If we were to convene a panel of healthcare experts to choose a goal that holds the promise of being both achievable and influential at improving the value of healthcare, it may very well be the reduction in variation of care. We know from the manufacturing industry and the work of W. Edwards Deming that inherent within variation is a lack of quality, and quality improvement measures have been very successful at reducing variation. Healthcare has gone through several stages in an effort to improve care delivered to patients.
The next logical step was to formalize best available evidence into algorithms for a specific condition, hence the development of clinical guidelines. The algorithm provides the standardization of the process needed to deliver evidence-based care, with action steps and key decision points. While adherence to guidelines has been shown to improve both the outcomes of care and reduce the cost of care,2 there exist many barriers to their implementation. Barriers include abhorrence of 'cookbook medicine' by providers, lack of incentives (financial or administrative) for participating with guideline-based care, misuse of guidelines by insurance carriers to reduce costs and utilization (often without clarifying measure of appropriateness) and an unwillingness of providers to change their behavior, especially as Upton Sinclair suggested, when 'their income is dependent upon their current manner of thinking.' Consequently we have seen limited implementation of guideline based care.3
A clinical care pathway is a change in both the structure and the processes of a guideline. A pathway can be thought of the application of a guideline in the broader context of a healthcare delivery system. The key elements that constitute a clinical care pathway include a specific care algorithm that defines best evidence and patient expectations, enhanced communication (most notably by incorporation of evidence based care into electronic health records), coordination of care (to include multiple disciplines), a classification system, allocation of resources to ensure sustainability, continued monitoring of outcomes (including stakeholder satisfaction) and processes, with focus upon the point of entry of the patient into healthcare system.4 A clinical care pathway puts the patient at the center, builds an evidence-based guideline for care around the patient and only then adds those providers who bring value to the delivery of care. Value is defined as quality outcomes balanced by cost.
While a pathway considers healthcare for a specific condition, a clinical care platform considers 'families of conditions' with a platform of care built around commonalities of this family of conditions. Key elements of a platform include:
A well developed clinical care pathway can serve as a foundation for a platform.
Our current model of healthcare delivery appears to be unsustainable financially. Novel and disruptive approaches to the delivery of care and reimbursement will still need to operate within a broader framework, such as a clinical care pathway or platform. This union has the best chance to bring value to patient care. As noted previously, a process of care built with the patient at the center and only then adding providers who bring value, offers the greatest hope for improving quality while managing costs.
Footnotes:
1 Sackett D. et al. Evidence based medicine: what it is and what it isn’t. BMJ 1996; 312: 71-2.
2 Dagenais S, et al. Synthesis of recommendations for the assessment and management of low back pain from recent clinical practice guidelines. The Spine J 2010; 10: 514-29.
3 Cabana M, et al. Why don’t physicians follow clinical practice guidelines?: a framework for improvement. JAMA 1999; 282(15): 1458-65.
4 Fourney et al. A systematic review of care pathways for lower back pain and introduction of the Saskatchewan spine pathway. Spine 2011; 36(21S): 164-171.
5 Bohmer MJ et al. Care platforms: a basic building block for care delivery. Health Affairs 2008; 27(5): 1336 – 1340.
With 30 years of clinical experience as the co-owner of a 5 doctor practice with 4 locations, Dr. John Ventura's clinical work has also included working with a hospital-based spine center and a multidisciplinary free health center. He served on faculty at University of Rochester School of Medicine, New York Chiropractic College and D’Youville College and has taught numerous post-graduate courses. He has training in Total Quality Management, Lean Six Sigma and has recognition status with National Committee for Quality Assurance in management of back pain. He is a partner in Spine Care Partners, a company which brings value and high return on investment to the establishment of spine centers.
After 28 years in private practice, Dr. Brian Justice changed hats slightly, now working with community health policy and programs. He is now a medical director at Excellus BC/BS in Rochester, N.Y., as well as medical director of Pathway Development and the Spine Program at Lifetime Health Medical Group. Dr. Justice strongly feels that healthcare must adopt clinical pathways that are best evidence and patient focused, while at the same time demonstrating value to the community. He leans heavily on his background in process, community building and clinical knowledge of spine related conditions to help create reproducible models of care.
Shifts in achieving better care
In the field of healthcare we have witnessed a hierarchical shift of methodology to achieve 'better care.' Medical thought was generally driven by anecdote and convention in the early 19th century. By the 1850s, observation as a means to define healthcare took hold, culminating in the more scientific approach of standardized empiricism. In more recent times David Sackett defined evidence-based care as "the conscientious, explicit and judicious use of best evidence in making decisions about the care of individual patients."1 He went on to define evidence-based care as practicing at the intersection of best available evidence, expertise of the provider and values of the patient. While a definite movement in the right direction, this model still lacks any formal methodology for achieving its desired goals.The next logical step was to formalize best available evidence into algorithms for a specific condition, hence the development of clinical guidelines. The algorithm provides the standardization of the process needed to deliver evidence-based care, with action steps and key decision points. While adherence to guidelines has been shown to improve both the outcomes of care and reduce the cost of care,2 there exist many barriers to their implementation. Barriers include abhorrence of 'cookbook medicine' by providers, lack of incentives (financial or administrative) for participating with guideline-based care, misuse of guidelines by insurance carriers to reduce costs and utilization (often without clarifying measure of appropriateness) and an unwillingness of providers to change their behavior, especially as Upton Sinclair suggested, when 'their income is dependent upon their current manner of thinking.' Consequently we have seen limited implementation of guideline based care.3
Clinical guidelines for treating lower back pain
Of note is the condition of lower back pain, with more than 10 formal clinical guidelines from around the world. Yet we have witnessed exponential increases in both the direct and indirect costs of back pain over the past two decades, with tremendous variation in back pain care.A clinical care pathway is a change in both the structure and the processes of a guideline. A pathway can be thought of the application of a guideline in the broader context of a healthcare delivery system. The key elements that constitute a clinical care pathway include a specific care algorithm that defines best evidence and patient expectations, enhanced communication (most notably by incorporation of evidence based care into electronic health records), coordination of care (to include multiple disciplines), a classification system, allocation of resources to ensure sustainability, continued monitoring of outcomes (including stakeholder satisfaction) and processes, with focus upon the point of entry of the patient into healthcare system.4 A clinical care pathway puts the patient at the center, builds an evidence-based guideline for care around the patient and only then adds those providers who bring value to the delivery of care. Value is defined as quality outcomes balanced by cost.
While a pathway considers healthcare for a specific condition, a clinical care platform considers 'families of conditions' with a platform of care built around commonalities of this family of conditions. Key elements of a platform include:
- Categorization into 'families' of conditions, for example, chronic stable disease;
- An integrated process to deliver reliable, low-cost care;
- Identification where exceptions to the process are likely to occur and develop contingencies to deal with them;
- Defined accountability for the patient, provider and for the entity that operates the platform; and
- Care is provided by those who provide the highest quality service, satisfy the requirements of the patient and are least expensive to employ.5
A well developed clinical care pathway can serve as a foundation for a platform.
Our current model of healthcare delivery appears to be unsustainable financially. Novel and disruptive approaches to the delivery of care and reimbursement will still need to operate within a broader framework, such as a clinical care pathway or platform. This union has the best chance to bring value to patient care. As noted previously, a process of care built with the patient at the center and only then adding providers who bring value, offers the greatest hope for improving quality while managing costs.
Footnotes:
1 Sackett D. et al. Evidence based medicine: what it is and what it isn’t. BMJ 1996; 312: 71-2.
2 Dagenais S, et al. Synthesis of recommendations for the assessment and management of low back pain from recent clinical practice guidelines. The Spine J 2010; 10: 514-29.
3 Cabana M, et al. Why don’t physicians follow clinical practice guidelines?: a framework for improvement. JAMA 1999; 282(15): 1458-65.
4 Fourney et al. A systematic review of care pathways for lower back pain and introduction of the Saskatchewan spine pathway. Spine 2011; 36(21S): 164-171.
5 Bohmer MJ et al. Care platforms: a basic building block for care delivery. Health Affairs 2008; 27(5): 1336 – 1340.
With 30 years of clinical experience as the co-owner of a 5 doctor practice with 4 locations, Dr. John Ventura's clinical work has also included working with a hospital-based spine center and a multidisciplinary free health center. He served on faculty at University of Rochester School of Medicine, New York Chiropractic College and D’Youville College and has taught numerous post-graduate courses. He has training in Total Quality Management, Lean Six Sigma and has recognition status with National Committee for Quality Assurance in management of back pain. He is a partner in Spine Care Partners, a company which brings value and high return on investment to the establishment of spine centers.
After 28 years in private practice, Dr. Brian Justice changed hats slightly, now working with community health policy and programs. He is now a medical director at Excellus BC/BS in Rochester, N.Y., as well as medical director of Pathway Development and the Spine Program at Lifetime Health Medical Group. Dr. Justice strongly feels that healthcare must adopt clinical pathways that are best evidence and patient focused, while at the same time demonstrating value to the community. He leans heavily on his background in process, community building and clinical knowledge of spine related conditions to help create reproducible models of care.