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DEVELOPMENT AND IMPLEMENTATION OF CLINICAL PATHWAYS:REDUCING VARIATION TO IMPROVE PATIENT OUTCOMESbyCaitlin ColkittB.A., Economics, Allegheny College, 2011Submitted to the Graduate Faculty ofHealth Policy ManagementGraduate School of Public Health in partial fulfillmentof the requirements for the degree ofMaster of Health AdministrationUniversity of Pittsburgh2016i

UNIVERSITY OF PITTSBURGHGRADUATE SCHOOL OF PUBLIC HEALTHThis essay is submittedbyCaitlin ColkittonApril 27, 2016and approved byEssay Advisor:Mark S. Roberts, MD, MPPProfessor and ChairDepartment of Health Policy and ManagementGraduate School of Public HealthProfessor of MedicineIndustrial Engineering and Clinical and Translational ScienceSchool of MedicineUniversity of PittsburghEssay Reader:Oscar C. Marroquin, MD, FACCVice President, Clinical AnalyticsUPMC Health Services DivisionAssistant Professor of MedicineEpidemiology and Clinical and Translational SciencesSchool of MedicineUniversity of Pittsburghii

Copyright by Caitlin Colkitt2016iii

Mark S. Roberts, MD, MPPDEVELOPMENT AND IMPLEMENTATION OF CLINICAL PATHWAYS:REDUCING VARIATION TO IMPROVE PATIENT OUTCOMESCaitlin Colkitt, MHAUniversity of Pittsburgh, 2016ABSTRACTThere is a wide, unexplained variation in treatment and results for specific medicalconditions. Health systems development clinical pathways to reduce clinical variation, improvequality, which ultimately leads to lower cost of healthcare. Much research has already been doneto determine best practices for developing clinical pathways, but data supporting the trueeffectiveness of clinical pathways on reducing variation to improve patient outcomes byproviding the appropriate care is limited. The development of robust clinical pathway dataanalytics will benefit beyond the health systems and have a public health significance byimproving quality, reducing clinical variation to provide the most appropriate clinical care, andincreasing the understanding and treatment of high-risk disease trends. This paper will focus onthe best practices for developing and implementing clinical pathways, and discuss clinicaloutcome reporting findings and data limitations that should be considered.iv


LIST OF TABLESTable 1. Characteristics of Clinical Pathways Derived from Sentinel Articles . 5vi

LIST OF FIGURESFigure 1. UPMC Pathway Development Process . 7Figure 2. Pathway Utilization, May 2015-December 2015 . 13Figure 3. Stroke Pathway Utilization . 19Figure 4. Acute Pancreatitis Pathway Outcomes . 23vii

1.0INTRODUCTIONAs both private and public efforts to reform the U.S. healthcare system gain momentum, it isclear that innovation must encompass more than just new medical devices or products. Healthcare innovation needs to explore new areas, including value based reimbursement, care modeldesign, data analytics, patient engagement, and provider incentives.Examining clinical variation in medical practice is an important step to measuringefficiency and effectiveness in care delivery. Due to unique patient preferences and care-settingcharacteristics, there will always be a degree of appropriate variation in the practice of medicine,even for patients with the same diagnoses. It is clear, however, that through the use of evidencebased and data-based approaches to clinical decision-making, hospitals and providers across thecountry can do much more to reduce inappropriate or unwarranted variation.1

2.0HEALTH CARE REFORMPresident Obama enacted the Affordable Care in 2010 with the goals of increasing the qualityand affordability of health insurance, lowering the uninsured rate by expanding public andprivate insurance coverage, and reducing the costs of healthcare for individuals and thegovernment. Healthcare spending in the United States has gradually spiraled out of control, andaccounts for 17.5 percent of the gross domestic product (Davis, Stremikis, Squires, & andSchoen, 2014). A 2007 study by the American Journal of Medicine found approximately 62percent of all personal bankruptcies in the United States were related to medical bills. Even morealarming, 78 percent of those involved had health insurance and were bankrupted due to gaps incoverage (co-payments, deductibles, uncovered services, etc.) (Himmelstein, Thorne, Warren, &Woolhandler, 2009).The United States also ranks behind most countries on many measures of healthoutcomes, quality, and efficiency (Davis, Stremikis, Squires, & and Schoen, 2014). Physicians inthe Unites States face particular difficulties receiving timely information, coordinating care, anddealing with administrative hassles. Numerous countries outside of the United States havesucceeded in the adoption of modern health information systems, but U.S. physicians andhospitals are still playing catch-up in many regards as they respond to financial incentives toadopt and make meaningful use of multiple health information technology systems.2

Additional provisions in the Affordable Care Act have encouraged organizations to findinnovative ways to efficiently delivery of health care, as well as investment in importantpreventive and population health measures. As the focus shifts from filling hospital beds andkeeping volumes high to keeping patients healthy and out of the hospital, the culture ofhealthcare delivery will be forced to change in order to meet these new initiatives.As healthcare payers and providers seek to transition to new, value-based paymentmodels, clinical pathways are one strategy used to fulfill the goals of the Affordable Care Actand promote appropriate, evidence-based care.3

3.0CLINICAL PATHWAYSAs the Affordable Care Act continues to gain momentum, health systems are forced to adopt newmodels to provide patients with the highest quality of clinical care. Many health systems areturning to clinical pathways as a way to analyze costs, reduce variation, and improve clinicalquality. However, the basic concept of clinical pathways is not a new phenomenon in healthcaretoday. Clinical Pathways were introduced in the early 1990s in the UK and the USA, butadoption of pathways has increased as the over utilization of low value services has led to highvariation and increased costs. This trend has encouraged healthcare systems to look forinnovative ways to provide high quality, appropriate clinical care to patients in a cost effectiveway (OpenClinical, 2005). Clinical Pathways provide detailed guidance for each stage in themanagement of a patient, such as treatments and interventions, with a specific condition over agiven time period. Additionally, the implementation of the Electronic Medical Record (EMR)has improved the data analytic pathway reporting capabilities.This next section will identify best practices identified through a review of the literature,as well as the current clinical pathway development and implementation process that is used bythe University of Pittsburgh Medical Center (UPMC).4

3.1DEFINITIONThree recent articles provide a strong foundation for the modern perception of Clinical Pathwaysand key points are summarized in Table 1.The following five criteria were derived from these three sentinel articles: (1) theintervention was a structured multidisciplinary plan of care (Campbell HHR, 1998); (2) theintervention was used to channel the translation of guidelines or evidence into local structures(Campbell HHR, 1998); (3) the intervention detailed the steps in a course of treatment or care ina plan, pathway, algorithm, guideline, or protocol (De Bleser, et al., 2006); (4) the interventionhad timeframes or a criteria-based progression (De Bleser, et al., 2006); and (5) the interventionaimed to standardize care for a specific clinical problem, procedure or episode of healthcare in aspecific population (Vanhaecht K, 2006).Table 1. Characteristics of Clinical Pathways Derived from Sentinel Articles(Source: What is a Clinical Pathway? Kinsman, Rotter, James, Snow, & Willis, 2010)The overall purpose of clinical pathways are to improve outcomes by providing a mechanism tocoordinate care, reduce fragmentation, and increase the use of appropriate medical testing,5

medications, and procedures. Clinical Pathways differ from practice guidelines, protocols, andalgorithms as they are utilized by a multidisciplinary team and have a focus on the quality andcoordination of care (OpenClinical, 2005). Reducing the amount of unnecessary, non-valueadding inappropriate clinical care will contribute to the overall cost reduction of healthcare.6

3.2DEVELOPMENTSuccessful development of a new clinical pathway, or adaptation of a currently existing clinicalpathway, requires the formation of a group that will develop, implement and evaluate theproposed Clinical Pathway. Figure 1 illustrates the clinical pathway management workflow atUPMC.Source: UPMC Chief Medical and Scientific Office, 2016Figure 1. UPMC Pathway Development Process7

The Pathway Executive Committee manages all of the clinical pathways for the entiresystem, but anyone (usually physician led) can propose a request for a new clinical pathway.High-volume, problem-prone or high-risk issues serve as the keys to identifying the focus ofneed for clinical pathways. Clinical areas with poor health outcomes and low quality scores mayalso be examined. Similarly, the dynamics of cost and/or physician or payer interest may helpisolate the issue to be addressed. UPMC aims to implement pathways that will improve qualityby providing the appropriate intervention and reducing clinical variation, affect a large numberof patients, which downstream effects should reduce the total cost of care for hospitals andpatients. If the disease specific area falls into one of those three buckets, the pathway will mostlikely be accepted.When forming a Clinical Pathway development group (local pathway ream), it isimportant to think about the various clinical roles that will be affected by the introduction of thepathway. The pathway team usually beings by engaging physicians, but it is important to alsoobtain the perspective and expertise of nurses, pharmacists, therapists, and any other keycomponents of the care team. Each local pathway team will have a slightly different makeup, andit is critical to engage the appropriate people based on the scope of the proposed clinicalpathway.It is important to consider the necessary tasks that the group will need to complete toimplement the pathway and all of the skills required for the project such as data collection,outcome analysis, training, and continuous education. For example, the local pathway team for aUPMC Foot and Ankle surgery pathway will have a different composition than the Acute KidneyInfection (AKI) pathway team. Due to the surgical nature, the first step in identifying thepathway focus started with the surgical supply cost. The financial analyst pulled the supply costs8

for employed and non-employed physicians that performed surgery at a UPMC hospital. Thiscreated the starting point for discussion when the pathway team was trying to determine theappropriate coding, supply use, and clinical procedures. In contrast, the AKI pathway team atwas comprised solely of employed physicians within the department of Renal-Nephrology. Theobjective of the AKI pathway was to determine the appropriate criteria for recognizing anddiagnosing AKI since creatinine ratios is a highly disputed topic between nephrologists. For thescope of this pathway, there was no need to include a financial analyst on the AKI local pathwayteam.In addition to determining whether to include data and financial analysts in the pathwayteam, equal consideration should be given to the inclusion of certain physicians andadministrators within the care spectrum. In a health system as large as UPMC, local pathwayteams should aim to obtain buy-in from colleagues from the urban academic setting, communitysetting, and even some key private physician groups that have a strong presence in a UPMCfacility. It is important to closely examine the areas within the care continuum that the proposedpathway may affect. Some clinical pathways may span more than one disease area or specialty.The local pathway team should always try to engage physicians and where appropriate, some keyadministrators, to represent each clinical area within the pathway to ensure buy-in.3.3IMPLEMENTATIONComputerized physician order entry (CPOE) is defined by the Healthcare Information andManagement Systems Society (HIMSS) dictionary as an "order entry application specificallydesigned to assist clinical practitioners in creating and managing medical orders for patient9

servicesandmedications"(HIMSS,2010).TheCPOEisan electronicmedicalrecord technology that allows physicians to enter orders, medications, or procedures directly intothe computer instead of handwriting them (HIMSS, 2010). Traditionally, physicians would enterorders, medications, and procedures by writing them on a piece of paper, however manyinstitutions have switched to the electronic medical record started to enter these orders throughthe use of an “order set”. An order set is a group of related orders, and can be general or diseasespecific. One of the benefits to using an order set is that it allows users to issue “prepackagedgroups of orders that apply to a specified diagnosis or a particular period of time,” whichultimately reduces the time that the physician spends finding and entering the specified orders(Franklin, 1998).UPMC uses the CPOE in Cerner in all of its inpatient facilities, and each inpatientclinical pathway algorithm developed at UPMC is turned into a PowerPlan. A PowerPlan is verysimilar to an order set, and can include multiple phases. Some of the key benefits of PowerPlanusage include improved care quality and patient safety through interdisciplinary planning by useof a phased approach to patient care based on organizational standards (Cerner, 2014).It is important to establish a timeframe for implementation with the intent that thepathway team meets frequently during the initial months to allow for feedback and discussion.Before the pathway can be rolled out to all sites, an initial pilot site should be determined for thefirst round of “go-live”. Once the local pathway team has developed the clinical content, thepathway algorithm is integrated into Cerner and turned into a PowerPlan. Training sessions areheld at each site before go-live to ensure that all end-users are aware of the pathway are educatedon the benefits and technical components of using the pathway and accessing the PowerPlan.10

3.3.1 Barriers and Facilitators to ImplementationSome physicians have embraced the use of clinical pathways, while others have resisted. One ofthe most common responses from physicians when asked about their resistance to clinicalpathways say it's too much of a “cookie-cutter approach” to practicing medicine (Gisme &Wiseman. 2011). In a 2011 Journal of Oncology Practice article, Dr. Bruce A. Feinberg, VicePresident and Chief Medical Officer of P4 Healthcare, quoted:“I always derived my greatest satisfaction from making the diagnosis, managing toxicity,and managing patient care throughout the process. That's where the art of medicine is—not in selecting which three-drug combination I'm going to prescribe” (Gisme &Wiseman. 2011).A survey of thirty-two UPMC physicians in 2014 revealed that the top three most significantbarriers to successful implantation of clinical pathways were engagement of providers,integrating the pathway into the workflow and care of the patient, and resistance to changingclinical practice. Although the local pathway teams are predominately physician led, it is criticalto engage providers and obtain input from physicians at all sites and not just ones within theacademic medicine setting. It is extremely common for variation of clinical practice to occurbetween physician groups in addition to urban and community hospital setting. Furthermore,many physicians create their own customized order sets and pick and choose the orders theyneed for treating a patient. It was reported that the layout and location of the PowerPlan was notconducive to their workflow. The purpose of a clinical pathway and PowerPlan is to streamlinethe process for treating disease specific conditions, but lack of provider PowerPlan training andeducation make some physicians revert back to using order sets because they feel more11

comfortable and can access more quickly. The most important factor identified as integral toadherence and successful implementation was leadership from the Chair/Departmental level.When asked their opinions and suggestions for accelerating physician led developmentsof pathways across all major disease and procedure areas, many physicians said that there neededto be a change in the compensation model. Consequently, the data shows that the pathways thatare tied to compensation have the highest utilization. Total Joint Replacement and Spine FusionSurgery pathways have two of the highest utilization levels, and both are tied to bundledpayments and shared savings programs. The UPMC Department of Surgery has already started toinclude pathway utilization in physician incentive plans, and effects of this inclusion can be seenin Figure 2.12

Source: UPMC Chief Medical and Scientific Office, 2016Figure 2. Pathway Utilization, May 2015-December 201513

3.4INPATIENT PATHWAY UTILIZATIONInpatient pathway utilization is calculated by the total number of times the physicianappropriately initiated the PowerPlan for a patient, divided by the total number of patients withinthat population in which the PowerPlan should have been initiated. For example, if a patientpresents to the hospital with COPD, the attending physician should initiate the COPD PowerPlanon that patient. If the physician sees

Successful development of a new clinical pathway, or adaptation of a currently existing clinical pathway, requires the formation of a group that will develop, implement and evaluate the proposed Clinical Pathway. Figure 1 illustrates the clinical pathway management workflow at UPM

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