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Finding Where Technology Fits: An Integrated Care Program Development Example


Meera Vignarajah ,

University Health Network, CA
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Kelly Lane,

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Lindsay Maynard,

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Marsha Alvares,

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Samra Mian-Valiante,

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Christian Veillette

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As digitally-enabled medicine becomes synonymous with mainstream practice, carefully selecting tools that integrate into existing workflows and improve patient and provider experience is needed in order for the impact of digital solutions to be fully realized. In 2019, the Schroeder Arthritis Institute at the University Health Network created an integrated care program for musculoskeletal (MSK) patients to promote integration in health care delivery between hospitals and community providers, drive high-quality efficient care, and improve patient outcomes and experience. Collaborative consensus building was used to identify where digital solutions could enable integrated patient-centered pathways.

Aims Objectives Theory or Methods

The first phase of program development focused on in-depth current and future state analysis of a specific service within the program (Hip & Knee Surgery). Four exploratory in-person sessions were conducted to identify gaps and opportunities where digital solutions could enable integrated patient-centered care. The sessions were hosted with 20 participants across 14 staff unique roles including physicians, allied health clinicians, administrative staff, and a patient partner to understand the care pathway from referral to post-acute rehabilitation. Once the current workflow was understood, the group identified areas for improvement. The patient’s lived experience was central to determining these opportunities.

Highlights or Results or Key Findings

Four opportunities identified for improvement could be addressed in part through new digital tools and centralized systems.

1) Patient risk stratification tools to alert the care team of high-risk patients based on clinical and social risk factors prior to surgery could reduce unexpected downstream complications.

2) Patient communication tools to provide direct access to the care team could address patient anxiety when awaiting information about their care plan.

3) Greater system integration of existing booking and care processes to address administrative users’ fatigue with patient registration across multiple domains. 

4) Central access and visibility of real-time patient information across the care team and with the patient could be strengthened. The main information gaps occurred when patients transitioned from primary care to hospital, hospital to rehab provider or when medically managed.

Access to the right information at the right time emerged as a key tenant for supportive technology integrated care.


By first understanding existing gaps in care, digital systems can be strategically deployed to strengthen relationships between patients and providers. Future work will include identifying key differences for services beyond Hip & Knee surgery to ensure selected solutions are applicable in those contexts and expanding integrated models enabled by technology.

Implications for applicability/transferability sustainability and limitations

Funding for procuring digital solutions is often limited so new models for cost recovery should be explored. New integrated funding models for Total Joint Replacement surgery in the province presents an opportunity to invest earnings from efficiencies gained into resources and technology.

How to Cite: Vignarajah M, Lane K, Maynard L, Alvares M, Mian-Valiante S, Veillette C. Finding Where Technology Fits: An Integrated Care Program Development Example. International Journal of Integrated Care. 2022;22(S2):56. DOI:
Published on 16 May 2022.


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