We use cookies on this site to improve our service, perform analytics, and remember website preferences. By using this site, you consent to these cookies. For more information visit our Privacy Policy

Integrating heart failure care from hospital to home

HHF collaborated on the design of a service that would enable heart failure patients to self-monitor and connect with their care team virtually, ultimately keeping them out of hospitals. Hundreds of patients have benefited from this service, with measurable improvements in health outcomes and quality of life.


Ted Rogers Centre for Heart Research and Peter Munk Cardiac Centre at UHN

In Collaboration With

The Centre for Digital Therapeutics at UHN


Ethnographic Research, Service Design, UX/UI Design


Heart failure, the inability of the heart to effectively pump blood throughout the body, turns a person’s life upside down. With everyday activities suddenly leaving them out of breath, and a prognosis of often only a few years to live, finding ways to help people live well with their heart failure is critical. In an effort to transform the experience of living with this chronic deteriorating illness, we sought to design a digital tool and accompanying service that would enable people to better manage their disease, to keep connected to their care team, and ultimately to remain out of hospital and in the comfort of their homes.

unnamed image



To ensure that we designed a product and service that put people at the core, we spent time with dozens of people living with heart failure to understand the intricacies of their experiences. While people with heart failure work hard to manage their condition, many find that their health can fluctuate dangerously day-to-day, leading to ER visits and hospital admissions. These fluctuations are the single most common reason for hospital admissions in Canada, so the need to proactively support patients before they need acute care is critical. Our team also spent a week in a busy cardiac clinic to understand the complexities of providing care for this unique group of people. The critical insight that emerged from our discovery was that there was a tension between the patients’ need to be cared for through the ups and downs of their illness, and the constant pressure that care teams were feeling in a clinic that was seeing increasing patient volumes and budgetary constraints.

unnamed image
unnamed image

Building upon this in-depth understanding, we designed a service that enables patients to easily track their daily heart failure-related symptoms, to receive customized advice, and to receive interventions from their clinicians when required. At the heart of this service lies a suite of digital tools, built on a clinical algorithm, that created a seamless and intuitive way for patients to share how they are doing each day and to feel cared for. Wrapped around the digital tools was the design of the Medly service, with custom designed touchpoints, which was critical to ensuring that clinicians were able to easily integrate these new workflows into their busy days.

unnamed image

Patients and the nurse coordinator immediately receive critical alerts. All readings and symptoms are stored for review by the patient, nurse coordinator, and cardiologist.

unnamed image

Patients self report symptoms, and can enter readings manually or with a Bluetooth device

unnamed image
Medly alerts image


To date, this service is being used by over 520 people living with heart failure. Its measured impact has been significant. The service has been shown to stabilize patients’ heart failure, to improve their quality of life, to reduce the number of times they are admitted to hospital, and to shorten their length of stay when they are there.

In 2019, a 6-month pre-post evaluation demonstrated significant improvement for patients’ quality of life, self-care, and heart health, as well as a reduction in the number of hospitalizations.

These outcomes are meaningful, given the shortened life-span and new way of living that people with heart failure must usually adapt to. By staving off physical decline, helping people to live well, and reducing the amount of time they need to spend in hospital, Medly enables them to spend their final months or years in the ways that matter most to them.

View Medly website
  • 50%
    reduction in the number of heart-failure related hospitalizations
  • Increased quality of life
    measured by the MLHF Questionnaire
  • Improved patient self-care
    measured by the SCHF Index
  • 59%
    reduction in BNP values, a biomarker of heart failure instability
View Medly website