case study was conducted to derive findings on the use of IPJM during Learning to Evaluate
Blood Pressure at Home (LEANBH), a connected health project that developed an HIT solution for the perinatal health context.
Data were collected from over 700 hours of participant observations and 10 semistructured interviews.
Results: The findings indicate that IPJM offered a constructive tool for multidisciplinary teams to work together in designing
an HIT solution, through mapping the physical and emotional journey of patients for both the current service and the proposed
connected health service. This allowed team members to consider the goals, tasks, constraints, and actors involved in the delivery
of this journey and to capture requirements for the digital touchpoints of the connected health service.
Conclusions: Overall, IPJM facilitates the design and implementation of complex HITs that require multidisciplinary participation.
(JMIR Hum Factors 2020;7(3):e17416) doi: 10.2196/17416
KEYWORDS
health information technology; health care quality; data analytics; multidisciplinary research; mobile phone
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Introduction
Prior Work
Significant investment continues to be directed toward service
reform strategies to deal with the sizable challenges facing health
care sectors [1]. These challenges include, but are not limited
to, an increasing demand for chronic care, shortages in skilled
medical labor, and an aging population [2,3]. In the United
Kingdom, the government pledged a £20.5 billion (US $27
billion) increase in the National Health Service’s budget between
2019 and 2024 to foster widespread performance improvements
across both primary and secondary care with the aim of tackling
these challenges [4]. This trend toward increased spending is
likely to continue into the future as nations across the globe
seek to deal with large-scale economic and demographic changes
[1].
Health care service redesign through the adoption of health
information technology (HIT) is being proposed as a means of
increasing both the efficiency and effectiveness of health care
services, reducing waiting times, and improving the standards
of patient care [5,6]. In particular, connected health has emerged
as a promising area of research for addressing some of the
current challenges [7-9]. This blends the physical and digital
realms by capturing real-time data from numerous connected
HIT devices (eg, smartphone apps, weighing scales, blood
pressure monitors, etc) to ensure that health care stakeholders
(eg, patients, carers, clinicians, etc) are provided with timely,
accurate, and pertinent information regarding the patient’s status
[8,10]. Combined with advanced data analytics, connected health
platforms can also contribute to the improvement of health
outcomes through targeted and early interventions [11]. For
instance, data analytics can provide clinicians with key insights
derived from patterns in large patient data sets, which can in
turn contribute to improved clinical decision making. This can
help reduce decision makers’reliance on gut feelingor intuition
by fostering a data-driven, evidence-based approach to clinical
decision making and decision support [12-14]. Connected health
platforms, combined with the use of smartphone apps, also offer
the possibility of deploying coaching on a broad scale to
improve adherence and outcomes for those affected by a variety
of conditions, such as diabetes [15-17].
However, Chen et al [18] noted that these targets can only be
achieved through appropriately designed interventions. This
requires inputs from all relevant stakeholders to design
connected health solutions that not only fit the needs of patients
[19] but also fit within the health care ecosystems and are viable
and sustainable in the long term [18]. The mapping tool that we
present in this paper is aimed specifically at eliciting and
channeling the opinions and preferences of a varied group of
stakeholders around the possible use of HIT across a medical
pathway.
According to Doyle et al [20], there are 3 core pillars of health
care quality, which health care reform strategies (including those
involving connected health) must cater to, clinical effectiveness,
patient safety, and patient experience. Their contention has been
broadly supported by other researchers (for instance, the study
by Anhang et al [21]), with their paper receiving over a thousand
citations and many researchers adopting their 3-pillar
framework. The core argument in this stream of research is that
the relationship between patient experiences and other aspects
of care is symbiotic and critical. We agree with the view that
patient experiences are an integral aspect of care quality (even
if they may not be directly related to clinical processes and
outcomes [22]. We strongly agree that we need to understand
how patient experiences are associated with the effective use
of structures, the underlying health care processes, and the
occurrence of health outcomes. This knowledge ought to be
directed toward improving the efficiency and effectiveness of
care [21]. Thus, in this study, we adopted the 3 pillars of health
care quality by Doyle et al [20] as a guiding framework.
To date, health service reform initiatives have focused on
measures of clinical effectiveness and patient safety, with patient
experience receiving less attention [5,23]. It does not follow
that an efficient and compliant service will mean a good patient
experience. For instance, a patient might receive an appointment
quickly, but their overall experience may be poor if, for example,
they feel that their unique needs are not catered to. In most
cases, connected health solutions involve patients who directly
engage with apps, often in their homes or in the community.
Given the absence of direct supervision, it is critical that the
apps and devices are easy to use and that they promote
appropriate, accurate, and safe usage. Generally, connected
health solutions raise significant and new ethical concerns,
which need careful consideration [24]. Therefore, it is crucial
that their design considers all 3 central pillars of health care
quality (clinical effectiveness, patient safety, and patient
experience) in tandem [20,25]. Failure to consider these pillars
may mean that key requirements and constraints are overlooked,
leading to problems later—poor quality data, low utilization of
health care services, ineffective decisions by health care
professionals, or unethical use of data [20,26].
Although methods are available for exploring each pillar of
health care quality in isolation, to the best of our knowledge,
there is no single design tool currently in use that addresses all
3 pillars collectively, and more particularly in the context of
technology-intensive and multidisciplinary fields such as
connected health. This paper, goes some distance to address
this shortfall by presenting a design tool we developed called
Integrated Patient Journey Mapping (IPJM). This tool is
primarily aimed at supporting the analysis and design of
connected health apps. Inspired by the concept of journey
mapping, it allows researchers and practitioners to
simultaneously and explicitly consider the factors of clinical
effectiveness, patient safety, and patient experience in tandem.
The tool has primarily been validated through its use in a series
of projects. In this paper, we focus on its use in a project called
Learning to Evaluate Blood Pressure at Home(LEANBH) that
involves the development of a connected health app focused on
the investigation of preeclampsia, a disorder of pregnancy that
can lead to a variety of adverse outcomes.
The remainder of the paper is structured as follows: On the basis
of a review of existing literature, the Introduction section offers
a background to the development of the mapping tool in the
context of connected health and describes IPJM. The Methods
section explains the methods, while the Results section provides
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results from the LEANBH project on the use of IPJM in a
perinatal context. A discussion of the findings as they pertain
to academic and practitioner communities is outlined in the
Discussion section.
Background
Connected Health and Data Analytics
Connected health has been defined as a novel, conceptual model
for health care management “where devices, services, or
interventions are designed around the patient’s needs, and
health-related data is shared, in such a way that the patient can
receive care in the most proactive and efficient manner possible”
[10]. Connected health aims to provide all actors involved in
the delivery of health care services with timely, accurate, and
pertinent information around the patient’s current state of
well-being [8,10,27,28]. This is made possible by the
development of information technology (IT) platforms that
seamlessly integrate numerous connected health devices, which
allow real-time management and monitoring of patients’
well-being across different settings [28-30]. This has been made
possible through the increasing availability of new wireless
networks (eg, Wi-Fi, Bluetooth, and 4G or 5G networks) that
enable high-speed seamless integration of connected health
devices and secure data repositories for storing health-related
data.
Connected health platforms also enable health care actors to
take effective measures for managing the patient’s state of
well-being by analyzing health data from these devices [10,30].
Collected data from connected devices can be continuously
analyzed and shared to provide actors with key insights that
allow them to take effective action. For instance, feedback can
be derived from an analysis of a patient’s home-based blood
pressure readings or blood glucose levels taken from wearable
body sensors or connected devices that record patients’ vitals
[31,32]. In addition, rule-based systems can be employed to act
as early warning systemswhereby health care professionals are
notified when a patient’s vitals pass certain thresholds, as
detailed in the relevant clinical guidelines [33].
Connected health solutions and data analytics support a
proactive model of care in which all stakeholders are provided
with critical feedback at key touchpoints between the patient,
the connected health platform, and the health care service
[10,34]. At the same time, this provides a clear opportunity to
re-engineer relevant pathways to boost their effectiveness while
also leveraging leading-edge technology to reduce the
transaction cost or increase the throughput of key health care
services. However, the mapping of these touchpoints can be a
challenging task, given the complexity of the pathways as well
as the ubiquity and diversity of patient data in connected health
scenarios [35]. Existing modeling techniques often fail to
identify the ideal placement and configurations of connected
health solutions within the health care service network [35].
Central Pillars of Health Care Quality
Quality improvement is the primary goal of all modern health
care service organizations, which strive for better patient health
care outcomes, service performance, and professional
development in the delivery of health care services [36].
According to Doyle et al [20], there are 3 central pillars that
constitute health care quality
Clinical Effectiveness
Clinical effectiveness concerns the improvement of the current
clinical practices and their related health care service outcomes
[25]. Clinical effectiveness can be improved through the
identification of nonvalue adding steps that fail to directly
improve the quality of patient care [37]. Workflow analysis can
help improve the effectiveness, efficiency, and efficacy of
clinical services based on an in-depth understanding of the status
quo [38,39]. For instance, workflow analysis can be undertaken
to investigate and identify potential variations in service delivery
and to identify issues such as bottlenecks and resource
constraints.
Patient Safety
Patient safety aims to safeguard different dimensions of patient
well-being through regulation and proactive measures in practice
[25]. The health care sector is a highly regulated environment,
which demands that patient safety is taken into consideration
in service reform initiatives. Examples of the constraints that
ought to be considered when addressing patient safety include
medical protocols and clinical guidelines (eg, the National
Institute for Health and Care Excellence guidelines), ethical
standards (eg, the Hippocratic Oath), medical device certification
(eg, Food Drug Administration approval in the United States
and Conformité Européene (CE) Marking in the European
Union), and data protection (eg, General Data Protection
Regulation). These factors act as guide rails that aim to improve
patient safety [40].
Patient Experience
Patient experience centers on a patient’s “personal interpretation
of the service process and their interaction and involvement
with it during their journey or flow through a series of
touchpoints” [41]. Zomerdijk and Voss [42] state that
experiences are constructed based on the interpretation of
encounters and interactions designed by the service provider.
Although providers cannot directly offer an experience, they
can create the foundational basis on which stakeholders (eg,
customers, patients, and employees) can derive their own
experiences. Although operational service quality looks at
whether a service is delivered to its predefined specification,
patient experience is based on the patient’s feelings, judgments,
and perceptions of the benefits derived from the service [41,43].
Patient experience is a key factor in ensuring compliance with
recommendations as patients are much more likely to disregard
or abandon tools and practices if they contribute to a poor
experience. Patient experience must also be considered from
an ethical viewpoint where patients must be fully aware “of the
nature, scope, and granularity of data collected and what
information they are actually consenting to provide” [24].
However, although some methods for improving clinical
effectiveness and managing patient safety are relatively well
established in the health care sector (eg, process mapping,
service blueprinting, etc), methods for enhancing patient
experience are less entrenched, particularly within connected
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health [5,23,35]. The following section looks at journey mapping
as a patient-centric tool for designing health care service reform.
Journey Mapping
Journey maps have been used in several areas to offer pictorial
illustrations of complex processes or interactions that would
otherwise be difficult to apprehend. Howard [44] noted that
journey maps evolved from the field of service design when
designers sought to re-engineer or optimize the service delivery
of organizations or developed blueprints for new services (see
the study by Stickdorn and Schneider [45]).
In particular, journey maps can be used to depict the health care
service from the perspective of different actors, such as patients
[37,42,46]. In the case of the patient, they are based on mapping
consecutive touchpoints between the patient and the service,
the nexus of where patient experience is actively shaped
[23,42,47]. They see the relationship between the patient and
service organization as something emergent, dynamic, and
ubiquitous within the larger context and go beyond the more
static view provided by other service design methods [42].
Percival and McGregor [48], for instance, proposed a mapping
technique that includes a number of layers: staff roles, processes,
information creation or movement, HIT solutions, IT
infrastructure, patient needs or practice guidelines or policies,
and metrics. Journey maps incorporate both physical and
emotional aspects of the patient’s journey with the aim of
capturing and shaping the patient’s behavior, feelings,
motivations, and attitudes across the episodes of care, taking
into account such important factors as the environment or
context. They also help professionals to visually externalize
their disciplinary knowledge and collect multidisciplinary
insights. This promotes alignment but also empathy toward
patient groups by placing the patient at the heart of the modeling
process [49] and by creating a visually compelling story of the
patient’s experience [43].
User representations are developed to categorize and personify
different target groups through the description of fictional users,
that is, name, picture, personal background, and goals. User
personas involve creating representations of typical users to
help design teams to better understand and take account of the
mental models of these groups, that is, their expectations, prior
experience, and anticipated behavior [50]. LeRouge et al [50]
stated that user personas address the limitations of common
modeling tools such as Unified Modeling Language diagrams
by integrating the conceptual model of users, their cognitive
structures, and present behavior that drives health care thinking,
future behavior, and demand.
Journey maps can be combined with user personas in the
requirements gathering process to direct increased attention
toward patient experience. The added contribution of personas
to journey maps is that instead of being static representations
of demographic profiles, they offer dynamic views of customers
and users’ experiences in their interactions with current and
proposed products and services. The combined approach can
then be employed to make design decisions and evaluate design
solutions according to the unique needs of each persona. This
stimulates creativity among team members when trying to
address user needs and usability across numerous different
real-life scenarios [51]. Critically, a small number of personas
have been found to support the consideration of large, diverse
populations, making the concept particularly useful for health
care scenarios [52].
Developing Complex Apps
The area of HIT development has received considerable
attention over the last 40 years. This time has seen the
emergence of increasingly sophisticated platforms and
development environments. Recently, the availability of
cloud-based solutions, smart interconnected devices, and mobile
apps has unleashed the potential for connected health apps.
Unfortunately, these benefits can often be offset by the
complexity and cost of developing connected health apps. The
set of required development skills is becoming increasingly
specialized, as is the complexity of the project management of
the multidisciplinary teams required when developing such
solutions. Mapping tools might be a useful approach for building
cohesion within such teams, but at the same time, they must be
understandable by diverse groups and professions to ensure that
shared knowledge can be nurtured during the development
process.
In the following section, we describe IPJM, a visual tool
developed to help design teams to meet these challenges and to
understand how to best reconcile the sometimes divergent
requirements arising out of the need for clinical effectiveness,
patient safety, and patient experience when designing connected
health solutions. IPJM is also intended to promote harmonious
team performance by negotiating and finding the right balance
between the somewhat competing needs of different groups.
This requires collaboration between different competencies on
multidisciplinary teams. It also requires the management of
conflict, which is likely to emerge from a comprehensive
consideration of all viewpoints [53-55]. As a result of using
IPJM, we hope that robust and high-quality designs will emerge
for the solutions being considered.
IPJM
The IPJM tool was built using an ontology that conceptualizes
the journey of a patient along a medical pathway. The ontology
aims to promote a common vocabulary [56] among
multidisciplinary design teams based on the 3 core pillars of
health care quality. It captures the key elements of the journey:
the structure of elements, relationships between elements, and
implicit rules that govern the behavior of elements [57]. The
ontology depicted in Figure 1 is provided in the literature. In
addition, it has been validated through qualitative feedback from
a number of projects that involve the use of IPJM, including
the LEANBH project, which is described in the Methods section
of this paper.
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Figure 1. Integrated Patient Journey Map Ontology.
The ontology is split into 3 main areas: the patient persona, the
medical timeline, and the medical pathway. First, the patient
persona provides a characterization of a user group under
consideration (eg, an expectant mother who is at risk of
hypertension) and is inextricably linked to all other elements
of the ontology. The medical timeline adds a temporal aspect
to the episode of care by dividing it across a defined time frame
(eg, the weeks of a pregnancy). The medical pathway centers
on the consecutive events or steps in the episode of care [46]
and consists of 7 subcomponents that are defined and described
in Textbox 1. In particular, the medical pathway describes the
physical journey, the emotional journey, and the device
touchpoints associated with an episode of care. The physical
journey is further divided into tasks, and these tasks are further
subdivided into goals, constraints, and actors.
Textbox 1. Components of the medical pathway.
•Physical journey: maps the movement of the patient across an episode of care as she moves from one touchpoint to another in different settings
(eg, patient’s home, general practitioner clinic, or emergency room) where the health care service is delivered and the patient experience is derived
•Emotional journey: shows how the patient’s experience changes as she moves through the different touchpoints
•Device touchpoints: lists the technological solutions utilized by the different actors (eg, doctor, general practitioner, and patient) at each touchpoint
•Actors: lists the stakeholders involved in the delivery of the health care service (eg, hospital doctors, general practitioners, and nurses)
•Task: details the tasks undertaken by each actor in the health care service delivery (eg, measuring the patient’s blood pressure and registering
appointments)
•Goals: comprises the desired outcomes that actors aim to deliver when carrying out tasks (eg, clinical, operational, and administrative goals)
•Constraints: outlines the constraints such as treatment guidelines based on medical protocols, governance, safety, and clinical guidelines
In this way, the ontology provides the foundational basis for
IPJM by outlining the context in which the patient journeys
transpire. Going back to the underpinnings of the concept of
journey maps, the mapping tool (through the use of the ontology)
visualizes the journey of a persona facing a scenario. This can
sensitize designers and developers to the intricacies of individual
personas and scenarios and minimize the risk of designing for
normative situations that do not reflect the real situations of
actual patients. Commercial firms and public sector agencies
have used such ontologies very successfully in seeking to
develop interaction mechanisms with their customers and with
members of the public who need to access their services, such
as in the case of disabled people who have special mobility and
cognition needs [58].
IPJM can be used to show the as is and the to be comparison
between the existing medical pathway and the intended modified
pathway enhanced with technology, devices, apps, and other
new components and interactions. This ensures the tool’s
usefulness for negotiation and communication of the design of
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the proposed connected health solution, especially between
clinical specialists and designers or developers of the solutions.
In seeking to make a business case for new pathways, the map
can be used to demonstrate to relevant health care authorities
the potential impact of proposed changes.
IPJM Template
Building on this ontology, we iteratively designed and evaluated
the visual elements of a journey mapping tool called IPJM. An
example of a base template, constructed iteratively using the
ontological components, is shown in Figure 2. The patient
persona is situated on the left side of the template, the medical
pathway and its subcomponents are positioned in the center,
and the medical timeline is displayed horizontally on the top of
the template. Tasks, goals, constraints, and actors are listed
within the safety and governance component.
Figure 2. Base Integrated Patient Journey Map Template.
Each of these areas of the IPJM maps to the 3 core pillars of
health care quality previously outlined in the Background
section. For instance, the physical journey aims to provide
insights into the clinical effectiveness of the health care service
by plotting the sequence of steps involved in the delivery of
care. This, in turn, can be used to examine the steps to identify
those that do and do not add value to the health care service.
The emotional journey deals with patient experience. This is
based on the likely emotional response of the patient to
individual steps in the health care service. Finally, safety and
governance maps the aspects of patient safety based on the
responsibilities of different actors and their associated regulatory
constraints.
The device touchpoint area caters for the connected health
context and maps the different connected devices and data
analytic solutions that are employed by actors when delivering
the service. For instance, one touchpoint between the patient
and the health care service could involve the use of a smartphone
app and a connected medical device for tracking and sharing
data on the patient’s state of well-being. Another touchpoint
could involve the use of data analytics by clinicians to gain
insights into the patient’s state of well-being, forecasting
potential health issues and intervening when required.
A design science approach was followed to ensure that there
was a rigorous basis for the construction of the tool [59]. A
description of the researchers’ approach to design science was
previously presented in a study by McCarthy et al [60].
Following O'Raghallaigh et al [56], the design science approach
consisted of 2 central activities: (1) identifying and generating
foundational abstract knowledgefrom academic and practitioner
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literature to guide, explain, and justify the design approach and
(2) using and refining abstract foundational knowledge in
developing and evaluating prototypes through engagement with
potential users of the tool. The approach thus sought to integrate
both design practices(construction of the artifact supported by
existing knowledge) with design science (generation of
knowledge through the construction and evaluation of the
artifact). For example, the initial version of the ontology was
developed from a scientific understanding of the academic
literature. On the other hand, the first version of the mapping
tool was largely developed through practice.
Prototypes of the IPJM tool were evaluated using different
techniques. Evaluation primarily focused on examining the use
of the tool by design teams during projects focused on increasing
health care quality (clinical effectiveness, patient safety, and
patient experience). In addition, the general evaluation looked
at IPJM as an analytical tool to support the collection of
requirements for connected health apps. In the case of the
LEANBH project, evaluation involved a multidisciplinary team
of stakeholders working together to populate IPJM templates
for 8 personas across diverse scenarios (such as white-coat
hypertension, chronic hypertension, gestational hypertension,
and preeclampsia). A separate template was used to map the
journey for each persona facing a scenario. Post-it notes were
used to fill in the components of the journey, and these were
positioned across the 4 areas of the template. This approach
allowed the journey to be easily modified by iteratively adding,
moving, or removing the post-it notes. Different colored markers
were used to connect and codify post-it notes and to indicate
where changes needed to be made to the journeys based on
discussion among the team members. Table 1 provides a
summary of the evaluation techniques used during the LEANBH
project.
The following section outlines the in-depth case study of the
LEANBH project.
Table 1. Techniques used to evaluate the Integrated Patient Journey Mapping during the Learning to Evaluate Blood Pressure at Home project.
PurposeBrief descriptionData collection
Exploratory design of the model-
ing tool
Four full-day workshops involving a multidisciplinary group of stakeholders. The
workshops focused on deriving requirements for a connected health system that
would monitor the well-being of expectant mothers across different settings such as
the antenatal clinic, general practitioner’s practice, and an expectant mother’s home
Workgroup
Individual stakeholder’s subjec-
tive evaluation of IPJM
Semistructured interviews each lasting about 1 hour were conducted with the 10 in-
dividual team members to gain further in-depth insights into the IPJMatool. Interviews
were conducted with the principal investigator, project manager, 2 developers, a
funded investigator, data architect, clinical lead, clinical researcher, research nurse,
and the director of a commercial partner
Semistructured interviews
Evaluation of the prototype’s
ability to represent the current
best practices
A range of sources were used to ensure that IPJM considered clinical effectiveness,
patient safety, and patient experience goals. This involved analyzing best practices
around managing the patient pathway using sources such as the UK’s National Insti-
tute for Health and Care Excellence guidelines for managing hypertension during
pregnancy. In addition, information requirements were investigated based on the
Health Service Executive’s maternity health record in Ireland and Data Protection
Act guidelines around health care research
Analysis of supporting docu-
ments
aIPJM: Integrated Patient Journey Mapping.
Methods
Case Study Approach
An in-depth case study approach [61] was undertaken to explore
the use of visual tools for embedding health care quality in the
design of connected health solutions. The in-depth case study
in question followed the guidelines provided in studies by Yin
[62,63]. It centered around the LEANBH project, a pilot research
project that provides remote health care monitoring for expectant
mothers to improve the detection and treatment of hypertension
during pregnancy.
The LEANBH Case Study
Hypertensive disorders in pregnancy (eg, preeclampsia and
gestational hypertension) are a major cause of maternal and
neonatal mortality and morbidity worldwide, accounting for
16% of maternal deaths in developed nations such as Ireland
and 25.7% of maternal deaths in the developing nations of Latin
America and the Caribbean [64]. In particular, preeclampsia is
a hypertensive disorder of pregnancy characterized by high
blood pressure (>140/90 mm Hg), the presence of protein in
urine, and other associated symptoms such as headaches and
edema, which can lead to serious complications during
pregnancy [65].
The LEANBH project was a collaborative effort that involved
organizations from academia, the health care sector, and the
industry. The multidisciplinary project team consisted of a
principal investigator, a project manager, a full-time and
part-time developer, an analyst, and a data architect (which
made up the information systems [IS] subgroup) and a clinical
lead, a clinical researcher, and a research nurse (which made
up the clinical subgroup). The primary goals of the project were
to increase clinical effectiveness, patient safety, and patient
experience in a perinatal care context. The project team was
tasked with building a connected health platform that integrates
several IT artifacts, including a smartphone app, a home blood
pressure monitor, and a urine analyzer for use by expectant
mothers. An electronic health record was included to capture
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vitals for use by clinicians. The project also aimed to develop
novel forecasting algorithms for predicting the likelihood of
gestational hypertension and preeclampsia.
The project was an observational study in which each patient
followed the standard pathway and had access to both the
standard care and the connected health platform. This simplified
the ethical approval process, which was mostly concerned with
providing complete and precise information to participants and
in eliciting their consent on recruitment. This was achieved by
creating a comprehensive patient information leaflet and
assigning a dedicated research nurse to recruiting patients and
training them in the use of the smartphone app, blood pressure
monitor, and urine analyzer. Ethical approval was granted by
both the University Clinical Research Ethical Committee and
the Health Service Executive via the Hospital’s Local
Information Governance Group Research and Audit Committee.
The authorization covered 2 rounds of recruitment of 50 patients
each: the first group was an initial low-risk group and the second
group was a more representative group of pregnant women,
including women with preeclampsia.
Data Gathering
Qualitative data were triangulated using 3 data gathering
techniques: participant observations, interviews, and project
documents. First, the lead author was granted exceptional access
to the live project setting, which allowed him to carry out over
700 hours of in-depth participatory observations in the field for
a period of 6 months (June 2015 to January 2016). Participant
observations allowed the lead author to gain rich insights into
peoples’ actions and directly observe events as they unfolded.
In addition, semistructured interviews, each lasting about 1
hour, were then conducted with the 10 individual team members
to gain further in-depth insights into the project. The interviews
provided rich accounts of the subjects’own words. Finally, the
lead author also had access to project documents throughout
the development phase, which included emails, reports, and
project management outputs. These documents offered a
concrete account of the phenomenon of interest.
Data Analysis
Content analysis [66] was used to organize data into common
themes and triangulate findings from interviews, project
documents, and participatory observations. The content analysis
centered on both reflection-in-action and reflection-on-action
[67], with clinicians and IT specialists asked to validate IPJM
and the individual journey maps. This hybrid approach was in
keeping with our use of the case study method, in an intrinsic
rather than an instrumental mode [68].
The journey map was first evaluated through
reflection-in-action, with participant observations by the lead
author using vignettes. As noted by Denzin and Lincoln [69],
“it is important to keep in mind that when conducting qualitative
research, the researcher is the main tool for analysis.” Vignettes
provided “a focused description of a series of events taken to
be representative, typical, or emblematic in the case” [70].
Vignettes were used in the first instance as many parameters
were emergent in our data analysis, and we wanted to stay as
close to the data as we could. This technique allowed the
researcher to produce, reflect, and learn from data around key
moments in the everyday life of the project [70,71]. Gaining
familiarity with the data, although arguably time consuming,
was a positive aspect of the data analysis process and helped
deliver a better artifact as well as a deeper understanding of its
efficacy.
The efficacy of the journey map was also validated through
reflection-on-action by analyzing interviews. To enhance the
rigor in our data analysis, we used the computerized software
provided by NVivo (QSR International) to analyze the interview
transcripts. The lead author identified the codes of interest,
including variables such as concepts and properties as well as
the relationship between these variables [70]. As part of the data
analysis and evaluation process, the researcher’s perception of
variables and relationships, otherwise referred to as theoretical
sensitivity, was influenced by a reading of literature. The lead
author continuously reread interview transcripts and used NVivo
to manage the coding inventory.
Results
During the project initiation phase, the project manager
organized 4-day-long participatory design workshops that aimed
to build a collective vision for the project and to gather
requirements for the connected health platform. These
workshops involved stakeholders from the IS and clinician
subgroups. During the workshops, the project manager
encouraged the groups to work together in utilizing IPJM to
map the physical and emotional journeys of pregnant women
across the touchpoints of the proposed connected health service.
In this way, IPJM provided a canvas for the groups to explore
an improved antenatal pathway, technical considerations of the
connected health platform, and the needs and capabilities of
different stakeholders (eg, expectant mothers, clinicians,
developers, nurses, midwives, and other health care
practitioners). The groups used markers and post-it notes to
dialogically work through potential challenges faced by personas
in engaging with the proposed service. Owing to delays in the
ethical approval process, the interdisciplinary team did not have
direct contact with expectant mothers during this time.
The project team used IPJM during successive workshops to
superimpose the journeys of fictional personas of different
expectant mothers who would use the connected health service.
In total, 8 fictional personas were identified by the team to
represent the different hypertensive disorders that can occur
during pregnancy and the medical scenarios that can occur. This
included Sheila, a 31-year-old first-time expectant mother at
risk of hypertension during pregnancy because of a family
history of preeclampsia (Figure 3). Her journey through the
standard antenatal pathway was now complemented with her
use of the proposed connected health solution. Other personas
included Denise, a 25-year-old expectant mother who developed
preeclampsia, and Fiona, a 29-year-old expectant mother who
developed gestational hypertension.
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Figure 3. Snapshot of a Completed IPJM.
The project manager viewed the use of fictional personas as
vital in that they acted as surrogates for real expectant mothers
in the participatory design phase. This gave a voice to
individuals who could not be physically present in the room.
As a result, IPJM helped to build a bridge between multiple
voices both inside and outside the design process, including the
missing voices of expectant mothers. Interestingly, these missing
voices often acted as the arbitrator during group discussions.
For example, when individuals disagreed on a point, they would
often revert to asking one another what the personas would
want. This challenged the siloed thinking of both the clinical
and IS subgroups. Individuals would often speak out on behalf
of one of the personas and assert how certain decisions would
affect the physical and emotional journey of this expectant
mother. One powerful example of this emerged during
discussions around the journey of Brenda, an expectant mother
who (due to the white-coat syndrome) is incorrectly diagnosed
with gestational hypertension and admitted to the hospital. The
group discussed the emotional impact that this event would
have on Brenda and challenged itself to come up with ways in
which the connected health platform could be designed to avoid
the unnecessary hospitalization of Brenda.
IPJM proved useful in helping individuals to build a deeper
understanding of the challenges faced by different users of the
proposed connected health platform. An example is the case of
an expectant mother, Denise, who had young children to care
for during her pregnancy. Denise’s journey generated
discussions around the challenges she would face if the
smartphone app forced her to take blood pressure readings at
strict time intervals, which could interfere with her childminding
obligations. This challenged the group’s prior assumptions.
They ended up altering the service to provide flexibility when
blood pressure readings could be recorded.
IPJM enabled the group to develop a common language around
the antenatal pathway. It became a powerful means of building
a shared understanding. For example, the IS subgroup faced a
steep learning curve to reach an understanding of the obstetrics
domain and the various health care settings in which the
connected health platform would be deployed. Similarly,
clinicians had limited knowledge of the technical aspects of the
connected health platform. IPJM challenged siloed knowledge
around the clinical and technology pathways and helped bridge
disciplinary boundaries. The synergies arising from this
confluence of disciplinary knowledge were essential for
highlighting IT and clinical challenges, both previously known
and unknown. As pointed out by the developer:
It was useful. It was only when I walked through the
journey map explaining how the [smartphone] app
would work that I realised that others had different
interpretations.
It also emerged that the IPJM tool was equally a means of
generating shared commitment among the groups. Individuals
later noted how participatory design activities using IPJM
allowed the group to leverage the full range of capabilities
possessed by the interdisciplinary group. As stated by the project
manager, these activities represented a significant milestone
where:
Technical concerns and clinician concerns were
starting to be addressed as a unit as opposed to being
two separate entities... For the first time people
realised that the journey wasn’t a clinical journey, it
wasn’t a medical journey, but neither was it a
technological journey. It was all combined together.
In using IPJM, many individuals were largely unaware that they
were generating requirements for the proposed platform.
However, the analyst was able to capture requirements for the
platform from the discussions taking place as individuals worked
together in filling out the journey maps. The resultant journey
maps became a record of all relevant design knowledge. Owing
to the visual and instinctive nature of the journey maps,
individuals were able to handle the complexity of the medical
scenarios, whereas this would not have been possible if
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traditional modeling techniques had been used, as these require
a level of familiarity that some individuals did not possess.
Discussion
Principal Findings
The findings suggest that IPJM can support multidisciplinary
teams in exploring connected health solutions that consider the
3 pillars of health care quality: patient experience, clinical
effectiveness, and patient safety [20]. It supports groups in
understanding and negotiating conflicting requirements that can
arise during transformational projects. This is achieved using
journey mapping and user personas for graphically externalizing
key domain knowledge. IPJM also promotes creative thinking
around service reform goals and fosters dialogue among
stakeholders, potentially leading to better solutions overall [72].
In addition, the ontology behind IPJM places constraints on
groups, although it also allows the modeling to be easily adapted
to different specialties, such as cardiology. The accessibility of
the IPJM tool means that it can become a valuable boundary
object [73,74], for discussions between multidisciplinary teams
of stakeholders. For instance, IPJM enables ideas to be shared,
interrogated, and visually externalized at both individual and
group levels [56]. The use of mediums such as post-it notes
means that the template is easy to use and modify as well.
Compared with other mapping tools, IPJM offers the possibility
to focus on the comparison between the as isand to beversions
of the pathway under study—this is a significant advantage in
projects that pursue specific improvement targets. Its reliance
on a visual grammar that does not require pre-existing
knowledge (unlike other systems analysis and design
approaches, such as Data Flow Diagrams or Value Stream
Mapping, which require substantial training before participants
can use them meaningfully) is also an advantage. The
comparison with other techniques, such as Patient Journey
Model architecture (PaJMa), the method proposed by Percival
and McGregor [48], for instance, shows that IPJM manages to
accumulate and represent a similarly broad variety of knowledge
but with greater economy and without passing on the complexity
of tasks and process steps onto the participants in the design
process or, generally, onto the readers of the documentation.
Both PaJMa and IPJM offer improvements over other mapping
tools by allowing analysts to consider a much broader range of
knowledge, but the use of personas in IPJM delivers a sharper
focus on human aspects, such as the human experience, of
patients, which is fundamental for connected health solutions
that entail a context of use where patients are alone when using
apps. In contrast to PaJMa, IPJM is likely to be more user
friendly and more flexible in the case of first-time digitalization
of medical pathways that involve mobile components that either
patients or clinicians will use remotely.
IPJM can be used as a cornerstone for modeling health care
service reform where stakeholders collaborate to derive an
understanding of and commitment to requirements [75,76].
Textbox 2 summarizes the benefits inherent in the use of IPJM
identified in its use during the LEANBH project.
Textbox 2. Strengths of Integrated Patient Journey Mapping.
•Embeds pillars of quality: considers clinical effectiveness, patient safety, and patient experience in tandem
•Externalizes knowledge: allows stakeholders to externalize their domain knowledge and build a shared understanding
•Stimulates creativity: facilitates dialog between different stakeholders around developing creative solutions
•Accessible: easy for multidisciplinary stakeholders to understand, use, and modify
•Adaptable: can be adapted to the requirements of different contexts and specialties
•Emancipatory: facilitates the alteration of medical pathways and the development of solutions for addressing their shortcomings
•Educational: acts as a platform for communicating proposed changes, their impacts, and the intentions and ambitions of the teams
Beyond the benefits identified in Textbox 2, we argue that IPJM
can boost team cohesion during the execution of novel design
projects. Existing literature suggests that team cohesion is
essential to the performance of teams consisting of individuals
from diverse organizational and geographical backgrounds [77].
Team cohesion can be defined as the extent to which team
members are aligned in their shared understanding of and shared
commitment to project tasks, for example, the actions that
individuals and groups seek to perform based on agreed plans
[78,79]. Shared understanding involves a social process whereby
the divergent knowledge of individuals is transformed to
generate collaborative knowledge building [75,80]. Shared
understanding is required to explore design spaces and overcome
siloed thinking through the combination of existing knowledge
in new ways. Meanwhile, shared commitment goes beyond
shared understanding alone and requires team members to
commit time, effort, and resources in line with proposals that
have gained shared understanding [76,81].
Shared understanding and shared commitment are crucial to the
success of projects involving stakeholders from different
organizational and disciplinary backgrounds [54]. In the absence
of both shared understanding and shared commitment, the
perspectives and intentions of team members can become
increasingly fragmented, as individuals may not even be aware
of the intricacies of the issues around which they disagree [76].
IPJM provides team members with the opportunity to challenge
assumptions embedded in prebaked project proposals and
contribute diverse knowledge around the design of IT solutions.
This helps ensure that design efforts promote both a shared
understanding of users’ diverse needs and capabilities and a
shared commitment to the delivery of solutions that cater to
these needs. However, during the LEANBH project, not all
group members were equally committed to leveraging the tools
and to journey maps for modeling the problem domain and
gathering requirements. This is a key concern as there is a
possibility of a link between the involvement of stakeholders
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during the modeling process and their understanding of and
engagement with the project overall. Therefore, future versions
of the modeling tool need to consider how best to engage
practitioners from different backgrounds so that the entire team
rally around the journey maps and their validation.
Conclusions
The health care sector is currently facing the monumental
challenge of minimizing the costs associated with health care
delivery while simultaneously improving quality. Connected
health solutions can play a significant role in meeting this
challenge by transferring health care delivery to the least
expensive setting (ie, a patient’s home) in a way that does not
compromise quality. However, the successful design of
connected health solutions is far from a straightforward task,
and the success hinges on a quality-centric approach being
embodied during every step of the development lifecycle. At
this point in time, health care systems around the world are
seriously affected by their reliance on a one-to-one mode of
care delivery, where patients often wait for weeks and months
to see overstretched specialists. Crucially, connected health
apps can allow clinicians to better care for more patients by
giving them more frequent attention in a remote fashion and
without the need for face-to-face visits far more effectively [8].
It is here that the use of design tools such as IPJM can offer
significant value. This paper contributes theoretical and practical
insights into how visualization tools can be used to embed the
pillars of health care quality in the design of connected health
solutions. For instance, case study findings suggest that IPJM
can provide multidisciplinary teams with a canvas for designing
connected health solutions tripartite goals of clinical
effectiveness, patient safety, and patient experience. In
particular, IPJM can help ensure that patient experience is given
ample consideration when designing health care services, in
tandem with more traditional concerns such as resource
efficiency, waiting times, financial costs, and treatment efficacy.
In particular, IPJM can help bridge the gap, which is often
identified too late between the intended use of apps and the
observed system-in-use postimplementation. Such gaps often
lead to the occurrence of silent errors and require the complete
rethinking of apps and devices at considerable expense in time
and money, both of which are in short supply in the health care
sector [82].
Limitations and Future Research
However, IPJM is not without some limitations. For instance,
IPJM does not make explicit reference to key performance
indicators, such as throughput and waiting times, or other
metrics, such as productivity and cost-efficiency, although these
may be essential elements of the performance and success of
the services being designed. This clearly applies to the scenario
of a connected health solution being implemented to increase
the throughput of a medical pathway, to deliver cost savings,
and to improve visibility on patients’ conditions. Although
incorporating this element in the tool would be useful, there is
also a risk that increasing the level of detail may compromise
the overall accessibility and reliability of the maps. As a result,
it may be difficult to capture some of the inherent complexity
in health care systems, that is, when a patient is transferred from
a hospital during treatment. On the other hand, the tool can be
adapted according to the unique context in which it is to be used
to address any key elements that are missing. Its use within the
context of specific pathologies and medical specialties has the
potential to rapidly bring medical teams up a steep learning
curve toward developing connected health care apps.
Specifically, in the case of our research, we encountered other
limitations, although it may be unclear whether these were
circumstantial or if they were likely to also occur in other cases
and settings. We found it difficult at times to secure participation
from certain groupings in some meetings. For example,
clinicians sometimes found it difficult to commit time to use
IPJM, as they felt they were too busy and that the journey maps
were for the development team rather than for themselves.
Resolving these misconceptions is essential to producing maps
that are accurate and robust in the face of real-life scenarios.
Future research may also seek to develop a more interactive
version of IPJM to provide a more accessible view of the
patient’s journey. IPJM currently requires a large physical
display to ensure that all components are visible and legible.
During the project, we experimented with different display
dimensions and orientations before deciding on an A2 portrait
format. However, it may be necessary to consider whether
certain elements need to be reorganized so that the tool can be
displayed more easily across a variety of media and spatial
dimensions. A software program that would allow users to drill
down into subpathways and map components more effectively
could also be a useful extension.
Clearly, there are cognitive and presentational limitations that
apply to the mapping of macroservices, for instance, a national
or even transnational architecture for managing a certain
pathology or group of patients with dedicated needs. Although
the mapping of such a broad pathway might be desirable or
even essential as a communication tool for reaching a common
agreement, evidently difficulties will arise when attempting to
compile such a map where the need to be holistic and
comprehensive might be traded off against the necessity for
visual representations to remain comprehensible by most people
and therefore useful. Setting some boundaries that accommodate
both the need to capture the whole system as well as some of
its key components will be useful, although our research does
not provide clear avenues pertaining to how this may be
achieved. Weick [83] characterized the Bonini paradox (by
reference to Charles Bonini and his work on simulation,
published in 1963 [84]) as illustrative of situations where models
were proposed that were so complex in and of themselves that
it was no easier to understand them than it was to understand
the real world as observation could reveal it. We can hypothesize
that the Bonini paradox applies to journey maps and that die
hard attempts to capture a world without any ontological
boundaries would only yield theoretically excellent but
practically useless representations that would hamper design
efforts rather than help. The need for ontological boundaries,
such as those provided by the IPJM tool, is much needed and
is underresearched. Future research on this topic should explore
this new dimension.
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Acknowledgments
This publication has emanated from research conducted with the financial support of Science Foundation Ireland (Grant No.
SFI/12/RC/2272).
Conflicts of Interest
None declared.
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Abbreviations
HIT: health information technology
IS: information systems
IT: information technology
IPJM: Integrated Patient Journey Mapping
LEANBH: Learning to Evaluate Blood Pressure at Home
PaJMa: Patient Journey Model architecture
Edited by B Price; submitted 11.12.19; peer-reviewed by R Chan, S Chen; comments to author 16.03.20; revised version received
08.05.20; accepted 26.05.20; published 17.09.20
Please cite as:
McCarthy S, O'Raghallaigh P, Woodworth S, Lim YY, Kenny LC, Adam F
Embedding the Pillars of Quality in Health Information Technology Solutions Using “Integrated Patient Journey Mapping” (IPJM):
Case Study
JMIR Hum Factors 2020;7(3):e17416
URL: http://humanfactors.jmir.org/2020/3/e17416/
doi: 10.2196/17416
PMID:
©Stephen McCarthy, Paidi O'Raghallaigh, Simon Woodworth, Yoke Yin Lim, Louise C Kenny, Frédéric Adam. Originally
published in JMIR Human Factors (http://humanfactors.jmir.org), 17.09.2020. This is an open-access article distributed under
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copyright and license information must be included.
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