Wright Pinson, M.D.
VUMC rolls out evidence-based care initiative
Vanderbilt University Medical Center is moving evidence-based medicine to the front burner, setting out a strategy to help doctors and clinical teams routinely apply more evidence-based clinical guidelines.
Evidence-based medicine seeks to align the care of individual patients with the best scientific and medical evidence available. It's a deceptively simple concept that so far has eluded large-scale, mainstream application.
Clinical pathways are tools already familiar to many VUMC patient care groups. They are team-written documents setting out a standardized plan of care for a given diagnosis or patient procedure. The pathway includes goals for each phase of care, medications, diet, patient teaching, equipment, discharge planning and so on. The first VUMC clinical pathways went into use in 1990 and today reliance on pathways varies greatly across the Medical Center.
“The big prize in health care is to rid the system of unwanted variability, improving the quality and safety of care while lowering cost,” said Harry R. Jacobson, M.D., vice chancellor for Health Affairs. “Our evidence-based pathways initiative can help achieve that. It's designed to help teams review the available evidence and reach consensus about the best way to care for patients, translate that into guidelines for day-to-day practice, and continuously evaluate the effects on quality and cost.”
According to Chief Medical Officer C. Wright Pinson, M.D., this new pathways initiative will use a more consistently rigorous approach to evidence and will bring more centralized resources to bear on helping teams develop and apply pathways.
“We have embraced evidence-based pathways and order sets that produce performance metrics and closed-loop feedback as one of the central strategic initiatives of the Medical Center,” Pinson said. Besides supporting quality and efficiency, he said guidelines and standardization help to lower opportunities for medical error.
“Well formulated pathways also serve as an excellent educational tool and the underlying framework serves as a tool for clinical research.”
The goal is about 50 pathways within the first year. Criteria are under development to help select the next VUMC clinical pathways to work on.
“I think we're on the verge of taking pathways to the next level, with tremendous high-level support and new resources,” said VUMC clinical pathways veteran Karen N. Robinson, a coordinator of case management practices with the Office of Case Management.
The Informatics Center will assist with information systems support for pathway application and evaluation. Librarians from Eskind Biomedical Library will help teams gather evidence. As always, Vanderbilt case managers — “pathway movers and groovers,” as one leader calls them — will facilitate pathway writing and implementation. Experts from the Center for Clinical Improvement and the Center for Evidence-based Medicine will help teams develop methods for ongoing evaluation of pathways.
“All our efforts will be concerned with replacing tradition, opinion and habit with evidence,” said Assistant Chief Medical Officer William J. Anderson, M.D., who heads the Pathways Integration Team, the group that will coordinate the pathways initiative. The team reports to the Clinical Cost Effectiveness Committee, which is led by Pinson and Vanderbilt University Hospital Chief of Staff Allen B. Kaiser, M.D.
A few Vanderbilt clinical services already swear by their pathways. Nearly all VUMC urologic surgery patients are admitted on one pathway or another, said Roxelyn G. Baumgartner, a nurse practitioner with the Department of Urologic Surgery.
“Soon we'll have enough data to answer whether the newer, robotic method for prostetectomy improves the patient's chances of regaining erectile function and urinary control,” Baumgartner said. This type of outcomes data will define the evidence-based medicine pathways initiative, leaders say.
“The ultimate objective is that evidence be consistently applied at the point of care using our order entry and medical records systems to improve adherence,” said Paul H. Keckley, Ph.D., executive director of the Vanderbilt Center for Evidence-based Medicine. Keckley said major studies show that adherence to evidence-based guidelines lowers costs 10 percent to 30 percent while improving clinical outcomes.
Anderson sees a “perfect storm” brewing that will force the issue of evidence-based medicine and, not incidentally, help to sweep in more routine use of clinical pathways at Vanderbilt.
“There was a time when idiosyncratic treatment was tolerated, but not any longer,” Anderson said. “Today, when a doctor's individual opinion flies in the face of the known medical evidence, it's not acceptable to clinician peers, payors or patients.”
Medicare and other payors have begun in a small way to base reimbursement on adherence to guidelines. Anderson said that trend will grow, and proven adherence to guidelines will increasingly be required for favorable external review by groups that publish hospital reports for health care consumers.
The performance measures used to evaluate VUMC clinical pathways will address not only the effectiveness of the individual pathway but also house-wide and external reviews of clinical effectiveness, Anderson said.
John M. Starmer, M.D., assistant professor of Biomedical Informatics and a member of the Pathway Integration Team, said pathway evaluation is apt to begin with data on care processes known to support quality outcomes, rather than with the outcomes themselves.
It will become easier to monitor actual outcomes as pathways and data gathering eventually expand to include the outpatient phase of care, Starmer said.
Vanderbilt nurses already use pathways to coordinate care and streamline documentation; an automated pathways system, PathworX, is in use in several hospital units, and on other units paper pathways are used.
Anderson said pathway teams will first bring into agreement the order sets used in the hospital's computerized order entry system, WizOrder, with the paper and electronic pathways used by nurses and the rest of the patient care team.
Anderson and Starmer foresee the eventual integration of the order entry system with the pathways system. In the meantime, Starmer said, the admitting screens in WizOrder can be used to help steer clinicians to make more use of order sets, and WizOrder discharge screens can be used to help gather information for pathway evaluation.
PathworX furnishes data on care processes and pathway goal achievement; Starmer said this information can be made to appear in the current meds and results sheet, an important summary of the care of the individual patient printed from WizOrder and used in rounds.
Within five years VUMC may be in a position to begin advancing beyond clinical pathways to personalized medicine, Starmer said.
By then, using techniques such as pattern recognition, statistical analysis and machine learning, VUMC information systems may be able to view each new patient against the broad history of practice and outcomes of all other patients in the system, giving clinicians something wholly new: sturdy, immediate comparisons of the likely benefits of each treatment option in each patient's case.