Key thoughts:
• Care pathways are used to bring a standard operating procedure to the practice of medicine, and reduce variances of patient care.
• There is no standard for creating pathways, it’s not clear which “best practice” is being applied, and there are limited forums for sharing methods or results.
• The act of putting stakeholders together in the care pathway design and implementation process is as important as the pathway itself, to result in improved patient outcomes.
Variation of care implies deviation from established “best practice,” leads to difficulty measuring landmarks through a patient’s journey, and results in unpredictable patient outcomes. Despite much work and progress with different fields of medicine establishing evidence-based Clinical Practice Guidelines, it’s challenging for physicians to stay up-to-date on the evolving landscape.
Critical pathways were introduced in the 1950’s as a way of securing high engineering tolerance to the production and processes of the Polaris missile, and they were extended to standardized patient care in the 1980’s for visiting nurses. Attempts to drive much of healthcare through care pathways by the National Health Service in Great Britain in the 1990’s were limited by physician coordination and other logistics. We now have a mandated electronic health record as a conduit coordinating physicians in a group, and the computing power to direct and analyze landmarks of care that will make the vision of pathways successful.
While pathways are now routinely used for everything from Enhanced Recovery After colorectal Surgery to process flow in a host of other applications [1], some emerging challenges are coming to light:
1. Although the US government hosted the National Guidelines Clearinghouse as part of the Agency for Healthcare Research and Quality (AHRQ), it was un-funded and soon to be opened on a subscription basis by the ECRI Institute. The subscription status impairs free exchange of information.
2. There are often overlapping Clinical Practice Guidelines (CPG’s) for the same disease, making it difficult to know which best practice is being applied, and under which circumstances.
3. CPG’s are constantly evolving with new science, and pathways need to reflect these ongoing changes.
4. Institutions mostly create their own pathways, with variability between institutions for the same application. While the fundamentals of best practice should be standardized, there does need to be agility create pathways for different situations or populations.
5. There is no public forum to share pathways, their analyses and results. Attempts to publish pathway development in the peer-reviewed literature are limited by lack of scientific rigor. Fortunately Intermountain Healthcare (among others) publishes their Care Process Models online.
6. Integration of pathways within an electronic health record is not always straightforward for the designer or the practicing physician.
7. Clinician engagement and buy-in is critical to compliance and success with pathways, although there is no established formula for their development. You need a pathway for creating pathways.
8. Efficiency is an iterative process that requires continuous monitoring and process improvement, so effective pathways require ongoing investment.
Modern patient care requires complex integration of many professionals, and care pathways have the potential to coordinate our efforts in a scalable way. Finding the time for busy clinicians to meet to develop and monitor care pathways is crucial, but it is as important as the pathway itself. Since pathways are ever evolving, the quest for better outcomes is best summarized by “It’s not the destination. It’s the journey [2].”
[1] Altman KW, Improving health outcomes and value with care pathways: the otolaryngologist's role. Otolaryngol Head Neck Surg. 2014 Oct; 151(4):527-9.
[2] Ralph Waldo Emerson.
This column is part of a series devoted to clarifying and enhancing the physician-health system relationship. Dr. Ken Altman is Chief of Otolaryngology at Baylor St. Luke’s Medical Center in Houston, TX. He is also Secretary/Treasurer-Elect of the American Academy of Otolaryngology – HNS, and past-President of the American Laryngological Association.