Clinical pathways: A special report

Clinical pathways set to experience technological rebirth’

Some hospitals at the beginning stage of automation

The age of computers has changed health care in many ways, and acute-care case management is no exception. Clinical pathways — also known as case management plans, care maps, action plans, or any number of other titles — are beginning to undergo a technological rebirth, in the form of automation. It makes sense: The hospital is crawling with computers these days, for Outcome and Assessment Information Set (OASIS) data collection and medical charting. Why shouldn’t case management and pathway care get in on the deal?

At present, larger health care institutions, such as New York University (NYU) Medical Center in New York City, are really the only ones to have begun using automated systems. Smaller hospitals might not be ready for the technology, according to experts. In fact, some larger hospitals, too, are only equipped for the early stages. "We’ve started the process," says Leslie Shain, RN, CCRN, MA, nurse case manager for congestive heart failure at NYU. "We’re still trying to get it up on our hospital information system."

NYU began automating in its surgery department, and case managers report that it’s going very well. "It’s called CareMinder, and it takes you through order sets," explains Shain. Based on the written pathways that the hospital had used for years, and set up with the help of nurse specialists working in information systems, the automated pathway takes physicians or case managers through patient care, step by step, using different screens on the computer. "It kind of flows along; you hit one thing, and it triggers you to the next thing. There is the option to go out [of the pathway’s guidelines] if you have someone who deviates a little from the pathway," she explains. Health care professionals can order lab tests or antibiotics directly on the computer with one click of a mouse or penlight.

Shain hopes that automation will filter through to all departments in the hospital. "I think it’s going to work better because you won’t really have a choice. Hopefully, it will be triggered by the emergency room doctors . . . and it will come up as order sets that they have to choose from. So it almost forces them to put the patient on a pathway and enter all the appropriate orders," she says.

"Right now, [the pathway] is a piece of paper on the chart, and most people don’t look at it. The treatment protocol is pretty straightforward, so for the most part, people are getting the treatment they should be getting." But automation will help because, Shain notes, nurses will have to chart against it, "whereas on a piece of paper, it’s not a charting tool. It doesn’t occur to them to check off or initial the outcomes that have been met."

Emory University Hospitals in Atlanta also has begun the automation of care pathways, notes Rosalie Przykucki, RN, MSN, coordinator of clinical performance improvement. One side benefit of the Emtek system, currently in place only on Emory’s intensive care units (ICUs), is that it has some graphing capabilities. "Some of the physicians want to see trends, like What’s his temperature been for the last 24 hours,’ and it actually builds a graph for you," she adds.

"I wish ours were completely automated, but they’re not," she says. Instead, Emory has been busy structuring its paper pathways to be the same at both Emory University Hospital and Crawford Long Hospital — the result of the merger of the two Atlanta facilities.

That’s probably going to be a common obstacle to automation, Przykucki says, with all the mergers going on around the nation. "I think a big thing is software compatibility between institutions, or even within the institution." Of course, Health Insurance Portability and Accountability Act (HIPAA) rules also will govern the technology as it develops further in that direction.

Working out the bugs

Currently, when a patient leaves the Emory ICU, all the pathway information is downloaded and printed onto a readable chart copy, which will then follow the patient. "It kind of truncates the system a little bit, because there are components we didn’t purchase that might have made it available to some of the [other] units," Przykucki notes.

Other problems include the constant struggle of getting physician support for case management-developed pathways, according to both Przykucki and Shain.

One of the physicians who has reviewed Shain’s automated heart failure pathway is concerned about it being a little too restrictive, "which it really isn’t," she says. "What we’re putting in is really basic stuff that relates to heart failure. There are those who may not agree with every single order that we like to enter."

Barbara Delmore, RN, a nurse case manager on the NYU surgery unit, says that using the automated system is great, unless there’s no buy-in. "We find that it works very well when the attending surgeon is behind it and monitors its use to some degree . . . [but] if there is not buy-in or monitoring of the system by a champion,’ then it’s an uphill struggle."

Perhaps the automatic aspect of the new technology gives doctors even more reason than usual to call it "cookbook medicine": the automation or computerization of anything can make it seem less personal, less tangible, and more remote. In this case, physicians might feel removed from the individual patient.

In fact, the opposite is true; having pathways on the computer makes it much easier to change and modify them to fit individual patients’ needs. Przykucki notes, in addition, that more physicians are buying into the pathway process through this technology. "I think as more and more physicians go through their medical training, they’re going to find that this is a tool that really helps them, just as the Merck manual did in the ’60s and 70s."

One other glitch, of course, is the threat of system errors or technical difficulties. Delmore says her unit uses both automated and paper pathways, and always keeps order sets available in case CareMinder undergoes any technical problems. "Even though a pathway is on CareMinder, there is always a paper version," she says. The paper versions still get filed in the patient’s chart for staff reference.

Getting really technical

The real state of the art, according to case management experts, is when the automated pathways and order sets become electronically linked to outcomes. "Everybody would love that," Przykucki says, "because right now what we get are the pink sheets.’ They’re the outcomes reports, still pen and paper, probably the same information that’s [in the computer]. I end up having to input all that data and then send them back a report. If I could get into Emtek and everything were all linked, it would be a two-second project, rather than a day and a half."

Unfortunately in this day and age, she continues, health systems must consider the costs of implementing new software programs. "You have to count every dollar and cent. Is it worth it? Is it going to be outdated tomorrow? Especially in the age of HIPAA requirements, you’ve got to have something that’s not going to go away."

The next thing Przykucki says she would like to see is physician order entry, where the doctors can order lab tests and antibiotics with their personal digital assistants (PDAs). "These palm devices . . . they can carry [them] around from patient to patient, and basically have all the patient information right at hand," she says. Many physicians use them already for reference materials, taking notes, and access to e-mail.

At Cedars-Sinai Health System in Los Angeles, palm devices are used for remote access to lab results, imaging reports, surgical reports, consults, emergency room records, and some ICU data, according to Ray Duncan, MD, director of technology and architecture for Enterprise Information Systems. "We don’t have any policies, pathways, or guidelines available via the palm at this point. That is all available on our intranet, but we haven’t had any requests to format it and make it available on the palms. Since there are PCs everywhere throughout our patient care areas, people tend to use the PCs and a Web browser if they are here on campus, and that is the only time they have much need for access to pathways and guidelines," he says. But Cedars-Sinai is building a physician order entry system right now, "for planned go-live at the end of this year. Eventually we hope to make this capability available via PDAs," he adds.

Przykucki says, "I think that [PDA technology] will work its way into case management, too. The nursing CMs will have to have something equivalent, because they’re carrying as high a caseload as any of these physicians," she says. "But that’s on my wish list, and Santa Claus hasn’t delivered yet."

[For more information, contact:

Barbara Delmore, RN, Nurse Case Manager, New York University Medical Center, 560 First Ave., New York, NY 10016. Telephone: (212) 263-7946.

Ray Duncan, MD, Director, Technology and Architecture Enterprise Information Services, Cedars-Sinai Medical Center, 8700 Beverly Blvd., SSB-335, Los Angeles, CA 90048. Telephone: (310) 423-6415.

Rosalie Przykucki, RN, MSN, Coordinator of Clinical Performance Improvement, Emory University Hospitals, 1364 Clifton Road, F-225, Atlanta, GA 30322. Telephone: (404) 712-4665.

Leslie Shain, RN, CCRN, MA, Nurse Case Manager, New York University Medical Center, 560 First Ave., New York, NY 10016. Telephone: (212) 263-0493.]