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What we learned from surveying 140+ professionals involved in clinical operations at virtual-first, traditional and hybrid care providers on the tools and practices they use to deliver high-quality care.
Scaling care delivery efficiently while maintaining the highest quality of care for patients and ensuring a sustainable work environment for the care team is a big challenge. What is the ideal team composition to design and implement care processes that balance efficiency with sound clinical practice? What metrics do care teams use to measure performance? What is the ideal patient-to-provider ratio?
To answer these questions, together with Health Tech Nerds we launched the State of CareOps Survey 2022 collecting data over the months of July & August 2022. With over 140 responses this is the first research of its kind into CareOps tools and practices.
This report will give you the insights to compare how your care delivery organization structures its team, implements care flows, measures their performance and improves them continuously over time.
Welcome to the very first State of CareOps report. The survey and report are driven by Awell in collaboration with Health Tech Nerds and a group of individual contributors.
The purpose of our research is to provide a view on the practices and tools of care provider organizations (virtual, traditional or hybrid) to build, operate and optimize software-powered care flows that drive outcomes improvements for patients and efficiencies in care delivery.
To collect the data for our research, we surveyed 147 healthcare professionals active in clinical operations in the period of July & August 2022. We were able to cover a broad range of care providers from the early startups seeing a handful patients per month to companies with 100,000+ patients that have been operating for more than 15 years.
Our research shows a lack of common framework in team composition to design care flows as well as metrics to measure performance. It takes significant time to design and implement these care flows in both patient-facing and care team facing software applications. This leads to the majority of care processes being poorly documented and/or implemented. With regards to monitoring, the majority of care teams are flying blind to some extent. Iterations to care flows are mainly driven by performance metrics rather than by new medical knowledge or clinical outcomes data. Finally, there is a big variation in iteration frequency across care providers.
We focus on highlighting what’s not going right today in order to kick start improvement across the industry. But it’s not all bad. We see a glimpse of elite performers who are including the right stakeholders when designing care flows, who have shorter design & implementation timeframes than their peers, who are monitoring a balanced set of metrics to drive insights for iterations and who are iterating more often than others.
We’re aware that insights alone will not drive better care. That’s why we’re hosting a panel discussion with Dr. Ali Khan (CMO at Oak Street Health), Dhruv Vasistha (VP Product at Firsthand), Wayne Li (VP Care Operations, Headspace Health), Mariza Hardin (Co-founder & COO, Zócalo Health) and David Lerman (CTO, Boulder) to discuss what tools and processes top-performing organizations use to drive high-quality care. You can register for the webinar here.
We’re looking for other operators in the space that want to contribute to the concept and viewpoints of our articles and data. If you’re interested in becoming part of the conversation please reach out to rik@awellhealth.com.
Sections of the report:
We first highlight the 4 key insights we extracted from the analysis. We then list all of the other insights organized by the three stages in the CareOps Lifecycle. Then we provide a glimpse on what elite performance looks like. We finish off with demographics & firmographics of the respondents and explain our methodology.
If you are already familiar with the terms CareOps and care flow, skip this section and feel free to go straight to the results.
CareOps is a set of practices and tools to build, operate and improve software-enabled care flows. It applies principles from agile software development, quality improvement and design thinking to healthcare processes.
CareOps brings people from clinical, operations, product and compliance teams together, overseen by strong clinical leadership. Ultimately, CareOps increases a provider organization’s ability to deliver higher quality care at lower cost and drive improvement cycles more frequently than its peers.
For more context on CareOps, read What is CareOps and why do we need it?
Clinical operations or clinops is a function that helps making sure care is getting delivered.
CareOps is a cross-functional practice to design, implement and optimize software-enabled care flows that power clinical operations.
The central concept of our research is the “care flow”. At different care providers different terms are in use for this term, such as care program, care pathway, care plan, patient flow, patient journey, care journey, clinical protocol, care process, (clinical) service line, care process model, clinical workflow or even digital therapeutic.
In essence they’re all sequences of activities completed by a care team and/or patient to maintain or achieve a desired health status for that patient.
Care flows are often defined at the medical condition / population level: a care flow for “Anxiety”, “Type 2 diabetes”, “Total joint replacement with obesity for 65+”, “Menopause”, “Sexual health for LGBTQ+”, “Discharge after surgery”, etc. and can be patient facing only, care team facing only or include activities for care team and patient.
We’ve used “care flow“ as an umbrella term in the survey as well as in the results.
We asked the respondents what roles at their organization are involved in designing care flows. The results show 66 unique team combinations across 81 responses. This means there is no "standard team" to do this work.
If there is no standard team, it means conversations around best practices and sharing of knowledge to design, implement and optimize care flows is likely happening in a fragmented way both inside those organizations as in the community. This impacts the ability to learn as an industry.
Care flows touch upon all core aspects of a care provider’s organization, requiring a multidisciplinary approach to design care flows that drive operational efficiency and high-quality care. In the CareOps articles we formulated 4 key roles (clinical, clinical operations, product and software engineering) complemented by regulatory and data teams where relevant. Further below in the report we’ll have a look at the most prevalent team compositions and whether the core CareOps roles are represented in those.
Of the 69 respondents who provided an answer to the question how long it takes to design a care flow, 26% (n= 18) reported it takes 3 months or longer to design a single care flow and 78% (n= 52) reported at least one month.
38% (n= 42) of all respondents are either not measuring this, don’t know how long it takes or did not provide an answer to this question. Not knowing or measuring how long it takes might signal that the ability to design care flows rapidly is not yet seen as a competitive advantage by all care providers.
The ability to design care flows in less time means faster time to market and faster scaling. It’s a powerful competitive advantage for any care provider. Even those with a specialty focus addressing only one or a narrow spectrum of medical conditions require multiple care flows at their organization in order to cover the full continuum of care for their patients from acquiring and onboarding patients up to the point their services end.
Of the 42 respondents who provided an answer, 90% (n= 38) said it takes more than a month to implement a care flow and 48% (n= 20) reports more than 3 months. We’ll dig a bit deeper into different cohorts of care providers further in the report.
A surprising 62% (n= 69) of all survey respondents don’t know, are not measuring or failed to provide an answer to the question how long it takes to implement a care flow into the EMR or application used by the care team.
Similar to the previous insight - a care provider’s ability to implement a care flow in the tools used by their care teams is a competitive advantage.
If you can design care flows rapidly but they are stuck in PDF or paper format, you fail to capture the full value of your care flows. Even worse, the risk to amass significant ClinOps debt increases significantly. As a care provider this has a direct impact on your gross margin and profitability.
As we argued in Metrics for the CareOps Practice, with regards to care flows 4 categories of metrics should be monitored: performance metrics, financial metrics, clinical outcomes and patient-reported outcomes.
Each one of these provides a crucial piece of the puzzle. Leaving out one or more pieces means in the best case, care teams cannot extract insights from those categories. In the worst case, it means they’re optimizing for one category of metrics to the detriment of the ones they are not measuring.
We see that only 10% (n= 12) of all survey respondents monitor metrics from all 4 categories. This means the vast majority of care providers are flying blind to some extent.
In the current climate payers and employers are getting more sophisticated about asking care providers to prove they improve outcomes and reduce costs. Therefore, it's crucial to track all four metrics and develop strong real world evidence (RWE) from day one.
This stage in the CareOps lifecycle covers the collection of inputs needed to design a care flow and validate it with the relevant stakeholders in order to optimally support patients and care teams’ daily clinical operations.
In the Key insights, we already saw that it takes significant time to design care flows. The other insights from the Design & validate stage are:
We looked at whether there was a difference in the use of care flows based on organization age, revenue model, spectrum (speciality vs primary care) or care delivery model but across all these dimensions the distribution is largely the same: 80% use care flows and 20% don’t.
It has been widely documented in research that care flows can improve outcomes, reduce costs, lead to better performing care teams and decrease variability in outcomes. Standardizing your care delivery process to some extent by utilising care flows is necessary if you want to decrease unwarranted variation in that same care delivery process. The fact that 20% of care organizations are not using care flows is a sign that standardization is not embedded in those organizations.
In the key insights we already mentioned the results show 66 unique team combinations across 81 responses. But what roles are included in those teams and do they represent the 4 main CareOps roles: clinical operations, clinicians, product managers and software engineers?
First, let’s have a look at what roles are being included in care flow design.
It’s no surprise to see clinical operations, clinicians, clinical experts, product managers, care coordinators and software engineers represented at the top of this list as they correspond to the 4 CareOps roles. What is surprising though is that only 19% of respondents include input from patients when designing care flows. Especially because the goal of each care flow is to deliver better care for patients.
Patient expectations are rising and patients have more and more options to choose from when it comes to staying healthy and dealing with health issues. Creating a great patient experience is probably one of the strongest competitive advantages of any care provider. That’s why it’s important to include input from patients when designing such care flows. This input will help you identify gaps, improve care delivery and eventually lead to higher patient satisfaction.
Apart from patient involvement, it’s clear that designing care flows is a multi-stakeholder effort.
Of the 81 people providing an answer to this question, 84% (n= 68) report involving three or more roles in the design process. 49% (n= 40) involve between four and six roles, 19% (n= 15) involve five roles and 26% (n= 21) involve more than six roles.
This begs the question: when is multidisciplinary involvement too much? The more people involved in a design process, the more difficult it becomes to get alignment on all perspectives and move fast.
While too many cooks could spoil the broth, involving too few people is definitely risky given the strong multidisciplinary nature of healthcare. 31% (n= 25) of respondents report three or fewer roles are involved in designing care flows. This means they are missing crucial input from specific stakeholders which will likely negatively impact the quality of the care delivery process.
Finally, let’s look at team composition alignment with the CareOps roles. How many respondents involve at least Clinical operations, Clinicians, Product managers and Software engineers in the design of their care flows?
Of the 81 respondents answering the question what roles are involved, 27% (n= 22) have teams where the 4 CareOps roles are represented.
Of the 73 organizations that provided an answer to what tools they use for designing care flows, 88% (n= 64) use only static/non-dedicated tools like word processors (Microsoft Word, Google Docs), flowchart making software (Lucidchart, Draw.io), digital whiteboards (Miro) or presentation software (Microsoft PowerPoint).
Using static tools means multidisciplinary teams lack interactive prototypes they can use for validation of the care delivery processes, which has a negative impact on the design process.
Additionally, 30% (n= 22) of respondents uses 3 tools or more to design their care flows and 22 toolset combinations were unique across the 73 responses. There is in other words no unified toolset to design, validate and share care flows. Information on the care flow is fragmented across different tools: maybe the patient-facing aspect lives in a design tool but the clinical logic is written out in a protocol in Word. With information spread across tools, collaboration becomes more difficult and implementation takes longer.
During the Build & Operate stage of the CareOps lifecycle, the validated care delivery processes are built into the patient and care team software applications and deployed for use in clinical practice.
In the Key insights, we already saw that it takes significant time to implement care flows into the care team application / EMR. The other insights from the Build & operate stage are:
How many patients does each of my providers see per month? What is a sustainable number to ensure the highest quality of care while optimizing for gross margin?
To answer these questions, we calculated the patients per provider ratio in the following way:
63% (n= 70) of all survey respondents sees between 15 and 450 patients per provider per month. We looked at whether there are differences between providers based on care delivery model or organization age but ratios are largely the same across these cohorts.
As a care provider, the biggest part of your COGS (cost of goods sold, which determines your gross margin) is the care team staff. For an equal amount of patients and equal clinical outcomes, seeing more patients per employed care team member will directly impact on the bottom line.
The other side of this coin is the concept of care contribution. What % of your individual provider staff’s time should go to providing care? If a care provider works 40 hours per week, seeing patients for those 40 hours requires an enormous amount of coordination and does not seem like a sustainable way of working for that individual.
To get more insight into this ratio and what is optimal, we realize that we should do better with our questions next year. We are conscious that this first throw is only a very rough proxy so the numbers should be taken with a big grain of salt. We still wanted to include this in the report as we wanted to see whether a concentration towards a certain range existed across providers.
We can indeed see a concentration between the 15 - 450 ratio. This is still a broad range but it's a start. Next year we plan on finding out whether there are meaningful differences between cohorts, for example between care that is more multidisciplinary vs. more monodisciplinary in nature.
Although 80% (n= 91) of all survey respondents report using care flows at their organization, only 36% (n= 40) report having more than 6 and 24% (n= 27) more than 10 care flows live.
If you think about the breadth of medical conditions patients bring to care organizations, it's fair to say that the majority of clinical processes are still poorly documented. Note that this also holds true for care providers focusing on one or a handful of medical conditions considering the different phases of a care delivery process (patient onboarding, triage, diagnosis, treatment, follow-up, recurrence of disease, etc.).
This begs the larger question, and one we haven’t addressed in this year’s State of CareOps Survey: how to make sure that a care flow as designed is how it is actually deployed in clinical practice?
The number of live care flows grows with the size of the organization. Of the respondents who provided an answer to both questions, 21% (n= 5) who see less than 1.000 patients per month report having 6 or more care flows live, while this number is 77% (n= 30) for those organizations seeing more than 1.000 patients.
The number of live care flows also grows with the age of the organization. Of the respondents who provided an answer to both questions, 44% (n= 18) of respondents whose organization has been providing care for less than 5 years have 6 or more care flows live, while 81% (n= 22) of respondents whose organization has been providing care for more than 5 years have 6 or more pathways live.
If there would only be a handful of care flows for each care provider, the number of live care flows would be fairly constant across organization size and age. This confirms earlier insights that it takes time to design and implement these care flows, and that the majority of care flows is not implemented properly at all.
Imagine if it took all businesses at least 5 years to document and implement the majority of their processes.
Of the 77 people that report using a software application like an EMR or a dedicated web app to support clinical operations with care team-facing flows, 44% (n= 34) use 2 or more tools
Switching tools means switching contexts, losing time and potentially making errors. We all know clinicians are allergic to clicking around, and rightfully so. The ability to offer their care teams a single tool with all relevant information at hand at the right time represents a strong competitive advantage for care providers. Not only does this drive efficiency (e.g. the patient per provider ratio) but in a world where clinicians have more and more options to work, this becomes a powerful advantage when attracting and retaining clinical talent.
We’d also like to point out that this insight shows a too rosy picture of reality. 30% of all survey respondents did not even provide an answer to this question and considering that most care flows are not implemented into the primary work applications of care teams, those with “just” 2 or 3 software applications are much better off than the even larger number of care teams running their clinical operations playbooks off of documents and PDFs.
During the Monitor & Improve stage of the CareOps lifecycle, the organization monitors how the care flows that are being used in day to day clinical operations are performing. The goal of this monitoring is to be able to intervene when things are not going according to plan or design. Afterwards, data should be analyzed with the goal of extracting insights which in turn are inputs for improvements to care flows, closing the feedback loop of the CareOps lifecycle.
In the Key insights, we already saw that less than 10% of respondents are using metrics from all 4 categories (performance metrics, financial metrics, clinical outcomes and patient reported outcomes) to monitor care flow performance. The other insights from the Monitor & Improve stage are:
While getting the patient perspective is crucial to delivering patient-centered care, only 36% (n= 40) of all survey respondents collect patient-reported outcomes (PROMs) like the PHQ-9, GAD-7, PROMIS-10 or others. This is surprising given there is plenty of scientific evidence that PROMs improve quality of life, reduce emergency room visits, and decrease hospitalizations.
Of the 66 respondents who provided an answer to the question what metrics are used, almost 32% (n= 21) only measure performance metrics (e.g. sign up, drop off, engagement, completion rates) for their care flows.
You can only improve what you measure, and generally what is measured ends up being optimized. This means many organizations are optimizing for performance without taking quality of care into account. A potential reason is that performance metrics are leading indicators and outcome measures are lagging indicators, often taking significant time to be a valuable signal. Another potential factor at play is financial incentive. The more a care provider takes on risk / has value-based contracts, the more important outcome measures are vs. performance.
Only 19% (n = 21) of all survey respondents use new medical research to drive iterations.
It’s very simple, this number should be 100%. Where is the challenge? How come this number is so low?
Knowledge about what works and what doesn’t in healthcare is evolving continuously. New insights are published at a rapid clip and some sources even claim that medical knowledge is doubling every 73 days (down from every 3.5 years in 2010). With less than 20% of organizations using new medical knowledge to drive care flow iterations, it starts to dawn why it takes on average 17 years for research to reach practice.
This is again an opportunity to create a sustainable competitive advantage. Organizations that have processes and tools in place to continuously fold new medical knowledge into their care delivery will be able to show better outcomes than their peers. The result is a stronger negotiation position with payers, employers and customers based on clinical excellence.
Performance metrics (38%, n= 42) and user feedback (34%, n= 38) are used more often as a source to iterate than clinical outcomes or patient-reported outcomes (31%, n= 34).
In total, 44 respondents didn’t provide an answer. This could signal low importance of iteration or iteration sources at their organizations.
Additionally, when looking at the combination of sources used to drive iterations we see 27 different combinations in total and the most used combination is answered by only 7 respondents.
This signals a lack of standardization or common framework around what sources of data should drive iterations to care processes. It feels like those who are working on this each do it in their own corner of the globe and for a significant cohort this is not even on the radar.
Of all the respondents that provided an answer to the question of how often they iterate on existing care flows, 97% (n= 60) have iterated at least once on their existing care flows in the last 12 months, and 63% (n= 39) iterated three times or more.
On the other hand, 44% (n= 49) of all survey respondents either didn't know, aren't measuring this or didn't answer.
Iteration frequency is the driving force that sets healthcare winners apart from the rest. A quarterly iteration means potentially 4x the amount of learnings vs. a competitor that iterates once a year. As learning faster than the competition is the only truly sustainable competitive advantage, this is why care providers should build the organizational muscle to continuously experiment and iterate on their care delivery processes.
In other words, care provider survival depends on a radically faster CareOps lifecycle.
What does elite performance in CareOps look like? Are we looking for unicorns or can we see a group of elite performers emerge among respondents? As this year is the very first installment of the State of CareOps report, we anticipate evolution of maturity with regards to CareOps over the coming years.
But are there any organizations in this year’s data set that we can identify as high performers? This begs the question what criteria determine who’s an elite performer. We also anticipate that this will evolve over time as the community further refines the concepts around CareOps.
An elite CareOps performer:
Applying these criteria to our dataset, we arrive at a grand total of 2 organizations (less than 2% of all survey respondents).
We’d love to get your feedback on this. Do these criteria make sense? Would you like to suggest other criteria?
This very first State of CareOps report provides us with an initial glimpse on the landscape. Although many of the concepts discussed have been around for ages, we are excited to bring them together, discover patterns and drive the field forward.
We need your help with this. What other analyses would you like to see? What was going through your mind when reading this report? Is there anything you strongly (dis)agree with? Do you have hypotheses on what is behind some of these numbers? What questions should we ask next year? What benchmarks would be relevant to develop?
Please reach out to rik@awellhealth.com if you'd like to contribute.
We collected demographic and firmographic information from each survey respondent. Categories include years of experience, care delivery model, number of employees and more.
This year we saw a high representation of companies that provide virtual care only (x%). Over x% of respondents work in a clinical operations or clinical role. Additionally, we see a good representation of different levels of experiences.
Respondents largely consist of individuals who work in clinical operations (35%), clinical (21%), product teams (20%) and executives (12%).
Experience level among respondents to this year's survey is distributed. 38% reports having less than 2 years of experience in their current role, 23% reports between 3 and 5 years of experience and 39% have more than 5 years of experience.
Since digital health has boomed over the past two years, it is no surprise that 33% of care organizations are less than two years old. 25% have been providing care between 3-5 years, 15% between 6-10 years, 4% between 11-15 years and 23% are providing care for more than 15 years.
About 42% of organizations provide care only virtually, 33% provide care mostly in person but partially virtual, 22% provide care mostly in person but partly virtual, and 4% provide care completely in person.
45% of respondents work for organizations that provide care to one or a handful of medical conditions, 34% is focused on care across conditions and 21% is focused on both primary and speciality care.
34% of organizations have between 0 - 1,000 monthly active patients (MAPs), 17% between 1,001 - 10,000 MAPs, 16% between 10,001 - 100,000 MAPs and 17% have over 100,000 MAPs. While MAPs is probably a north star metric for all care organizations, funny enough 15% of survey respondents don’t know this number at their organization.
23% of organizations have between 0-10 people that provide care at their organization, 17% between 11-50, 15% between 51-200, 16% between 201-1000, 12% between 1001-5000 and 8% have more than 5000 healthcare professionals in their workforce.
The vast majority of organizations are active in North America (68%) and Europe (17%).
Respondents come from a variety of organization sizes. 11% of respondents are at companies with more than 5,000 employees and 17% are at companies with 1,001 - 5,000 employees. Another 15% of respondents are at organizations with 201 - 1,000 employees. We also saw a fair representation of respondents from organizations with 51 -200 employees at 23%, 11 - 50 employees at 22%, and finally 1 - 10 employees at 12%.
Survey respondents work for a variety of organizations with different business models. 30% has a B2B(2C) revenue model, 18% a DTC or B2C model and 37% sells to insurance / health plans. Interesting to see is that 10% of organizations are moving from DTC to selling into B2B(2C) or insurance / health plans. Adtionally 3% of care organizations did not decide on a revenue model yet.
The State of CareOps Survey 2022 was developed by Awell and Health Tech Nerds in collaboration with operators at leading care providers such as Cityblock Health, Bicycle Health, Recora, Boulder Care, Ophelia and more.
The survey was distributed from July 10 to August 31 2022 via several platforms, including the HealthTechNerds newsletter, LinkedIn, Twitter and personal outreach.
In total 147 professionals involved in clinical operations (clinical operations staff, clinicians, product managers, software engineers…) at virtual-first, traditional and hybrid care providers were surveyed. Given the confidential nature of many questions, we allowed respondents to complete the survey anonymously.
We asked a qualifying question of whether the respondent works at an organization that provides care. Those who answered “no” were excluded from the results for analysis purposes. The remaining total is 111 respondents. When we refer to “all survey respondents” in the analysis, we mean 111.
None of the questions were mandatory which means some respondents didn’t provide an answer to all questions. In the analysis, where relevant we zoom in on the number of people who provided a response to the question. In that case the total number of respondents is made explicit.
Given the channels we used to distribute the survey, the data is skewed towards people active in digital health/health tech and as consequence is not necessarily representative for the healthcare industry as a whole. We anticipate that over the coming years, the number of respondents on the State of CareOps survey will grow and the data will become more representative of the healthcare industry.
This report contains the analysis done at the closure of the survey. CareOps as a field is still young and the team behind the survey and analysis is small. If you have an appetite to dig into the data and help us shape additional insights, that’s possible! We can make the data available to you under an open license. Contact rik@awellhealth.com to find out more.
The State of CareOps 2022 report was made possible with the help of other passionate healthcare innovators. The authors would like to thank all of these people for their input and guidance on the report this year. All acknowledgements are listed alphabetically.
Anna Coffey
Arpan Parikh
Benjamin Lee
Benjamin Schwartz
Carlene MacMillan
Chelsea Karato
Chris Turitzin
Ellen Su
Erica Webb
Jordan Hansen
Josh Heurung
Marin Rothenberg
Mary O’Connor
Molly McGrath
Nimish Parikh
Oliver De Troyer
Ryan Gallagher
Ryan Russell
Additionally we’d like to thank our knowledge partner Health Tech Nerds for this fruitful collaboration.
Thomas Vande Casteele is the Co-Founder & CEO of Awell. Prior to founding Awell in 2018, Thomas was an entrepreneur in e-commerce and digital marketing where he spent 8 years improving customer journeys for companies like Samsung, Audi and Nestlé before becoming obsessed with value-based healthcare principles. He is passionate about how software can help people perform at the very best of their abilities.
Rik Renard is a nurse practitioner turned into a startup operator. He is currently Partnership Lead at Awell. For the past three years, he implemented +25 care flows at +15 care organizations ranging from oncology to musculoskeletal to cardiovascular diseases leading to improved patient outcomes and time gained for care teams. He obtained his M.Sc in Health Care Management and Policy from Ghent University. In addition to his passion for streamlining care processes, he is also a passionate dog lover/owner.
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