In health care as in sports, consistency is key

Sept. 26, 2017
Headshot of patient, Stephen Lee, who has sickle cell disease
Stephen Lee, who has sickle cell disease, is among the many patients who have gained from the care pathways program.

Consistency is the font of excellence. Great hitters make solid contact all season long. Great quarterbacks make plays regardless of who happens to be across the line of scrimmage. Great golfers never duff; great tennis players commit precious few unforced errors.

It’s the same in health care, where consistency gets less fan appreciation but can be a matter of life and death.

Achieving consistency in a hospital or clinic is simple enough in theory. You figure out the very best approach, based on the very latest medical science, to treating a particular health issue – a broken leg, a splitting headache, a tumor, heart failure, pneumonia, you name it – and then you have doctors, nurses and other caregivers hew closely to that ideal care pathway, diverging only when merited by the special needs of a patient.

UCHealth University of Colorado Hospital Emergency Department has spent thousands of hours developing formal care pathways. While that may not be something patients (much less sports fans) pay much attention to, those pathways are making a big difference for people in Colorado and beyond.

Portrait of Dr. Richard Zane
Dr. Richard Zane is UCHealth’s chief innovation officer.

Follow the path

UCHealth has established dozens of thoroughly vetted, best-practice care pathways, and with help from development partner AgileMD, has embedded them into UCHealth’s Epic electronic health record – a first. All 28 UCHealth Emergency Departments now use the pathways and other services have joined in: cancer care, cardiothoracic surgery, nursing, and hospital medicine are among the growing list. Other hospital systems have licensed the AgileMD software and its pathways, too, including Scripps Health in San Diego, Johns Hopkins in Maryland, and the University of Chicago, among others.

Why would highly trained medical providers from some of the world’s top health care institutions need vetted pathways to help ensure optimized care?

Headshot of Dr. Jennifer Wiler
Dr. Jennifer Wiler

“There’s no way any physician can keep up with the best evidence,” said Dr. Jennifer Wiler, executive vice chair of Emergency Department Programs at the University of Colorado School of Medicine, who helped launch the pathways program. “In a concise way, it allows physicians to always do the right thing for patients with a specific condition, and it helps coordinate care.”

They’re on it

Stephen Lee, 28, of Aurora, is a patient who has quietly benefitted. Lee has sickle cell disease, which in addition to anemia brings incapacitating bouts of pain due to clotting. The pain leads him to the UCHealth University of Colorado Hospital (UCH) ED. Wiler and others worked with Dr. Kathryn Hassell, a University of Colorado School of Medicine blood expert and the region’s top sickle cell specialist, to develop a care pathway for patients like Lee.

“In the ED, they’ll get you in there, get you your meds, get you in a room,” Lee said. “They stay checking on you. If you can eat, there’s a diet plan. They’re on it – they really are.”

Sickle cell is one of hundreds of conditions an ED physician might encounter. Given the evolving nature of best-practice care (new drugs, new surgical approaches, new therapies), it’s not easy for a doctor to be on it – much less all doctors to be on the same, optimal page. In fact, data show that, without some help, there’s a 50-50 chance that a given doctor won’t follow best-practice guidelines, said Dr. Richard Zane, the CU School of Medicine’s Emergency Department chair and UCHealth’s chief innovation officer.

“The guidelines are associated with improved outcomes or more efficient outcomes,” Zane said. “So from a patient’s perspective, there’s a smaller chance for error and a larger chance for better outcomes – and a much smaller chance for waste.”

First, imaging

Headshot of Dr. Kelly Bookman
Dr. Kelly Bookman

What became the care pathways effort has its origins with the move to the new, expanded UCH ED in 2013. Zane, Wiler and colleagues were looking to streamline care, and formal best-practice pathways were among several avenues pursued. To test their ideas, they created a decision support tool for ED doctors considering whether to do high-cost CT scans for patients with head and neck injuries as well as for patients with pulmonary embolism (a blood clot in the lung). The study, published in July, considered 235,858 patients treated.

It found that doctors who tended to order more high-cost imaging studies prior to using the pathway ordered fewer; those who tended to order fewer imaging studies ordered more; and those who ordered an average number of studies ordered about the same. While the total number of scans fell by 6,106, the key insight was that the pathway helped doctors provide more consistent care.

“So it’s pretty cool, and what’s interesting is this was a clunky first version,” said Dr. Kelly Bookman, the medical director of the Department of Emergency Medicine and the lead author of the study. “By partnering with AgileMD, we’ve gotten much more sophisticated by embedding entire pathways into the provider workflow as opposed to simple decision support tools.”

Faster, easier, better

If, for example, a patient arrives at a UCHealth ED with chest pain, doctors, nurses and others can work through the entire case using best practices established with UCHealth cardiologists and integrated into Epic via AgileMD. The patient’s status determines risk scores, which trigger different care pathways – from rushing to an operating room to letting the patient head back home knowing their heart’s doing just fine. Providers can place lab orders, imaging orders, consult orders, admission orders, prescription orders and anything else they might typically do, all as part of the pathway, and the buttons in AgileMD can trigger automatic notes in the patient record as they move along.

“Front-line docs want to get faster and make everything easier” as they make the right calls for patients, Bookman said. At the same time, hospital leaders “get to drive standardized care, which is what we want to do from a quality and safety perspective.”

The care pathways effort has continued under the auspices of the UCHealth CARE Innovation Center, cofounded by Zane and Wiler, who serves as its executive director. Among the 72 pathways established so far include ones for conditions as diverse as alcohol withdrawal, asthma, lower back pain, cellulitis, frostbite, hip fracture, headache, opioid overdose, rib fracture, sepsis, stroke, and vertigo. As new services join the effort (cardiology and primary care are coming soon, Zane said), the number of pathways will only grow, as will the integration of pathways across specialties, clinics and hospital units.

“I think this is the way of the future,” Bookman said. “I think that using pathways to drive care across the entire continuum of health care delivery is where it’s all going.”

About the author

Todd Neff has written hundreds of stories for University of Colorado Hospital and UCHealth. He covered science and the environment for the Daily Camera in Boulder, Colorado, and has taught narrative nonfiction at the University of Colorado, where he was a Ted Scripps Fellowship recipient in Environmental Journalism. He is author of “A Beard Cut Short,” a biography of a remarkable professor; “The Laser That’s Changing the World,” a history of lidar; and “From Jars to the Stars,” a history of Ball Aerospace.