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Digitization of cardiac rehabilitation helps maintain capacity and cuts waiting lists

Cardiac rehabilitation at Ålesund Hospital had its staff reduced significantly in 2019. The rehabilitation treatment had to be changed significantly: This was solved by taking advantage of the opportunities available in digitization. Today, the staff at the hospital can treat the same number of heart patients as before the downsizing. The long waiting list from 2020 has been reduced with the help of organizational changes, close collaboration internally and externally, as well as active use of digital tools. CheckWare has been involved in the entire digital journey.

Cardiac rehabilitation at Ålesund Hospital has a long and traditional history. The project was started in the spring of 1998, under the leadership of cardiologist Torstein Hole. The stated aim since then has been to offer heart patients who have undergone a heart attack, PCI or bypass surgery a medical treatment. The focus has been on reducing the risk factors and increasing security in relation to daring to exercise on your own.

- Through assessment, teaching, training and guidance, we facilitate the patients to make good choices themselves and choose a heart-friendly lifestyle after the cardiac rehabilitation is over. The program will contribute to raising awareness of the preventive factors that patients can make in their daily lives, says Ingrid Granøien, specialist physiotherapist at Cardiac Rehabilitation at Ålesund Hospital.

Ever since the end of the 90s, the health service at the hospital has been multidisciplinary, where physiotherapists, nurses and doctors have worked closely together. In addition, a clinical nutritionist has been linked to the group. The difference is that until 2019 this was a health service where all activity took place physically in the hospital.

- With the growing emergence and use of technology in the healthcare trust, we wanted to digitize parts of the health care service in order to look at opportunities to create a treatment pathway that is approximately the same, regardless of where the patient lives. With this in mind, we were awarded innovation funds in the spring of 2020, which went to finance a partial digitization of our health service, explains Granøien, who has been employed at cardiac rehabilitation since the start in 1998.

Ingrid Granøien

Specialist physiotherapist at Cardiac Rehabilitation at Ålesund Hospital

Found a solution with CheckWare

Today's operations are partially digitized with the use of CheckWare: This gives patients the opportunity to register data that the hospital needs before, during and after treatment.

- CheckWare has proven to be an effective tool in our cardiac rehabilitation health service, including assessing and teaching the patients, as well as for digital follow-up during the period when they exercise from home, says Ingrid Granøien.

The cardiac rehabilitation staff at Ålesund Hospital also spend far less time on tasks that were previously considered a waste of time.

- Digitization has made it much easier to arrange doctor’s appointments. Whereas before we had to call each individual patient, both to provide information about the rehabilitation health service and to arrange a possible start, 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 information video about cardiac rehabilitation, explains nurse Marie Horsgård Aarseth.

The patients to be referred receive an SMS with a link to CheckWare. There they answer a digital screening measure which ensures that the patients receive a health care service based on the answers they give. They are then assigned one of two treatment pathways: one where they primarily exercise from home, another where they meet physically at the hospital.

- The patients themselves feel they get a much better overview of the follow-up, and for us it becomes easier to differentiate the needs for doctor’s appointments and to plan for individual needs.

Today, approximately half of our patients carry out their exercise primarily away from home, i.e., the hospital. The remaining train at home, says Aarseth.

Ingrid Granøien, specialist physiotherapist at Cardiac Rehabilitation and nurse Marie Horsgård Aarseth, both at Ålesund Hospital

Ingrid Granøien

Specialist physiotherapist at Cardiac Rehabilitation at Ålesund Hospital

A dedicated school for the cardiac rehabilitation patients

With digital follow-up, the patients themselves have had to take more responsibility by conducting self-training at home. At the same time, they need adequate follow-up from the hospital. A dedicated school with a proper curriculum is therefore an important part of cardiac rehabilitation. Before, there were classroom-based courses. Today, this has been converted into e-learning, with the consequence that patients can choose to complete the different topics whenever it suits them best. The format also gives the opportunity to repeat the e-learning modules if necessary.

At the same time, a digital training diary has been developed where the patient logs all training from day one. The training diary has an important message function where patients can ask questions and describe how they experience the training, while the clinician can give feedback and guidance.

- There are many patients who are naturally anxious when they have had a heart condition. The same applies to relatives. Fortunately, most people cope with the digital tools very well. We have also offered physical education during a transitional period, says Marie Horsgård Aarset

The introduction of a digital cardiac rehabilitation school means that patients have access to relevant topics right from the moment they are referred and throughout the course. That way, they can get answers to questions and thoughts before they start the training, and that both patients and relatives can take the e-learning as many times as they want throughout the course. Time spent teaching in the classrooms is thus reduced, and there is a greater degree of flexibility for each individual participant.

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

Solved challenges from day one

Per-Henning Valderhaug, consultant for digitization at Helse Midt-Norge IT (Hemit), has been heavily involved in the implementation of the CheckWare solution at Ålesund Hospital. He says that from the start they discovered that there was room for major improvements.

- We had been given the task of re-establishing CheckWare as a common platform for digital measures in Helse Midt-Norge (the Health region of Central Norway). We saw that CheckWare had been put into use in bits and pieces throughout our region. We scrapped all that and instead established a common solution. This project ran in parallel with the implementation at Ålesund hospital in 2019/20. I was involved in both projects and quickly saw that we had a digital platform that would be very well suited to our needs. Ålesund Hospital became an early user of the re-established platform of CheckWare in Helse Midt-Norge, he says.

At the time, there was a miserable atmosphere at the cardiac rehabilitation because of downsizing and an uncertainty about how they were going to handle the needed assistance to the cardiac patients with fewer people.

- We spent a lot of time being a supporting party. Before we established a new type of cardiac rehabilitation, we had to get a picture of

how the rehabilitation had worked previously. We brought a four-metre-long process map with post-it notes into the workshops, so that we got a common picture. It turned out to be extremely useful, not least for those who work there, he says and believes it was very important to solve challenges straight away in order to make quick progress from the start of the project.

- Something very funny happened right away. We talked our way through the map and where there was trouble. Then we found things that the project application had not focused on at all, which were not really a topic, but at the same time represented a challenge in everyday life. They went about solving these very quickly. We fixed things that were not defined well enough, because no one had addressed them before. Then the atmosphere quickly improved, says Valderhaug.

As an addition to the landlines in the office, they were able to increase accessibility among the employees by purchasing a separate mobile phone for the department. Within a short time, the previous booking system for doctors was gradually improved by getting structured cardiac rehabilitation into an updated booking system, the Hemit adviser says.

- A smash hit!

- The journey has been both interesting and meaningful. We have an ambition to help get better healthcare services using technology, and we think we have achieved that here. Now there are no queues at the cardiac rehabilitation, and they handle all patients almost immediately. The hospital is back where it was before the downsizing, with doubled productivity. I was almost moved when we discussed this with the employees some time ago. It's been a fantastic journey, I'd say it's a smashing success!

Per-Henning Valderhaug

Consultant for digitization at Helse Midt-Norge IT

Per-Henning Valderhaug tells of a process where they have solved challenges during project development and found the solutions interdisciplinary.

Previously, an interview was conducted to clarify whether it is appropriate for the specific patient to begin the cardiac rehabilitation program, which took a lot of time and resources. Today, the same information is collected with a questionnaire from CheckWare which only consists of a set of 5-6 questions.

If the patient has agreed to rehabilitation, including self-training, a measure is included to give the patient control over training at home through self-recording of training activity, including graphs of heart rate and training load.

However, what was also called for was a form of communication, in addition to the mobile phone.

- Until then, no one in Helse Midt-Norge had used the chat function of CheckWare. We had to find this new path on our own and set up a chat in a safe environment. We certainly received assistance from CheckWare, but it turned out to be a much bigger job for us than we had anticipated in advance. We also ran a risk analysis before launching the chat function, out of consideration for patient safety. It was the first case in the whole of Central Norway to use chat with a patient, which 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 get better healthcare services through the use of technology, and we think we have achieved that here. Now there are no queues at the cardiac rehabilitation, and they handle all patients almost immediately. The hospital is back where it was before the downsizing, with doubled productivity. I was almost moved when we discussed this with the employees some time ago. It's been a fantastic journey, I'd say it's a smashing success!

Findings from the project

The digitization project confirms the significant need for individually adapted follow-up of patients.
E-learning is a good and effective substitute for physical teaching
It has now become easier to provide the same health care service to cardiac patients, regardless of where they live.
Patients save time and money by avoiding traveling to the hospital, unless they need it.
Employees save time contacting and informing patients about the health care service, and spend more time arranging a good treatment plan for the patient

Om Ålesund sjukehus

Ålesund Hospital is the largest hospital in Helse Møre and Romsdal and is the local hospital for Ålesund and the municipalities around the northern part of Sunnmøre
The hospital has approx. 2,500 employees, and has on-call functions within medicine, surgery, orthopaedics, radiology, anaesthesia, gynaecology, paediatrics, ENT, eye, cancer, adult psychiatry, child and adolescent psychiatry and drug and addiction medicine.
The children's department is the largest in the county and has its own neonatal intensive care unit.
The hospital has several affiliated DPSs

Helse Møre og Romsdal's use of CheckWare

Respondent tools:

Measures
Measure report
Content packages
Plans
Secure Messages

Clinician tools:

Clinical reports
Clinician insight
Treatment roles
Export of raw data
Export templates
Flags
Decisions
Respondent handling

System administration tools

System settings
Access contro
System log
System reports
Clinician administration
Authentication: Levels 3 and 4
Plans
Content management