Dr. Tewari and his group use a multidisciplinary approach to pathway development. “We invite key individuals from different disciplines and specialties to serve on a committee that is run by a physician and a nurse leader. These individuals are responsible for reviewing articles and other information and performing specific assigned tasks,” he explains.
The group starts with a tremendous amount of information. In addition to articles from the literature, they review national guidelines on the topic being addressed, as well as pathways used by other facilities or organizations.
The group takes the best clinical evidence and information they find, and they incorporate it into a tool that is useful and practical for the hospital.
“To be truly effective, these tools have to be institutionalized to your facility and practical in terms of what can be done or handled in this setting,” suggests Dr. Tewari.
Once the group reaches consensus on a completed draft, the document goes to several hospital committees for review. The original group then compiles the comments, makes any revisions or additions deemed necessary, and produces a final pathway. “This isn’t a short process,” cautions Dr. Tewari. On average it takes six months to a year from start to finish.
The final pathways are posted online, and physicians can print copies. Elsewhere, the pathways are available on the floors and in the emergency department as well. Currently, the pathways aren’t available for electronic applications such as PDAs. However, Dr. Tewari doesn’t rule this out as a possibility for the future.
Of course, Dr. Tewari emphasizes, just publishing a pathway or making it available to clinical staff isn’t enough. “You have to educate people about the pathways and gain their buy-in,” he notes. At his facility, each clinical department staff meeting involves a representative who will talk about pathways and spell out how to use them. This also presents another opportunity for practitioners and team leaders to have input on the tools.
The pathways aren’t mandatory, Dr. Tewari emphasizes, but they are strongly encouraged. “We don’t have statistics yet, but throughout the hospital, utilization probably is at about 50%. Within our hospitalist group, utilization is close to 100%. We hope to have some hard numbers soon to back this up.”
No Crystal Balls Needed: Guidelines Have a Future
Guidelines soundly rooted in evidence-based medicine have a future, predicts Dr. Simone.
“I think these are essential for the Medicare pay-for-performance measures that are coming down the pike. Medicare is likely to identify three to five different diagnoses to look at and may want hospitals to develop guidelines for these. Hospitals—as well as hospitalists and other physicians—will be rewarded if their performance is good in these areas based on these guidelines.”
Some hospitals already are using guidelines or order sets to prove quality. “We put our order sets together partly because we are part of a CMS [Centers for Medicare and Medicaid Services] pay-for-performance project,” says Dr. Psaila.
Guidelines that are commonly available via laptop or PDA also are coming. “Hospitalists tend to use technology more than other physicians, and they increasingly will want guideline applications for handheld devices,” notes Dr. Strachan.
There already are several companies offering such products. “Some of these are really useful tools,” he continues. “They allow you to pull up an order set for a particular illness and use it. You can click on medications and check the evidence basis for their use. You then can print out this information or transmit it electronically.”
The real future is to have electronic medical record solutions that interface with orders, predicts Dr. Strachan. However, he suggests that current availability and use of such systems is less than 10% of hospitals and hospitalists.