Clinicians are trained to use a standard approach to similar clinical problems. When a group of clinicians agrees upon and documents a similar approach, it is called a “clinical pathway”. As the field of evidence-based medicine matures and data collection about quality increases, those who are charged with overseeing quality initiatives and controlling costs naturally push for their development and implementation given the fact that in certain instances, clinical pathways have been proven to control costs and ensure quality.
Although diseases behave in predictable ways, there is often more than one way to approach diagnosis and treatment. Evidence-based medicine is maturing as a field, but good evidence is often lacking to support one single approach to most clinical problems. So, many clinical pathways are based on “guidelines” created from the “consensus opinion” of “expert panels”. This leaves room for individual clinicians to customize their approach to given problems. Ideally, this should then become a “personal clinical pathway” that is consistently followed. Following this standard approach ensures that all critical elements of care are delivered at the right time to all patients. It should be noted that although the primary focus of a clinical path is to improve a clinical outcome, some elements fulfill regulatory requirements, collect data for quality control, improve patient satisfaction/service or are necessary for reimbursement. Standard practice is a requirement of quality assurance (consistent quality) and quality improvement (always get better). You cannot make improvements if the baseline approach is not standardized.
Even when good evidence exists for a best practice, we know that patients don’t always fit those molds and respond differently. Some frontline providers are so consumed with managing these exceptions that they fail to recognize the standard path they typically follow and so reject the notion of “clinical pathways” as cookbook medicine (In actuality all great chefs follow recipes. They use their creativity to develop the recipes.) Encouragement to follow these pathways is seen as an infringement on their autonomy as a physician. They are more likely to identify themselves with the “art” rather than the “science” of medicine. In point of fact, given that this variation in patient response is more often psychological, rather than biological, they fail to realize that there is plenty of room to use their creativity to individualize their care of each patient. The emotional, educational, cultural, and spiritual backgrounds that patients bring to their healthcare experience require individualization. If the standard part of the pathway can be implemented automatically, then that leaves more time for the busy clinician to customize his communication and delivery of care to the individual. This includes having a path or plan for what the patient does when they leave the formal clinical care setting and return to their full lives in the world.
Typical clinical pathways tell the clinician what critical steps they should follow but
don’t always address the issue of getting patients to follow those steps. Keeping patients
on track with their care, a process that often involves changes in lifestyle and behavior is
often neglected, in part because there is even less evidence to support any one
approach. This last mile of care may have the greatest effect on the desired outcomes of care. Communication with the patient is where the “art” of medicine lies and done properly is the key to a good outcome and a satisfying patient experience. Patients need just the right amount of information at the right time in order to trust and understand their diagnosis, follow their treatment plan at home, know how to contact their providers should problems occur, and finally to feel that they have been heard and had all their questions answered. They want to understand what they should expect from the outcome of their care, how much it will cost, the availability of other options and an expected time course of recovery. If they need to change their lifestyle, they want focused, practical advice and coaching.
How does a provider go about creating a personalized clinical pathway?
How can Twistle help the development and implementation of the pathway?