Digitalization of cardiac rehabilitation helps maintain capacity and reduces waiting lists

The cardiac rehabilitation unit at Ålesund Hospital experienced a significant staff reduction in 2019. The treatment offering had to be changed substantially: This was resolved by utilizing and exploiting the potential within digitalization. Today, the hospital staff can treat as many heart patients as before the downsizing. The long waiting list from 2020 has been reduced through organizational changes, close internal and external collaboration, and active use of digital tools. CheckWare has been part of the entire digital journey.

Cardiac rehabilitation at Ålesund Hospital has a long and proud history. The project was launched in spring 1998, led by cardiologist Torstein Hole. Since then, the stated goal has been to offer heart patients who have undergone a heart attack, PCI, or bypass surgery medical treatment. The focus has been to reduce risk factors and increase confidence in exercising independently.

- Through mapping, education, training, and guidance, we facilitate patients making good choices themselves and adopting a heart-healthy lifestyle after cardiac rehabilitation is completed. The program aims to raise awareness about preventive factors that patients can manage themselves in daily life, says Ingrid Granøien, specialist physiotherapist at Cardiac Rehabilitation at Ålesund Hospital.

Since the late 1990s, the hospital's offering has been multidisciplinary, with physiotherapists, nurses, and doctors working closely together. Additionally, a clinical nutritionist has been connected to the team. The difference is that until 2019, it was a treatment offering where all activity took place physically at the hospital.

- With the growing emergence and use of technology in the health trust, we wanted to digitalize parts of the operation to explore opportunities to create treatment pathways that are approximately the same irrespective of where the patient lives. With this purpose, we were awarded innovation funds in spring 2020 to finance a partial digitalization of our treatment offering, explains Granøien, who has been employed in cardiac rehabilitation since its inception in 1998.

Through mapping, education, training, and guidance, we facilitate patients making good choices themselves and adopting a heart-healthy lifestyle after cardiac rehabilitation is completed. The program aims to raise awareness about preventive factors that patients can manage themselves in daily life

Found a solution with CheckWare

Today's operation is partially digitalized using CheckWare: This gives patients the opportunity to register data the hospital needs before, during, and after treatment.

- CheckWare has proven effective as a tool in our cardiac rehabilitation offering, among other things for patient mapping and education, as well as for digital follow-up during the period they train at home, says Ingrid Granøien.

The staff at cardiac rehabilitation at Ålesund Hospital also spend far less time on tasks previously considered time-consuming.

- Digitalization has made scheduling much easier. Whereas before we had to call each patient individually, both to provide information about the rehabilitation offering and to arrange possible start dates, the information now goes out much faster and more efficiently. We refer patients to information on our website, where they can, among other things, watch an informational video about cardiac rehabilitation, explains nurse Marie Horsgård Aarseth.

Patients who are to be referred receive an SMS with a link to CheckWare. There they answer a digital screening form that ensures patients receive a tailored treatment offering based on their responses. They are then assigned one of two treatment pathways: one where they primarily train from home, another where they meet physically at the hospital.

- The patients themselves feel they get much better overview of the follow-up, and for us, it becomes easier to differentiate the scheduling and accommodate individual needs. Today, about half of our patients complete their training primarily off-site, i.e., at the hospital. The rest train at home, says Aarseth.

Ingrid Granøien, Specialist Physiotherapist at Cardiac Rehabilitation and Marie Horsgård Aarseth, Nurse, both Ålesund Hospital

CheckWare has proven effective as a tool in our cardiac rehabilitation program, including for patient assessment and education, as well as for digital follow-up during the period when they train at home.

Dedicated heart school for the patients

With digital follow-up, patients have had to take more responsibility themselves through self-training at home. At the same time, they need sufficient follow-up from the hospital. Heart school with education is therefore an important part of cardiac rehabilitation. Previously, there were classroom-based courses. Today, this has been turned into e-learning, which means patients can choose to complete the education whenever it suits them best. The format also allows for repetition of the e-learning modules as needed.

A digital training diary has also been developed where the patient logs all training from day one. The training diary has an important messaging function where patients can ask questions and describe how they experience the training, while the therapist can provide feedback and guidance.

"There are naturally many patients who are anxious when they have been diagnosed with heart disease. The same applies to relatives. Fortunately, most manage the digital tools very well. We have also offered physical teaching during a transition period," says Marie Horsgård Aarseth.

The introduction of digital heart school means that patients have access to relevant topics from the moment they are referred and throughout the entire process. This way, they can get answers to questions and thoughts before starting training, and both patients and relatives can take the e-learning modules as many times as they want for repetition throughout the process. Time spent on classroom teaching is thus reduced, and there is greater flexibility for each participant.

"We have many topics covered in the e-learning, such as treating heart disease and living with heart disease. A heart-healthy diet is, of course, important, but we also address physical activity, stress management, blood pressure, cholesterol, and heart medication," says Aarseth.

Challenges solved from day one

Per-Henning Valderhaug, advisor for digitalization at Helse Midt-Norge IT (Hemit), is one of those who has been heavily involved in establishing the CheckWare solution at Ålesund Hospital. He explains that they initially discovered there was room for major improvements.

"We had been tasked with reestablishing CheckWare as a common platform for digital forms in Helse Midt-Norge. We saw that CheckWare was being used piecemeal in various places in our region. We scrapped all of that and instead established a common solution. This project ran in parallel with the establishment at Ålesund Hospital in 2019/20. I was involved in both projects and quickly saw that here was a digital platform that would be very well suited. Ålesund Hospital became an early user of the reestablished CheckWare platform in Helse Midt-Norge," he says.

At that time, there was a heavy atmosphere in cardiac rehabilitation due to downsizing and uncertainty about how to maintain support for heart patients with fewer staff.

"We spent quite a bit of time being a supportive partner. Before developing a new form of cardiac rehabilitation, we needed to get a picture of how rehabilitation had worked. We brought a four-meter-long process map with post-it notes into workshops so that we could get a shared overview. It turned out to be very useful, especially for those working there," he says, emphasizing that it was very important to solve challenges immediately to achieve quick progress from the start of the project.

"Something very interesting happened right away. We talked through the map and where the problems were. Then we found things that the project application had not focused on at all, which weren’t really topics but still posed everyday challenges. These could be solved very quickly. We fixed things that weren’t well defined because no one had tackled them before. The atmosphere improved quickly," says Valderhaug.

As a supplement to the office landlines, they increased staff availability by purchasing a dedicated mobile phone for the department. Shortly thereafter, the previous doctor ordering system was improved by structuring cardiac rehabilitation into an updated booking system, the Hemit advisor mentions.

A smashing success!

The journey has been both interesting and meaningful. We have an ambition to help improve health services through technology, and we feel we have achieved that here. There are now no queues in cardiac rehabilitation, and they are handling all patients. The hospital is back where it was before the downsizing, with doubled productivity. I was almost moved when discussing this with the staff some time ago. It has been a fantastic journey; I would call it a smashing success!

Per-Henning Valderhaug talks about a process where they resolved challenges during project development and found solutions across disciplines.

Previously, interviews were conducted to determine whether it was relevant for a specific patient to start the cardiac rehabilitation program, which took a lot of time and resources. Today, the same information is gathered with a CheckWare questionnaire consisting of only 5-6 questions.

If the patient agrees to rehabilitation, including self-training, a form is included to help the patient control their training at home through self-reporting training activity, including graphs of heart rate and training load.

However, a communication method was also requested, in addition to the mobile phone.

"Until then, no one in Helse Midt-Norge had used the chat function in CheckWare. We had to blaze that trail on our own and set up chat in a secure environment. We absolutely received assistance from CheckWare, but it was a much bigger task for us than anticipated. We also conducted a risk analysis before launching the chat function, for patient safety reasons. It became the first case in all of Midt-Norge to use chat with patients, something we are definitely proud of," says Valderhaug, who is very pleased to be involved in the project:

"The journey has been both interesting and meaningful. We have an ambition to help improve health services through technology, and we feel we have achieved that here. There are now no queues in cardiac rehabilitation, and they are handling all patients. The hospital is back where it was before the downsizing, with doubled productivity. I was almost moved when discussing this with the staff some time ago. It has been a fantastic journey; I would call it a smashing success!"

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