A major advantage of the pathway view of healthcare is that it allows us to compare the actual of process of treatment with agreed protocols. A protocol represents a consensus view among experts on the most appropriate way of treating a particular condition.
Although such consensus often exists, it’s striking how frequently what actually happens differs substantially from accepted best practice. Sometimes it’s for good reasons associated with the particular case, but often it’s simply a failure to stick to guidelines with the result that care falls short of the highest standards. Oddly, poor care may often be more expensive too, since additional work is needed to correct what could have been done right in the first place. So there’s a double reason for trying to eliminate this kind of variation.
Unfortunately, today’s hospital information systems generally find it difficult to support pathway analysis and comparisons with protocols. This is partly because the information needs to be brought in from multiple sources and then integrated, which may seem dauntingly difficult. However, there is actually a great deal that can be done with relatively simply data. There’s a lot to be said for not being put off by the difficulty of doing a fully comprehensive job, when one can start with something more limited now and add to it later.
Take the example of cataract treatment in a hospital that has decided to follow the guidelines of the NHS version of the Map of Medicine. The Map suggests the preferred procedure is phacemulsification. Routine cases have day surgery with a follow-up phone call within 24 hours and possibly an outpatient review after a week. This allows us to build a pathway for routine cases entirely from PAS data or at worst PAS and other Contacts data.
Map of medicine suggests non-routine cases occur where there is a particular risk of complications, the patient only has one eye or the patient is suffering from dementia or learning difficulties. In these instances, we would expect daily home visits in the first week and certainly an outpatient attendance for review within one to four weeks of discharge.
So here’s a second pathway structure:
Again, information about home visits might be in the PAS or might have to be added. We also need to check on diagnosis information from the PAS for dementia or learning difficults.
The two pathway structures shown above correspond to the two protocols. So now we can compare them with similar pathways built for real patients in the hospital. The aim is to limit the number of cases that we investigate further to only those that differ significantly from the guidelines.
So any cases where the pathway is the same as for routine cases can be ignored.
Any cases where the pathway is the same as for non-routine cases can be ignored as long as there is evidence of dementia or of learning difficulties, or the patient had a single eye or there was a serious risk of complications. It's possible that the last two pieces of information aren't routinely collected, in which case we shall find ourselves investigating some cases that didn't need it until we can start to collect them.
Overall what this approach means is that we can eliminate a lot of cases from examination and concentrate management attention on only those where there may be a real anomaly, and action could lead to an improvement in the future. That has to be a huge step forward over what most hospitals can do today. Yet it involves relatively straightforward work on information systems.
Adding other data could improve the analysis. Information from a theatre system would tell us about, say, how long the operation takes. If patient-level information about medication is available, it can be linked in to check that appropriate drugs are being administered at the right times.
In the meantime though, we would be working with a system that should be relatively easy to implement and can help us make sure patients are being treated both effectively and cost-effectively.
That sounds like a something it would be good to do, given today's pressure to deliver more while costing less.
Most of the information to check on compliance will be in hospital Patient Administration Systems (PAS).
The PAS records procedures so we can check whether phacoemulsification was used or not. In some acute hospitals, the PAS may not record non face-to-face contacts, which would cover the telephone follow-up, but the information is certainly held somewhere and it should not be insuperably difficult to link it with PAS data. All these data items have dates associated with them, so we can apply rules to check that the right actions were taken at the appropriate time.
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