Introduction

Heart Failure (HF), the inability of the heart to effectively pump blood around the body, takes a serious toll on a person’s life. For people living with HF, walking up a few stairs leaves their heart pounding, lying down makes it hard to breathe, and their lives are instantly turned upside down by a prognosis of only a few years left to live. With more than 50,000 diagnoses annually, this is the experience of over one million Canadians.

People with HF work hard to manage their condition, but many have trouble adapting. Their health can fluctuate dangerously day-to-day, leading to ER visits and hospital admissions. These fluctuations are the single most common reason for hospital admissions in Canada, costing the system approximately $482 million in 2013.

With these costs estimated at over $722 million by 2030, the need to proactively support patients before they need acute health services is critical.

Most people living with HF only see their cardiologist every six months, creating an opportunity to design a healthcare service that helps them to manage their disease at home. The ultimate goal of this project was to help patients to better manage their HF and to reduce HF-related hospital admission rates, helping patients remain in the comfort of their homes.

Process Overview

Our team carried out a 6 phase design process: (i) discovery (ii) problem framing (iii) prototyping (iv) development (v) pilot and (vi) pivot. This process immersed us into the lives of people grappling with this chronic deteriorating condition, it gave us exposure into a world-renowned cardiac clinic constantly abuzz with clinicians, patients, and families, and it saw us continuously iterate on an HF service until we were confident we had designed one that would not only stick, but that would transform the delivery of care.

(i) Discovery: We began by immersing ourselves into the world of chronic condition management and remote patient monitoring through an in-depth literature review and conversations with experts in this space. We then spent an entire week in the cardiac clinic observing what happens day-in and day-out, with a focus on understanding the culture of the clinic, the ways in which people work, the ways in which people experience care, and the blockers and facilitators of change.

To contextualize our learnings, we then interviewed 12 clinicians and administrators, and 24 patients, to dive more deeply into the nuances of their individual experiences.

(ii) Problem Framing: The critical insight that emerged from our discovery was that there was a tension between the patients’ need to be cared for through the ups and downs of their illness, and the constant pressure that care teams were feeling in a clinic that was seeing increasing patient volumes and budgetary constraints.

This was the moment in which we realized that the service that supported the digital tool we hoped to design, was of more importance than the digital tool itself. As a digital system, in the absence of a service that is intentionally crafted with an in-depth understanding of the culture of the clinic, and of the needs of the patient, would never achieve adoption and ultimately improve the lives of patients.

This insight, and others, were framed through a current-stage service blueprint, a suite of challenge statements, and design principles to guide the development of a digital tool to support patient self-care.

(iii) Prototyping: After our synthesis, we quickly moved to building, testing and improving the digital tool and accompanying service. By designing clickable prototypes and by staging the overarching HF service, we were able to quickly understand the ways in which clinicians diagnose and manage patient instability,
the ways in which patients experience their heart failure at home, and the drivers and blockers of adoption.

This enabled us to ensure that the service we designed allowed clinicians to identify at risk patients as quickly as possible, that it integrated into clinical workflow, and that it fit into the day-to-day activities of a patient’s life.

(iv) Development: Our team then designed and developed a patient website, patient smartphone application, and clinician web application. Knit together, they resulted in a service that enables patients to easily track their daily HF-related symptoms, to receive customized advice through a clinical algorithm, and to receive intervention from their clinicians when
needed.

Our team also custom designed all of the peripheral touchpoints of the service, such as the instruction booklet, carrying kits, clinical forms, and clinic signage. Additionally, we worked with the clinic staff to define and implement standard operating procedures to ensure seamless integration into clinic flow.

(v) Pilot: Alongside our client, we then launched an in-clinic pilot that enabled us to collect live data through observing the service in action and analyzing usage patterns to identify areas for improvement. Here we were able to observe the service operating at scale and co-design changes with employees who encountered challenges that were previously unforeseen.

(vi) Pivot: Post-pilot, our team made multiple improvements to the service model, user interfaces, and peripheral touchpoints. For example, to help frame the HF service as an important part of clinical care, we transitioned to a model in which the service is prescribed by a cardiologist, rather than suggested.

We also simplified the onboarding process once we saw how much time and paperwork it created, creating a digital onboarding that can be done on an iPad, to ensure that the person-to-person interaction wasn’t disrupted by a laptop or large computer screen.

Outputs

Throughout the life of this project, a multitude of artifacts were created. Each served a unique purpose, but as a collective, they operated as a suite of visual tools that enabled us to communicate, collaborate, align, and inspire change.

Throughout discovery, our team designed a current state service blueprint that documented the clinical workflow for follow-up visits at the cardiology clinic. The creation of this blueprint brought stakeholders together to discuss their roles and experiences, how they fit together and relate to one another, and where things needed to change.

The collective understanding that we gained from the design of this blueprint was invaluable as we moved into the development and prototyping phases to keep the group grounded in the research insights.

In order to translate the research insights into a well defined course of action, our team created challenge statements, design principles and a prioritized feature-set. These tools helped us to document the core problems to be solved, capture the way they should best be solved and manage the feature-level design tasks needed to meet the needs of end-users.

Before we began designing the digital and physical touchpoints of the service, we created an overarching philosophy to underpin the service’s brand, to ensure that we were communicating the right tone and emotion throughout. Based on our research insights, we decided that each touchpoint of the service needed to have a calming tone and aesthetic, avoiding any sense of urgency, so that patients felt cared for throughout their experience and that their chronic deteriorating illness, while serious, could be managed from the comfort of their home.

This brand direction created the foundation for each of the digital and physical outputs that make up the HF service, which includes: the design of each screen on the patient smartphone application and clinician web application, the program website, instructions for use, labeling, a screen printed bag (to carry home the patient’s scale and blood pressure cuff), clinical paper forms, and signage to support wayfinding and onboarding. Collectively, each output creates a cohesive, calming, and supportive experience throughout a patient or clinician’s use of the service.

To support the design and implementation of the service, we also created a future state service blueprint. Initially, the future state blueprint was critical in helping people to understand the intricacies and objectives of the service, creating alignment among key stakeholders. It also acted as living document throughout the iterative design process.

As we created service prototypes to act out specific workflows, the blueprint was critical to demonstrating and to tracking how changes to the service were made and how they impact other processes, other roles, and ultimately the patient and clinician experience.

Making improvements and refining touchpoints with the blueprint to align us throughout our journey allowed us to build confidence and trust with the cardiac team, as we all equally understood the challenges we encountered in testing and in implementation, as the changes we collaboratively made to ultimately improve patient care.

Impacts

To date, this service is being used by over 300 people living with HF at one hospital, and is poised to scale across 4 additional health centres in the coming year. Its measured impact has been significant. In a pre-post evaluation, the HF

Service has been shown to positively impact patients’ health, their quality of life, and healthcare utilization. Most impressively, the HF Service has helped to stabilize patients’ heart failure. This was measured by a significant reduction in Brain Natriuretic Peptide (BNP), a biological marker of heart failure instability, measured using a blood test. Specifically, there was an 18.9% decrease when compared with baseline BNP at 6 months.

Use of the service also resulted in significant improvements in measures of wellbeing and self-care at 6 months as measured by the Minnesota Living with Heart Failure Questionnaire and the Self-Care of Heart Failure Index.

When compared to baseline, we saw a statistically significant improvement in overall HF-related quality of life, physical HF-related quality of life, self-care maintenance, and self-care management.

The HF Service also drove a reduction in healthcare utilization, enabling us to achieve our objectives of designing a solution that would keep patients in the comfort of their own homes, and out of hospital. Patients using the HF Service exhibited a 28% reduction in the number of hospitalizations and a 25.2% reduction in length of stay in the 6 months after enrollment
compared to the 6 months prior.

These outcomes are meaningful, as patients diagnosed with HF are typically given a bleak prognosis of only a few years to live. Any intervention that has the capacity to stave off physical decline, to help people to live well, and to reduce the amount of time they need to spend in hospital, enables them to spend their final months or years in the ways that matter most to them.

Conclusion

The path that brought the HF Service to life was one of a typical roller coaster design journey. We began with heartfelt and heartbreaking conversations with people living with a chronic deteriorating illness as they grappled with what it meant to live well, and with the clinicians who make it their life’s mission to impact these peoples’ lives.

We also went through countless iterations of product and service design to ensure that we were building something that knit into the context of people’s lives, of their work, and of their aspirations.

Ultimately, the decision to design not only an HF product, but an HF service, was what enabled the integration of the HF Service into busy clinical workflows and into the unique context of the lives of people living with this disease.

The HF Service’s quick and rapid adoption within its first hospital has resulted in significant and meaningful impact for patients, providers, and the health system more broadly. In the coming years, we look forward to scaling the HF Service experience across health centres and health systems, so that we can continue to drive impact both near and far.