Judy Ozbolt is project director for PathworX implementation, scheduled for completion by the end of next year. (photo by Dana Johnson)
PathworX: A new tool for clinical improvement
Health care appears to be moving in the direction of reducing unwanted variability in patient care delivery through greater use of evidence based practice guidelines. A new network computer application developed at Vanderbilt, called PathworX, is helping VUH clinical teams do just that.
Over the past decade, clinical pathways have become a key outcomes improvement strategy of many VUH patient care teams. PathworX casts clinical pathways onto the network of clinical workstations located throughout the hospital and clinic. Automation makes the pathway process more powerful and efficient.
A Vanderbilt clinical pathway is a concise multidisciplinary plan of care for a given patient group, usually defined by diagnosis or major surgical procedure. The team reviews the literature and forges consensus on best practice, and the resulting pathway document helps the team apply this agreement in daily practice and gather data for ongoing evaluation and improvement of care.
“Variability is the enemy of quality and cost effective care,” said Dr. Harry Jacobson, vice chancellor for Health Affairs. As an example, he points to a well-known cardiological consensus on preventing a second heart attack. There’s clear evidence that risk of a second heart attack is reduced by more than half by checking the patient’s blood lipid levels and treating any abnormality, placing the patient on a daily baby aspirin and an ACE inhibitor (drugs that increase the supply of blood and oxygen to the heart), and smoking cessation counseling. The recommendation is that these measures be put in motion by the time of discharge. “In some places the appropriate protocol is followed 80 percent of the time, while in other places it’s used in less than 20 percent of cases.
“There are two unacceptable results from this sort of variability: quality issues and higher cost,” Jacobson said. Evidence shows that unwanted variability begins with differences in physician training. The solution, said Jacobson, is twofold: make evidence based clinical protocols a larger part of physician education and training; and give clinicians easy access to guidelines in their daily clinical setting.
“For many patient problems, more research is needed to establish evidence based guidelines. But there’s no reason to delay in using the known guidelines.,” Jacobson added.
The pathway itself is a one- to four-page guide specifying goals, treatments and procedures, lab tests, drugs, diet, nursing assessments and so on, all on a time line, with patients advancing from one phase of care to the next according to whether the goals are met.
“The pathway isn’t meant to be cookbook medicine,” notes Dr. James O’Neill, Jr., John Clinton Foshee Distinguished Chair in Surgery. The pathway document comprises the recommended practice for plain vanilla patients; the less typical the patient, the greater the likelihood that practice will need to vary from the course outlined on the pathway.
Important supplemental products of the Vanderbilt pathway process include electronic pick lists of patient tests, medication, etc., for use in the automated order entry system WizOrder, and pathway-specific tools used by nurses for patient care documentation, patient teaching and discharge planning.
Daily use of PathworX
As the patient is admitted to the hospital unit, PathworX downloads patient information collected in the admitting office on the Medipac system. With mouse and keyboard, the nurse or case manager places the new patient on a pathway and makes any changes necessary to accommodate individual patient needs or abilities. The nurse prints the customized, pathway-based nursing flow sheet for documenting the initial phase of care. Every night, a nurse uses PathworX to record whether each of the day’s clinical goals were met and prints out the next day’s individualized patient care documentation forms.
When patient orders vary from the pathway, the idea is that nurses will follow up with the physician to ensure that the variance is intentional. Again, because not all patients with a given diagnosis are alike, the PathworX user at any point can customize the pathway to reflect individual patient needs.
By requiring the user to indicate whether daily clinical goals are met, and to note the cause of unmet goals, the system provides a new level of automated data for ongoing evaluation of practice.
Technical development of PathworX was led by Jeff Byrd, a systems engineer with information management, Grace Brennan, an information systems consultant in information management, and Irene Hatcher, a coordinator of clinical pathways and case management development. Judy Ozbolt, professor of Nursing and Biomedical Informatics, is project director for PathworX implementation.
Patient care documentation
and evaluation
Beyond its pivotal role in the management and evaluation of care, PathworX has the added benefit of making patient care documentation quicker and more complete. For an average length stay in VUH, PathworX cuts the number of pages used for nursing documentation by more than 40 percent. It gives nurses more time at the bedside by reducing the time needed for patient care documentation.
For each pathway goal, PathworX will produce data on goal achievement and the causes of unmet goals. Pathway goals for the various phases of care range from patient flow targets such as “start operation within two hours of admission,” to clinical factors such as pain management and lab test values. The idea is for clinical teams to first identify poorly performing pathways — by excessive length of stay, cost, morbidity and mortality — and then use goal variance data from PathworX to identify opportunities for process improvement.
“Because goals are tied to specific clinical processes, the feedback from PathworX is more sensitive than morbidity and mortality data,” Ozbolt said. “Patterns of unmet goals indicate where to look for improvement opportunities.”
New pathways needed
to feed PathworX
With the coming of PathworX, case managers will help patient care teams create an unprecedented proliferation of clinical pathways. The goal within each hospital unit is to create enough diagnosis/procedure specific pathways to cover 80 percent of patient days. Generic, comparatively blank pathways will be used for patients with undetermined diagnoses or exceptionally complex problems for which a specific pathway would be impracticable.
“First with WizOrder and now with PathworX, Vanderbilt is moving ahead of most everybody else in using information technology in the clinical setting to manage variability,” Jacobson said. “Our clinical department chairs are very active and positive on this score. The Vanderbilt faculty are well prepared and accepting of moving in this direction.”
When attending physicians become pathway advocates, the road to effective use of pathways becomes that much smoother. At Vanderbilt, there are several well documented examples of the effectiveness of clinical pathways in helping to improve quality and lower cost. However, the clinical pathway process is more amenable to some patient groups than to others. Today, there are parts of the hospital that use very few pathways and most outpatient areas don’t use any pathways.
“Pathways have potential to upgrade our performance,” O’Neill said. “It’s the job of physicians to verify and refine each pathway. Opting out is not an option. You can’t be too busy for the fundamentally most important things.”
Implementation of PathworX is expected to be complete across all units of VUH by the end of next year. There is no schedule yet for implementation in the clinic.