Reimagining patient experience with behavior-driven service design

A digital solution to track recovery patterns in patients

Despite significant advances in joint replacement surgery in recent years, up to 20% of patients remain dissatisfied with the outcomes. Reasons for dissatisfaction range from technical factors such as improper implant and surgical techniques, to patients’ functional status before surgery, and pre-existing health conditions. 

Dissatisfied patients discourage others from opting for surgeries. Hence, patients who may need immediate joint replacements delay the procedures, and continue to live with disabilities, which eventually not only decreases their life expectancies, but also burdens the healthcare ecosystem. Timely intervention, however, resolves issues sooner and better. Over the years, technological advances in implant design have reduced the variability in surgical techniques. Moreover, digital solutions have been developed and deployed to enhance the surgery experience and aid in recovery, for better post-operative patient reported outcomes (PROs). These are promising solutions, but they address only certain aspects of the recovery process including teleconsultation, patient education and community engagement.

There is a need for a digital solution to track recovery patterns through a holistic blend of physiological, physical, behavioral, and clinical monitoring to drive improved PROs and better patient satisfaction. The paper also proposes to integrate principles of service design and behavioral sciences throughout the episode of care, to address the needs of patients and other stakeholders in the joint replacement ecosystem..

A growing demand for joint replacements

Arthritis affects the knee, hip, hands, and spine in almost 7% of the world’s population, amounting to over 500 million people, a disproportionate amount of them being women. It is often associated with decline in mental health, increase in all-cause mortality, and inability to self-manage chronic conditions such as diabetes and hypertension. Of the number of advisable interventions, the best known and popular solution is total joint replacement. The most common of these procedures are replacements of the knee, hip, and shoulder. The success rate, as reported by several joint replacement registriesis,  over 82%, whereby the total-knee replacements survive even after 25 years. In general, the following factors govern the success of these procedures:

• Surgical process
• Recovery and rehabilitation
• Restoration of daily activities
• Managing patient expectations
• Addressing physical and mental health conditions

However, in certain cases, clinician-reported outcomes vary from patient-reported outcomes. Factors that influence negative PROs even for clinically successful procedures include ineffective pain relief, poor hospital experience, old age, preoperative comorbidities, and inadequate social support.

A multidisciplinary and multi-stakeholder approach towards patient care

We believe that much of the mismatch in patient expectations can be addressed by applying behavioral sciences, particularly from clinical and health psychology, psychotherapy, and rehabilitation sciences. To do that effectively, we will need to closely analyze the responses of all stakeholders including the orthopedic surgeon, physiotherapist, caregivers, and the patient, throughout the episode of care. We therefore need a multi-stakeholder and a multidisciplinary approach to improve patient satisfaction.

The role of behavior science

Patients’ health history and behavior, including their expectations, preconceived notions, lifestyle, and socio-economic factors affect PROs. Patients with pre-existing conditions are also likely to report significantly higher pain. In addition, conditions such as anxiety and depression are likely to emerge post-surgery, and impact pain perception and recovery outcomes over time. On the other hand, patients who adhere to prescribed medications and therapy routines report better outcomes. 

Role of the service-design approach

A patient’s journey in surgery care should be considered in totality with the journeys of the other stakeholders. An effective episode of care demands an empathetic and humane approach. A service experience design approach (Figure 1) enables conceiving a solution that meets expectations of all stakeholders in a holistic and empathetic manner. 

The service experience design methodology (as seen in Figure 1) encourages a rigorous, holistic, and scientific approach to understand patient expectations, experiences, and challenges they face, before, during and post-surgery. As shown in an example in Figure 2, the methodology helps to identify the support that patients may need at every stage of the journey.

Similarly, we can gather information from surgeons about the patient and ecosystem (longitudinal and emergent) at every stage of the journey. We can learn from the caregivers about the help and support they require for playing an active role in episodes of care. Concerns and constraints of all relevant stakeholders must be taken into account to conceive an empathetic solution, which also meets business needs (Figure 3).

Building an integrated digital-health solution

Digital technologies can capture and address patients’ clinical, physical, and behavioral parameters throughout the episode of care, in an objective and unobtrusive manner. The service experience design methodology ensures that needs of all stakeholders are clearly understood before designing the solution. Preliminary findings reveal the need for a digital solution to focus on the use of wearable devices and smart phones by patients, and digital dashboards by physicians. These will enable frequent capture of psycho-physiological data from patients and provide analytics to physicians. With this approach, a typical implementation of a digital-health solution consists of elements such as:

Wearable devices and sensors: To monitor range of motion (RoM) and gait in real time–before and after surgery.

Digital assistance apps: To collect information about patients’ expectations on surgery outcomes, experience of pain, and mental health states before and after surgery. These also help to continuously monitor progress, enable behavioral interventions for stress and anxiety, and ensure adherence to rehabilitation regimen. Moreover, patients can be educated on the dos and don’ts through articles and videos on their health conditions, surgery, and rehabilitation. These are also effective tools for patients to interact with clinicians for queries, guidance, and appointments. Additionally, features of community support aid patients to digitally connect with other patients with similar ailments to exchange best practices on recovery.

Clinicians’ portal: To assess activity levels, gait and RoM, and to monitor PROs pre-surgery. This also aids to monitor RoM, wound and pain post-surgery, and the level of adherence to the patient’s rehabilitation regimen.

Such a solution (Figure 4) offers surgeons near real-time access to precise information, without frequent in-person patient evaluation. In the pre-surgical phase, such information helps surgeons establish an objective baseline for outcome evaluation. It also enables timely interventions post-surgery, when a patient’s clinical progress or adherence to a rehabilitation regimen is below par.

For patients, it provides a convenient means to report RoM, pain and anxiety. It also provides accurate recovery status, education, and personalized behavioral interventions. Such a holistic solution can reduce the need for in-person interactions between patients and clinical staff and make necessary in-person interactions far more focused and efficient.

Driving large-scale adoption

We believe that such a digital-health solution will provide hospitals and surgeons with complete, timely and patient-centric information to help treat patients far more effectively. This has the potential to significantly improve patient satisfaction. While joint replacement is one example, the concept has considerable potential to enhance outcomes of several other surgical procedures. Clinical validation and adherence to relevant regulatory guidelines will be a prerequisite for large-scale adoption of such solutions. A word of caution, though such solutions must address concerns of privacy, safety, and efficacy, and adhere to best practices such as the WHO’s guidelines for digital-health solutions.