Significant investment continues to be directed toward service reform strategies to deal with the sizable challenges facing health care sectors [1]. These challenges include, but are not limited to, an increasing demand for chronic care, shortages in skilled medical labor, and an aging population [2,3]. In the United Kingdom, the government pledged a £20.5 billion (US $27 billion) increase in the National Health Service’s budget between 2019 and 2024 to foster widespread performance improvements across both primary and secondary care with the aim of tackling these challenges [4]. This trend toward increased spending is likely to continue into the future as nations across the globe seek to deal with large-scale economic and demographic changes [1].

Health care service redesign through the adoption of health information technology (HIT) is being proposed as a means of increasing both the efficiency and effectiveness of health care services, reducing waiting times, and improving the standards of patient care [5,6]. In particular, connected health has emerged as a promising area of research for addressing some of the current challenges [7-9]. This blends the physical and digital realms by capturing real-time data from numerous connected HIT devices (eg, smartphone apps, weighing scales, blood pressure monitors, etc) to ensure that health care stakeholders (eg, patients, carers, clinicians, etc) are provided with timely, accurate, and pertinent information regarding the patient’s status [8,10]. Combined with advanced data analytics, connected health platforms can also contribute to the improvement of health outcomes through targeted and early interventions [11]. For instance, data analytics can provide clinicians with key insights derived from patterns in large patient data sets, which can in turn contribute to improved clinical decision making. This can help reduce decision makers’ reliance on gut feeling or intuition by fostering a data-driven, evidence-based approach to clinical decision making and decision support [12-14]. Connected health platforms, combined with the use of smartphone apps, also offer the possibility of deploying coaching on a broad scale to improve adherence and outcomes for those affected by a variety of conditions, such as diabetes [15-17].

However, Chen et al [18] noted that these targets can only be achieved through appropriately designed interventions. This requires inputs from all relevant stakeholders to design connected health solutions that not only fit the needs of patients [19] but also fit within the health care ecosystems and are viable and sustainable in the long term [18]. The mapping tool that we present in this paper is aimed specifically at eliciting and channeling the opinions and preferences of a varied group of stakeholders around the possible use of HIT across a medical pathway.

According to Doyle et al [20], there are 3 core pillars of health care quality, which health care reform strategies (including those involving connected health) must cater to, clinical effectiveness, patient safety, and patient experience. Their contention has been broadly supported by other researchers (for instance, the study by Anhang et al [21]), with their paper receiving over a thousand citations and many researchers adopting their 3-pillar framework. The core argument in this stream of research is that the relationship between patient experiences and other aspects of care is symbiotic and critical. We agree with the view that patient experiences are an integral aspect of care quality (even if they may not be directly related to clinical processes and outcomes [22]. We strongly agree that we need to understand how patient experiences are associated with the effective use of structures, the underlying health care processes, and the occurrence of health outcomes. This knowledge ought to be directed toward improving the efficiency and effectiveness of care [21]. Thus, in this study, we adopted the 3 pillars of health care quality by Doyle et al [20] as a guiding framework.

To date, health service reform initiatives have focused on measures of clinical effectiveness and patient safety, with patient experience receiving less attention [5,23]. It does not follow that an efficient and compliant service will mean a good patient experience. For instance, a patient might receive an appointment quickly, but their overall experience may be poor if, for example, they feel that their unique needs are not catered to. In most cases, connected health solutions involve patients who directly engage with apps, often in their homes or in the community. Given the absence of direct supervision, it is critical that the apps and devices are easy to use and that they promote appropriate, accurate, and safe usage. Generally, connected health solutions raise significant and new ethical concerns, which need careful consideration [24]. Therefore, it is crucial that their design considers all 3 central pillars of health care quality (clinical effectiveness, patient safety, and patient experience) in tandem [20,25]. Failure to consider these pillars may mean that key requirements and constraints are overlooked, leading to problems later—poor quality data, low utilization of health care services, ineffective decisions by health care professionals, or unethical use of data [20,26].

Although methods are available for exploring each pillar of health care quality in isolation, to the best of our knowledge, there is no single design tool currently in use that addresses all 3 pillars collectively, and more particularly in the context of technology-intensive and multidisciplinary fields such as connected health. This paper, goes some distance to address this shortfall by presenting a design tool we developed called Integrated Patient Journey Mapping (IPJM). This tool is primarily aimed at supporting the analysis and design of connected health apps. Inspired by the concept of journey mapping, it allows researchers and practitioners to simultaneously and explicitly consider the factors of clinical effectiveness, patient safety, and patient experience in tandem. The tool has primarily been validated through its use in a series of projects. In this paper, we focus on its use in a project called Learning to Evaluate Blood Pressure at Home (LEANBH) that involves the development of a connected health app focused on the investigation of preeclampsia, a disorder of pregnancy that can lead to a variety of adverse outcomes.

The remainder of the paper is structured as follows: On the basis of a review of existing literature, the Introduction section offers a background to the development of the mapping tool in the context of connected health and describes IPJM. The Methods section explains the methods, while the Results section provides results from the LEANBH project on the use of IPJM in a perinatal context. A discussion of the findings as they pertain to academic and practitioner communities is outlined in the Discussion section.

Journey maps have been used in several areas to offer pictorial illustrations of complex processes or interactions that would otherwise be difficult to apprehend. Howard [44] noted that journey maps evolved from the field of service design when designers sought to re-engineer or optimize the service delivery of organizations or developed blueprints for new services (see the study by Stickdorn and Schneider [45]).

In particular, journey maps can be used to depict the health care service from the perspective of different actors, such as patients [37,42,46]. In the case of the patient, they are based on mapping consecutive touchpoints between the patient and the service, the nexus of where patient experience is actively shaped [23,42,47]. They see the relationship between the patient and service organization as something emergent, dynamic, and ubiquitous within the larger context and go beyond the more static view provided by other service design methods [42]. Percival and McGregor [48], for instance, proposed a mapping technique that includes a number of layers: staff roles, processes, information creation or movement, HIT solutions, IT infrastructure, patient needs or practice guidelines or policies, and metrics. Journey maps incorporate both physical and emotional aspects of the patient’s journey with the aim of capturing and shaping the patient’s behavior, feelings, motivations, and attitudes across the episodes of care, taking into account such important factors as the environment or context. They also help professionals to visually externalize their disciplinary knowledge and collect multidisciplinary insights. This promotes alignment but also empathy toward patient groups by placing the patient at the heart of the modeling process [49] and by creating a visually compelling story of the patient’s experience [43].

User representations are developed to categorize and personify different target groups through the description of fictional users, that is, name, picture, personal background, and goals. User personas involve creating representations of typical users to help design teams to better understand and take account of the mental models of these groups, that is, their expectations, prior experience, and anticipated behavior [50]. LeRouge et al [50] stated that user personas address the limitations of common modeling tools such as Unified Modeling Language diagrams by integrating the conceptual model of users, their cognitive structures, and present behavior that drives health care thinking, future behavior, and demand.

Journey maps can be combined with user personas in the requirements gathering process to direct increased attention toward patient experience. The added contribution of personas to journey maps is that instead of being static representations of demographic profiles, they offer dynamic views of customers and users’ experiences in their interactions with current and proposed products and services. The combined approach can then be employed to make design decisions and evaluate design solutions according to the unique needs of each persona. This stimulates creativity among team members when trying to address user needs and usability across numerous different real-life scenarios [51]. Critically, a small number of personas have been found to support the consideration of large, diverse populations, making the concept particularly useful for health care scenarios [52].

The area of HIT development has received considerable attention over the last 40 years. This time has seen the emergence of increasingly sophisticated platforms and development environments. Recently, the availability of cloud-based solutions, smart interconnected devices, and mobile apps has unleashed the potential for connected health apps. Unfortunately, these benefits can often be offset by the complexity and cost of developing connected health apps. The set of required development skills is becoming increasingly specialized, as is the complexity of the project management of the multidisciplinary teams required when developing such solutions. Mapping tools might be a useful approach for building cohesion within such teams, but at the same time, they must be understandable by diverse groups and professions to ensure that shared knowledge can be nurtured during the development process.

In the following section, we describe IPJM, a visual tool developed to help design teams to meet these challenges and to understand how to best reconcile the sometimes divergent requirements arising out of the need for clinical effectiveness, patient safety, and patient experience when designing connected health solutions. IPJM is also intended to promote harmonious team performance by negotiating and finding the right balance between the somewhat competing needs of different groups. This requires collaboration between different competencies on multidisciplinary teams. It also requires the management of conflict, which is likely to emerge from a comprehensive consideration of all viewpoints [53-55]. As a result of using IPJM, we hope that robust and high-quality designs will emerge for the solutions being considered.

The IPJM tool was built using an ontology that conceptualizes the journey of a patient along a medical pathway. The ontology aims to promote a common vocabulary [56] among multidisciplinary design teams based on the 3 core pillars of health care quality. It captures the key elements of the journey: the structure of elements, relationships between elements, and implicit rules that govern the behavior of elements [57]. The ontology depicted in Figure 1 is provided in the literature. In addition, it has been validated through qualitative feedback from a number of projects that involve the use of IPJM, including the LEANBH project, which is described in the Methods section of this paper.

The ontology is split into 3 main areas: the patient persona, the medical timeline, and the medical pathway. First, the patient persona provides a characterization of a user group under consideration (eg, an expectant mother who is at risk of hypertension) and is inextricably linked to all other elements of the ontology. The medical timeline adds a temporal aspect to the episode of care by dividing it across a defined time frame (eg, the weeks of a pregnancy). The medical pathway centers on the consecutive events or steps in the episode of care [46] and consists of 7 subcomponents that are defined and described in Textbox 1. In particular, the medical pathway describes the physical journey, the emotional journey, and the device touchpoints associated with an episode of care. The physical journey is further divided into tasks, and these tasks are further subdivided into goals, constraints, and actors.

In this way, the ontology provides the foundational basis for IPJM by outlining the context in which the patient journeys transpire. Going back to the underpinnings of the concept of journey maps, the mapping tool (through the use of the ontology) visualizes the journey of a persona facing a scenario. This can sensitize designers and developers to the intricacies of individual personas and scenarios and minimize the risk of designing for normative situations that do not reflect the real situations of actual patients. Commercial firms and public sector agencies have used such ontologies very successfully in seeking to develop interaction mechanisms with their customers and with members of the public who need to access their services, such as in the case of disabled people who have special mobility and cognition needs [58].

IPJM can be used to show the as is and the to be comparison between the existing medical pathway and the intended modified pathway enhanced with technology, devices, apps, and other new components and interactions. This ensures the tool’s usefulness for negotiation and communication of the design of the proposed connected health solution, especially between clinical specialists and designers or developers of the solutions. In seeking to make a business case for new pathways, the map can be used to demonstrate to relevant health care authorities the potential impact of proposed changes.

An in-depth case study approach [61] was undertaken to explore the use of visual tools for embedding health care quality in the design of connected health solutions. The in-depth case study in question followed the guidelines provided in studies by Yin [62,63]. It centered around the LEANBH project, a pilot research project that provides remote health care monitoring for expectant mothers to improve the detection and treatment of hypertension during pregnancy.

Hypertensive disorders in pregnancy (eg, preeclampsia and gestational hypertension) are a major cause of maternal and neonatal mortality and morbidity worldwide, accounting for 16% of maternal deaths in developed nations such as Ireland and 25.7% of maternal deaths in the developing nations of Latin America and the Caribbean [64]. In particular, preeclampsia is a hypertensive disorder of pregnancy characterized by high blood pressure (>140/90 mm Hg), the presence of protein in urine, and other associated symptoms such as headaches and edema, which can lead to serious complications during pregnancy [65].

The LEANBH project was a collaborative effort that involved organizations from academia, the health care sector, and the industry. The multidisciplinary project team consisted of a principal investigator, a project manager, a full-time and part-time developer, an analyst, and a data architect (which made up the information systems [IS] subgroup) and a clinical lead, a clinical researcher, and a research nurse (which made up the clinical subgroup). The primary goals of the project were to increase clinical effectiveness, patient safety, and patient experience in a perinatal care context. The project team was tasked with building a connected health platform that integrates several IT artifacts, including a smartphone app, a home blood pressure monitor, and a urine analyzer for use by expectant mothers. An electronic health record was included to capture vitals for use by clinicians. The project also aimed to develop novel forecasting algorithms for predicting the likelihood of gestational hypertension and preeclampsia.

The project was an observational study in which each patient followed the standard pathway and had access to both the standard care and the connected health platform. This simplified the ethical approval process, which was mostly concerned with providing complete and precise information to participants and in eliciting their consent on recruitment. This was achieved by creating a comprehensive patient information leaflet and assigning a dedicated research nurse to recruiting patients and training them in the use of the smartphone app, blood pressure monitor, and urine analyzer. Ethical approval was granted by both the University Clinical Research Ethical Committee and the Health Service Executive via the Hospital’s Local Information Governance Group Research and Audit Committee. The authorization covered 2 rounds of recruitment of 50 patients each: the first group was an initial low-risk group and the second group was a more representative group of pregnant women, including women with preeclampsia.

The findings suggest that IPJM can support multidisciplinary teams in exploring connected health solutions that consider the 3 pillars of health care quality: patient experience, clinical effectiveness, and patient safety [20]. It supports groups in understanding and negotiating conflicting requirements that can arise during transformational projects. This is achieved using journey mapping and user personas for graphically externalizing key domain knowledge. IPJM also promotes creative thinking around service reform goals and fosters dialogue among stakeholders, potentially leading to better solutions overall [72]. In addition, the ontology behind IPJM places constraints on groups, although it also allows the modeling to be easily adapted to different specialties, such as cardiology. The accessibility of the IPJM tool means that it can become a valuable boundary object [73,74], for discussions between multidisciplinary teams of stakeholders. For instance, IPJM enables ideas to be shared, interrogated, and visually externalized at both individual and group levels [56]. The use of mediums such as post-it notes means that the template is easy to use and modify as well.

Compared with other mapping tools, IPJM offers the possibility to focus on the comparison between the as is and to be versions of the pathway under study—this is a significant advantage in projects that pursue specific improvement targets. Its reliance on a visual grammar that does not require pre-existing knowledge (unlike other systems analysis and design approaches, such as Data Flow Diagrams or Value Stream Mapping, which require substantial training before participants can use them meaningfully) is also an advantage. The comparison with other techniques, such as Patient Journey Model architecture (PaJMa), the method proposed by Percival and McGregor [48], for instance, shows that IPJM manages to accumulate and represent a similarly broad variety of knowledge but with greater economy and without passing on the complexity of tasks and process steps onto the participants in the design process or, generally, onto the readers of the documentation. Both PaJMa and IPJM offer improvements over other mapping tools by allowing analysts to consider a much broader range of knowledge, but the use of personas in IPJM delivers a sharper focus on human aspects, such as the human experience, of patients, which is fundamental for connected health solutions that entail a context of use where patients are alone when using apps. In contrast to PaJMa, IPJM is likely to be more user friendly and more flexible in the case of first-time digitalization of medical pathways that involve mobile components that either patients or clinicians will use remotely.

IPJM can be used as a cornerstone for modeling health care service reform where stakeholders collaborate to derive an understanding of and commitment to requirements [75,76]. Textbox 2 summarizes the benefits inherent in the use of IPJM identified in its use during the LEANBH project.

Beyond the benefits identified in Textbox 2, we argue that IPJM can boost team cohesion during the execution of novel design projects. Existing literature suggests that team cohesion is essential to the performance of teams consisting of individuals from diverse organizational and geographical backgrounds [77]. Team cohesion can be defined as the extent to which team members are aligned in their shared understanding of and shared commitment to project tasks, for example, the actions that individuals and groups seek to perform based on agreed plans [78,79]. Shared understanding involves a social process whereby the divergent knowledge of individuals is transformed to generate collaborative knowledge building [75,80]. Shared understanding is required to explore design spaces and overcome siloed thinking through the combination of existing knowledge in new ways. Meanwhile, shared commitment goes beyond shared understanding alone and requires team members to commit time, effort, and resources in line with proposals that have gained shared understanding [76,81].

Shared understanding and shared commitment are crucial to the success of projects involving stakeholders from different organizational and disciplinary backgrounds [54]. In the absence of both shared understanding and shared commitment, the perspectives and intentions of team members can become increasingly fragmented, as individuals may not even be aware of the intricacies of the issues around which they disagree [76]. IPJM provides team members with the opportunity to challenge assumptions embedded in prebaked project proposals and contribute diverse knowledge around the design of IT solutions. This helps ensure that design efforts promote both a shared understanding of users’ diverse needs and capabilities and a shared commitment to the delivery of solutions that cater to these needs. However, during the LEANBH project, not all group members were equally committed to leveraging the tools and to journey maps for modeling the problem domain and gathering requirements. This is a key concern as there is a possibility of a link between the involvement of stakeholders during the modeling process and their understanding of and engagement with the project overall. Therefore, future versions of the modeling tool need to consider how best to engage practitioners from different backgrounds so that the entire team rally around the journey maps and their validation.

The health care sector is currently facing the monumental challenge of minimizing the costs associated with health care delivery while simultaneously improving quality. Connected health solutions can play a significant role in meeting this challenge by transferring health care delivery to the least expensive setting (ie, a patient’s home) in a way that does not compromise quality. However, the successful design of connected health solutions is far from a straightforward task, and the success hinges on a quality-centric approach being embodied during every step of the development lifecycle. At this point in time, health care systems around the world are seriously affected by their reliance on a one-to-one mode of care delivery, where patients often wait for weeks and months to see overstretched specialists. Crucially, connected health apps can allow clinicians to better care for more patients by giving them more frequent attention in a remote fashion and without the need for face-to-face visits far more effectively [8].

It is here that the use of design tools such as IPJM can offer significant value. This paper contributes theoretical and practical insights into how visualization tools can be used to embed the pillars of health care quality in the design of connected health solutions. For instance, case study findings suggest that IPJM can provide multidisciplinary teams with a canvas for designing connected health solutions tripartite goals of clinical effectiveness, patient safety, and patient experience. In particular, IPJM can help ensure that patient experience is given ample consideration when designing health care services, in tandem with more traditional concerns such as resource efficiency, waiting times, financial costs, and treatment efficacy. In particular, IPJM can help bridge the gap, which is often identified too late between the intended use of apps and the observed system-in-use postimplementation. Such gaps often lead to the occurrence of silent errors and require the complete rethinking of apps and devices at considerable expense in time and money, both of which are in short supply in the health care sector [82].

However, IPJM is not without some limitations. For instance, IPJM does not make explicit reference to key performance indicators, such as throughput and waiting times, or other metrics, such as productivity and cost-efficiency, although these may be essential elements of the performance and success of the services being designed. This clearly applies to the scenario of a connected health solution being implemented to increase the throughput of a medical pathway, to deliver cost savings, and to improve visibility on patients’ conditions. Although incorporating this element in the tool would be useful, there is also a risk that increasing the level of detail may compromise the overall accessibility and reliability of the maps. As a result, it may be difficult to capture some of the inherent complexity in health care systems, that is, when a patient is transferred from a hospital during treatment. On the other hand, the tool can be adapted according to the unique context in which it is to be used to address any key elements that are missing. Its use within the context of specific pathologies and medical specialties has the potential to rapidly bring medical teams up a steep learning curve toward developing connected health care apps.

Specifically, in the case of our research, we encountered other limitations, although it may be unclear whether these were circumstantial or if they were likely to also occur in other cases and settings. We found it difficult at times to secure participation from certain groupings in some meetings. For example, clinicians sometimes found it difficult to commit time to use IPJM, as they felt they were too busy and that the journey maps were for the development team rather than for themselves. Resolving these misconceptions is essential to producing maps that are accurate and robust in the face of real-life scenarios.

Future research may also seek to develop a more interactive version of IPJM to provide a more accessible view of the patient’s journey. IPJM currently requires a large physical display to ensure that all components are visible and legible. During the project, we experimented with different display dimensions and orientations before deciding on an A2 portrait format. However, it may be necessary to consider whether certain elements need to be reorganized so that the tool can be displayed more easily across a variety of media and spatial dimensions. A software program that would allow users to drill down into subpathways and map components more effectively could also be a useful extension.

Clearly, there are cognitive and presentational limitations that apply to the mapping of macroservices, for instance, a national or even transnational architecture for managing a certain pathology or group of patients with dedicated needs. Although the mapping of such a broad pathway might be desirable or even essential as a communication tool for reaching a common agreement, evidently difficulties will arise when attempting to compile such a map where the need to be holistic and comprehensive might be traded off against the necessity for visual representations to remain comprehensible by most people and therefore useful. Setting some boundaries that accommodate both the need to capture the whole system as well as some of its key components will be useful, although our research does not provide clear avenues pertaining to how this may be achieved. Weick [83] characterized the Bonini paradox (by reference to Charles Bonini and his work on simulation, published in 1963 [84]) as illustrative of situations where models were proposed that were so complex in and of themselves that it was no easier to understand them than it was to understand the real world as observation could reveal it. We can hypothesize that the Bonini paradox applies to journey maps and that die hard attempts to capture a world without any ontological boundaries would only yield theoretically excellent but practically useless representations that would hamper design efforts rather than help. The need for ontological boundaries, such as those provided by the IPJM tool, is much needed and is underresearched. Future research on this topic should explore this new dimension.