A patient’s care often extends beyond the time spent within the hospital itself. Unfortunately, even the best efforts of a care team to craft and communicate a long-term health management plan is subject to a raft of pitfalls that, ultimately, can hinder patients’ adherence and outcomes.

“[Care plans] are often fragmented, less collaborative and less conversational than we’d like them to be, and it also creates a setting where those involved aren’t aware of what others are doing or even what they should be doing,” Kaley Johnson, principal business analyst at the Mayo Clinic, said during a presentation. “From this problem emerged our vision of how we can increase patients’ participation in their care, support that collaboration between care teams and extend Mayo Clinic’s knowledge, expertise and best practices beyond our walls.

To answer these shortcomings, the Mayo Clinic launched what Johnson and her colleague Olivia Peavler, a health systems engineer at the Mayo Clinic, described as an “interactive care plan” — a digital record of a care team’s guidance that promotes clear management goals and extends a patient’s care.

“In other words, a mobile app for a patient’s symptoms and condition management,” Johnson said.

After speaking with their patient about their condition and goals, Mayo Clinic providers incorporate medical history, ongoing medications and other relevant information from the patient’s history to device a digital to-do list that is viewable by the care team and, through an app, the patient.

At home, the patient sees regular reminders relevant to the care plan, and if necessary can upload various vital signs. If these entries are abnormal, the app can trigger a notification to the patient that includes additional questions about their condition, which can be relayed to the care team for any necessary adjustments. Further, should a patient become non-adherent to their plan over time, the app can deliver personalized educational content and other prompts to reengage the user in their care.

While Johnson and Peavler said that the interactive care plan approach has generally yielded some success, they did note a handful of key takeaways worth considering when designing and implementing a similar type of digital health program. Their advice fell into three major categories:

People — seek endorsement from key stakeholders across your organization; recruit a project team with representation from multiple disciplines; and ensure that each has a clearly defined roles, responsibilities and delegation.

Process — remain iterative throughout the program while avoiding scope creep; make sure that your patient education strategy aligns with stated clinical goals and objectives; and feel free to rely on any available tools to streamline the creation process.

Technology — standardize clinical knowledge documentation and broader traceability; continuously solicit feedback from both patients and your providers; and build a feedback pipeline that can help inform the development of future products.

“We really have created this with the goal in mind to facilitate a seamless experience for the patient, and long term we hope that this solution will improve patient outcomes through making real interventions and reduce unnecessary face-to-face visits and other care-related costs,” Johnson said.