Implementing a four pillar digital heart failure program: real time outcomes, emergency department fast track, pathway automation and patient reported data
P Morais Sarmento, M Ferro Teixeira, B Neves, D Ribeiro, R MaioAbstract
Background
Heart failure (HF) is a leading cause of recurrent emergency department (ED) visits, unplanned hospitalizations, mortality and impaired quality of life. Health systems struggle to deliver guideline-directed medical therapy, detect decompensation early and systematically integrate the patient perspective into care. Existing digital solutions are often fragmented, targeting isolated elements such as telemonitoring or PROMs, without a cohesive program linking outcomes, workflows and engagement across the HF care continuum.
Purpose
To describe the design and early implementation of an integrated, digitally enabled, four-pillar HF care model in a large private healthcare group.
Methods
A multidisciplinary team (internal medicine, nursing, data and management) designed a four-pillar HF model embedded in routine care: (1) a real-time outcomes layer; (2) an ED-embedded HF fast track; (3) an automated, evidence-based HF clinical pathway; and (4) systematic PROMs collection. A Power BI-based dashboard integrates clinical and administrative data to track ESC HF quality indicators, including readmissions, ED revisits, mortality and prescription of guideline-directed pharmacotherapy, at patient, unit and group levels. In the ED, a fast-track rule flags patients aged ≥65 years with dyspnea, fatigue or peripheral oedema as potential HF, triggering alerts to ED physicians and the HF team and activating a guideline-based digital assistant to support standardized assessment, acute management, disposition and post-ED follow-up. A longitudinal HF care journey defines visit schedules, investigations and treatment milestones, embedding decision support and alerts into clinical workflows. HF-specific PROMs are sent automatically at predefined intervals via digital channels, with responses flowing back into the record and dashboards for consultation-level and population-level use.
Results
The four pillars were technically implemented and incorporated into usual care in the main hospital of the group, with live dashboards displaying ESC HF indicators and ED fast-track alerts generated for eligible patients. The digital pathway is in active use to support standardized HF assessment and management in ED and ambulatory settings, and routine automated PROMs collection has been initiated with visualization alongside clinical indicators. Formal quantitative evaluation of clinical outcomes and PROMs is ongoing.
Conclusions
A four-pillar, digitally enabled HF care model can be designed and operationalized within a multisite private healthcare group, embedding real-time outcomes, ED fast-track identification, automated clinical pathways and systematic PROMs into routine workflows. This model provides a scalable platform for value-based HF care, with the potential to support earlier decompensation recognition, increase uptake of guideline-directed therapy and deliver more consistent, patient-centered follow-up.