Beyond EMR: Care Management with Intelligent Pathways

In a recent article published by JAMIA (Journal of the American Medical Informatics Association), an AMIA task force outlined five broad goals that will improve the value that EMRs provide to patients, who are the ultimate customers of the Healthcare system. The goals summarized in a Healthcare IT News article generally aim to facilitate care delivery, foster innovation, and prioritize efforts on patients. 


One way to redesign in order to produce patient-centered care delivery is to focus on satisfying patient interactions in terms of experience and outcomes.  Taking a page from each of the playbooks focusing on patient journeys, applications of Design Thinking to better serve the patients, and use of care pathways to deliver better outcomes, it seems that the natural progression is an EMR design that considers all actions, actors, and artifacts (data included) in the patient’s care journey. 



Imagine such design attributes:


No specific interfaces, all participants - doctors, clinicians, DME vendors, SNLs, patients, loved-ones, other care providers, etc. - have some way to access what they need, and to add to the EMR the actions they have taken.


The “backbone” that holds all participants and their actions together is an intelligent pathway that drives even seemingly disparate actions toward the care goals, and possibly even toward each organization’s goals


Only information needed to move the patient along toward a better stage in the pathway is required. That way, no one needs to solve the difficult problem of collecting data from all organizations involved with the patient. But this means that the pathway, again, is intelligent enough to know, prompt for, or even automatically ingest the required data.



Now all participants are privy to the patient's requirements, and are guided accordingly toward the goals. The intelligent pathway even takes care of scheduling, as most participants cannot afford the time and efforts to track the patient's current pathway position, let alone identify the next required action. EMRs will still do what they do best – store data safely and maintain necessary privacy – but information access, decision making, and actions to take are now happening concertedly in the full social context of patient care. The intelligent pathway acts like an “Invisible Hand”, guiding the entire “care project”, which in many cases is lengthy and involves many agents, as they move toward the expected outcomes.

Where Are Your Patients in Their Journeys?

Every doctor has a desired care pathway in mind for each patient, however there is no smart way to support the execution of those care pathways.  Based on research results, patients that followed their pathways are more likely to achieve the desired outcomes than those that resorted to usual cares. Currently, clinics from San Francisco General Hospital to Singapore have devised creative methods such as 3 x 5 cards, and post-it stickers and notes. Care teams constantly perform chart reviews in order to put data from the EMRs and other sources (e.g. referrals, claims, DME vendors) into the context of each patient's care. We need an intelligent way to automatically ingest and digest such data and then proactively guide care delivery in care pathways.



Benefits of active intelligent pathways

We can leverage IT to keep track of the patients, activating pathways from their passive stages: the guidelines in medical literatures, and workflows in clinicians' minds. Computers are better than all of us in multitasking, and it’s much cheaper to deploy computers than to hire another clinician – throwing people at the problem doesn’t make it go away, it barely and inefficiently handles the current situation.

Imagine that the activated pathways can be created easily by a clinician via simple drag-and-drops. The pathways can also be customized for each patient on the fly.  Once a patient's pathway is activated, it will constantly collect data at the back end, coordinating care-team efforts and helping to inform the care-team's decisions about possible courses of action.

Now each day the clinicians can focus on completing bite-size tasks generated by the pathways, which are responsible for guiding their efforts toward - for example - patient safety, achieving expected outcomes, and patient and staff satisfaction.


We need active intelligent pathways to remain competitive

Within a competitive environment (healthcare reform), the fine touches show that you’re on top of your patients' goal, which helps to deliver satisfaction and ultimately better care. 

Healthcare organizations are not immune to competition; are you ready for the more educated patients who are demanding more today?


Care Flows: Patient-centric, Long-running Workflows

While I was working at my last world-renowned cancer center, we were faced with a unique challenge, the Center's leadership invested substantially to initiate a new survivorship program. By definition, cancer survivors are those who have completed the treatments in their treatment plan but who need continuous monitoring and support from their care teams.  As the first step towards building the program, we needed to identify a cohort of patients who have completed their treatment - sound simple?

We discovered that there is no simple way to find those patients in the EMR system without physicians spending weeks reading through clinical notes and charts.  It is a harsh reality that despite the huge amount of data in each patient’s record, there is no quick way of identifying any patient's current stage of their care journey. 

According to the 2010 IBM Healthcare and Life Sciences Thought Leadership study, Redefining Value and Success in Healthcare: Charting the Path to the Future, healthcare ranked as the least efficient industry in the world, with more than $2.5 trillion wasted annually.  Today the healthcare industry is facing similar challenges that other traditional manufacturing and commercial industries faced in the 1990s:Medical directors are trying to make their organizations fitter and smarter, in order to survive competition and further flourish.

Healthcare organizations are beginning to look at optimizing the healthcare IT environment to make it more flexible, with the ability to adapt to evolving business requirements.

The healthcare industry’s unique needs make it difficult to find a good solution.

The healthcare industry is unique, its overall processes are complex, and most importantly, it is not only operations-centric, but also people-centric. Traditional business process management techniques such as Six Sigma cannot meet comprehensive requirements such as these.

By being people-centric, business managers of healthcare organizations need to be able to visualize their current processes in the quickest and smartest way, and to hypothesize different scenarios without interrupting the current patient care processes.  They also need to focus on patient experience and dynamic case management.

With the absence of computerized tools, most healthcare organizations are adopting LEAN methodology which means manually conducting process improvement activities. After extensive discussions and a roomful of post-it notes and wall charts, all workflow is statically drawn on separate pieces of paper. There is no real-time connection between the paper workflow and the physical processes in the clinics.  Moreover, the data that can be mapped to the new workflow will not be available for the reporting team to query until months later.  

If we start thinking even more patient-centric, we quickly get out of the single office visit workflow, e.g. from arrival to departure, into "long-running workflows" in which many others may participate in ensuring the patient completes his/her care plan action items.  Such long-running workflows, which we call "care flows", are typical in specialty-care and chronic-care management.

In my next blog post, I will be writing about the kind of care flow management platform that will actually work in the healthcare environment.