Implementing a Computerized Clinical
Pathway based on Clinical Practice Guidelines
for Cardiology to Standardize and Improve
Work Processes.
Medical Informatics
Master Thesis
2018
Student: Ramon Abraham 10998063 Supervision: S.K. (Stephanie) Medlock, DVM, PhD B. (Bernard) Bresser2
Contact information
Student Ramon Abraham Amstelvlietstraat 22 1096 GG Amsterdam Tel: +316 31345352 College ID: 10998063 Email: ramon-abraham@hotmail.com Tutor S.K. (Stephanie) Medlock, DVM, PhD Assistant ProfessorDept. Medical Informatics, J1B-115-2
Academic Medical Center – University of Amsterdam Meibergdreef 15 1105 AZ Amsterdam Tel: +316 20719685 Email: s.k.medlock@amc.uva.nl Mentor B. (Bernard) Bresser Product Manager Nexus Nederland B.V. Weverstede 35 3431 JS Nieuwegein Tel: +316 29057073 Email: bernard.bresser@nexus-nederland.nl SRP address Nexus Nederland B.V. Weverstede 35 3431 JS Nieuwegein Tel: +31 (0)30 6015600 Email: info@nexus-nederland.nl SRP period November 2016 – August 2018
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Acknowledgement
I would like to express my gratitude to a number of people for their valuable contribution to my thesis. First, I would like to thank my tutor Stephanie Medlock for her excellent guidance, positivity, and for her confidence in me. Without her quick feedback and infinite patience, it would have been seemingly impossible to finish this thesis. Secondly, I would like to thank my mentor Bernard Bresser for his guidance, explanations, and for giving me the opportunity to pursue working in this business. Furthermore, I would like to thank Dick Schäfer, Ashiek Mohamedali, Marco Frishert, and Peter Venderbosch from Nexus Nederland B.V. for their availability, expertise and practical advices. Their advices really helped me in this research. I also would like to thank the cardiologists from the different local hospitals for their kindliness and willingness to cooperate with the interviews.
I want to thank Veroniqué Preemen, my beautiful girlfriend. Without her unconditional support, love, and belief in me, I would never be able to finish this thesis.
I also would like to thank my family. Thomex Abraham and Sonja Abraham, my parents, for their love, support, and faith in me. Jermia Abraham and Jessica Abraham, and Joël Abraham, my older brother and sister in law, and my twin brother, for their positivity. My parents in law, Léon Preemen and Yolanda Gagliardi, for their expertise and confidence in me. Viviënne Preemen and Stenly van den Broeke, my sister and brother in law, for inspiring me with their music. Without the love and support of my family, I would never be able to complete this thesis.
I thank my friend Raymond Pasman for his support, kindheartedness, and faith in me. Lastly, my deepest thanks to everyone who participated or contributed in anyway in this research.
Finally, I want to thank God for His grace and for giving me the strength to complete this journey.
Thank you.
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Samenvatting
Achtergrond: Hartfalen is een ernstige aandoening, waarbij het hart niet in staat is om genoeg bloed
door het lichaam rond te pompen. Klachten kunnen voorkomen en verminderd worden, door de juiste behandelingen toe te passen volgens de klinische behandelrichtlijnen. In de behandelrichtlijnen worden de wetenschappelijk onderbouwde aanbevelingen beschreven die artsen een houvast biedt voor diagnose en behandeling. Klinische zorgpaden kunnen gebruikt worden om artsen te ondersteunen in het volgen van deze richtlijnen. Een klinisch zorgpad is de verzameling van bewezen methoden en richtlijnen om de gezamenlijke besluitvorming van zorgprocessen te verwezenlijken.
Doelstelling: Ontwikkelen van een geautomatiseerd klinisch zorgpad dat gebaseerd is op de klinische
behandelrichtlijnen voor cardiologie en dat geïmplementeerd kan worden in een elektronisch patiëntendossier.
Methoden: een literatuurstudie om te achterhalen of en hoe klinische zorgpaden al worden toegepast
voor cardiovasculaire aandoeningen. Interviews met cardiologen om de werkprocessen in kaart te brengen en te bepalen of zorgpaden kan bijdragen aan het verbeteren van deze werkprocessen. Het ontwikkelen van een gestandaardiseerd klinisch zorgpad gebaseerd op de business process modelling notation techniek.
Resultaten: zes van de elf geïncludeerde cardiovasculaire aandoeningen in onze literatuurstudie, zijn
behandeld door zorgpaden. De studies laten zien dat sterftecijfers, ligduur, naleving en gebruiksvriendelijkheid van behandelrichtlijnen, patiënttevredenheid en patiëntveiligheid verbeterd kan worden door het gebruik van zorgpaden. Zes barrières en vier stimulansen voor implementatie van zorgpaden zijn gevonden. De geïnterviewde cardiologen volgen soortgelijke werkprocessen. Zeven barrières, zeven stimulansen en 23 behoeften zijn geïdentificeerd die invloed kunnen hebben op het gebruikersgemak van het huidige elektronisch patiëntendossier. Het ontwikkelde geautomatiseerde zorgpad bevat een algoritme voor de diagnostiek van hartfalen in de niet-acute setting dat een nauwkeurige weerspiegeling is van de klinische behandelrichtlijnen.
Conclusie: Het is mogelijk om een geautomatiseerd klinisch zorgpad op basis van de klinische
richtlijnen voor cardiologie te ontwikkelen, dat geïmplementeerd kan worden in een elektronisch patiëntendossier. Het includeren van zorgpaden is een veelbelovende manier om patiëntenzorg te verbeteren. Toekomstige studies zouden zich moeten richten op het evalueren van het gebruikersgemak en de effectiviteit van geautomatiseerde zorgpaden en het gebruikersgemak van hulpmiddelen om zorgpaden te ontwikkelen.
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Summary
Background: Heart failure is a chronic, progressive condition in which the heart is unable to pump
blood around the body properly. While heart failure cannot be cured, applying best practices and treatment strategies help to control symptoms for many years. These strategies are described in clinical practice guidelines, which include all available medical interventions for a particular condition aiming to support healthcare professionals make evidence based decisions. Clinical pathways could provide a means for professionals to improve compliance to the guidelines. A clinical pathway incorporates evidence-based recommendations and guidelines into an accessible format for healthcare professionals.
Objective: Build a computerized clinical pathway based on the clinical practice guidelines for
cardiology that can be implemented into an electronic patient record system.
Methods: Scoping review of the literature on computerized clinical pathways that are currently used for cardiovascular diseases. Expert interviews on cardiology workflows and how pathways might improve it. Development of computerized pathway prototype using the business process modelling notation technique.
Results: of the 11 cardiovascular diseases included in our literature search, six have been addressed by
pathways. Studies show that mortality rates, length of stay, adherence to guidelines and ease of use, patient satisfaction and patient safety can be improved with pathways. Six barriers and four facilitators were found for implementing pathways. All participants who were interviewed follow similar workflows. Seven facilitators, seven barriers and 23 different needs of using the current information system were found. The developed computerized pathway includes an algorithm for the diagnostic process of heart failure in the non-acute setting and correctly reflects to the clinical practice guidelines.
Conclusion: A computerized clinical pathway can be developed based on clinical practice guidelines
for cardiology that can be implemented into an electronic patient record system. The inclusion of pathways is a promising approach to improve patient care. Future studies should include evaluating the usability and effectiveness of computerized pathways, and usability testing of modelling tools.
Keywords: heart failure, clinical practice guidelines, computerized clinical pathways, barriers,
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Contents
1. General introduction ... 7 1.1 Background ... 7 1.2 Research objective ... 8 1.3 Organization of thesis ... 82. Implementing a Computerized Clinical Pathway based on Clinical Practice Guidelines for Cardiology to Standardize and Improve Work Processes: a Scoping Review. ... 10
2.1 Introduction ... 10
2.2 Methods... 10
2.3 Results ... 10
2.4 Discussion and conclusions ... 17
3. Expert interviews: Workflow of the cardiologist ... 19
3.1 Introduction ... 19
3.2 Methods... 19
3.3 Results ... 20
3.4 Discussion and Conclusions... 24
4. Development of a computerized clinical pathway that can be incorporated into the electronic health record... 26
4.1 Introduction ... 26
4.2 Materials and Methods ... 26
4.3 Results ... 27
4.4 Discussion and conclusions ... 30
5. General Discussion and Conclusion ... 31
Bibliography ... 33
Appendices ... 36
Appendix A ... 36
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Chapter I
General introduction
1.1 Background
Heart failure is a serious condition in which the heart gradually loses its ability to pump enough blood to meet the needs of the body. It is associated with symptoms like breathlessness, swollen limbs and fatigue [1]. About 26 million adults worldwide are living with heart failure and patient numbers are increasing with increasing age. In North America and Europe, more than 80% of patients with heart failure are 65 years of age or over. The survival rates across the globe remain poor; 17-45% of patients admitted to hospital die within 1 year and the majority die within 5 years of admission [2]. In the Netherlands in 2016, more than 30.000 patients were admitted to hospital and almost 8.000 patients died due to this condition [3]. Although heart failure cannot be cured, it can be treated, by applying best practices and strategies to improve health outcomes. Those best practices are described in clinical practice guidelines.
Clinical Practice Guidelines
Clinical practice guidelines summarize and evaluate all available evidence for using particular medical interventions for an individual patient with a given condition. For example, they describe how a healthcare professional could perform the diagnosis and treatment of a condition such as heart failure. Guidelines aim to help professionals make evidence-based decisions in their daily practice. Several governmental and professional bodies, such as The European Society of Cardiology (ECS) and The Dutch Association for Cardiology (Nederlandse Vereniging voor Cardiologie, NVVC) have been publishing guidelines for heart failure.
European Society of Cardiology
The European Society of Cardiology is an international independent and non-profit organization that discovers and disseminates best practices in cardiovascular medicine. They spread evidence-based scientific knowledge such as clinical practice guidelines to cardiovascular professionals to improve care and treatments for patients [4]. In addition, ESC associates healthcare professionals around the world to advance cardiovascular science. The most recent ESC guidelines for the diagnosis and treatment of acute and chronic heart failure were published in 2016 [5]. They were prepared by a task force consisting of a select group of cardiologists who were involved with the pathology of heart failure. In addition to the comprehensive description of the diagnosis and treatment, the definition of heart failure including epidemiology, aetiology, pathophysiology and nature history, and pharmacological non-device/surgical interventions used in the management of heart failure are described in the guidelines.
NVVC
The NVVC, a Dutch association, unites cardiologists and other healthcare professionals who are involved in the diagnosis and treatment of patients with cardiovascular diseases. They act as the representative for cardiovascular care on behalf of the cardiologists during the policy-making process in The Netherlands [6]. The NVVC sees it as their duty to facilitate and stimulate healthcare professionals to improve the quality of cardiovascular care. Good education, interchange of information, organizing seminars, and development of guidelines and accreditation relate to this mission. In 2010, NVVC published in collaboration with The Dutch College of General Practitioners (Nederlands Huisartsen Genootschap, NVVC) and The Dutch Internist Society (Nederlandsche
Internisten Vereeniging, NIV) the multidisciplinary guidelines for heart failure [7]. Like the ESC
guidelines but adjusted to the Dutch situation, diagnosis, treatment, palliative care, and interventions in the management of heart failure are described in these guidelines.
In collaboration with eight other associations, the NVVC published the national transmural agreements for heart failure (Landelijke Transmurale Afspraak hartfalen, LTA) in 2015. The involved healthcare
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professionals and their responsibilities, additional diagnosis, referral back from hospital to General Practitioner (GP), check-ups, information and lifestyle advisement, revalidation, and care during end-of-life phase are described in the LTA. The purpose of the LTA is to facilitate a framework for regional agreements between the involved healthcare professionals and their patients concerning the organization of heart failure care [8].
Compliance with the clinical practice guidelines is often associated with lower patient hospitalization and readmission rates and can be encouraged with clinical pathways [9, 2].
Clinical Pathways
A Clinical pathway is an evidence-based protocol or strategy to streamline patient care and minimize variability in physician practices to optimize care outcomes and reduce health costs. It operationalizes evidence-based recommendations and clinical practice guidelines into an accessible bedside format for healthcare providers. Clinical pathways are also known as critical pathways, clinical and critical paths, care maps, care paths, collaborative plans of care, multidisciplinary actions plans, or anticipated recovery paths [10, 11, 12, 13]. In this study, we aimed to build a computerized clinical pathway based on the clinical practice guidelines for cardiology that could be implemented in an electronic patient record. Since there are many different and extended clinical guidelines for heart failure, it can be inconvenient and time consuming for healthcare professionals to use them in their own daily practice. Therefore, it is essential that all end-users consent to the design of the pathway. Cardiologists for example, might want to integrate their own workflow into the pathway, which they believe is most effective, while the process described in the guidelines is different. Therefore, we needed to investigate firstly whether there is variation in cardiology workflows, which do not match with the guidelines. In addition, pathways have been implemented for other cardiovascular diseases as well, which could inform the design of our new pathway.
1.2 Research objective
The objective of this work was to develop a computerized clinical pathway based on practice guidelines for cardiology that can be implemented into a hospital information system. The research questions addressed in this study are:
1. How are clinical pathways currently used for cardiovascular diseases?
2. Is there variation in cardiology workflows which is incongruent (i.e. do not match) with the guidelines?
3. What are the barriers and facilitators for registration for clinicians?
4. What do clinicians think will influence their acceptance of a clinical pathway? 5. What aspects of a clinical pathway are helpful in getting structured data?
1.3 Organization of thesis
This thesis is organised into five chapters.
Chapter I is an introduction of the research project, the research objective, research questions and background information.
Chapter II is a scoping review of clinical pathways for cardiovascular diseases. We have searched for articles to find out how clinical pathways are currently used for cardiovascular diseases. The results are described and this chapter ends with a discussion and conclusion section.
Chapter III investigates the workflow of the cardiologists. We interviewed cardiologists to find out what their daily workflow looks like. In addition, cardiologists gave their opinion on clinical pathways and we discussed their needs that they believe are important to improve a hospital information system.
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Chapter IV is an elaboration of the design of the computerized clinical pathway. The designed pathway is based on the clinical practice guidelines and results of the interviews. In this chapter, we included images to show what the pathway looks like.
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Chapter II
Implementing a Computerized Clinical Pathway based
on Clinical Practice Guidelines for Cardiology to
Standardize and Improve Work Processes: a Scoping
Review.
2.1
Introduction
Since the 1990s, hospitals are using clinical pathways to reduce costs and enhance quality of patient care in order to grow and remain competitive [14]. The concept of clinical pathways had already been introduced in the mid-1980s [15]. The New England Medical Center Hospitals are considered the pioneers. They introduced a paper based clinical pathway that specified crucial incidents, combined with proper interventions, which should take place on a given day of hospitalization to achieve the standard outcomes within a reimbursement system.
Such paper based clinical pathways tend to be effective, led to reduced length of stay, increased use of recommended interventions, early discharge, improved human resource control, and a trend towards a reduced mortality [16, 17. 18, 19]. However, it is not currently known in what ways clinical pathways are used in today’s healthcare system, powered by medical information technologies such as the electronic patient record. Therefore, the objective of this review is to consult available scientific literature to find out how computerized clinical pathways are currently used for cardiovascular diseases.
2.2
Methods
Articles were sought in two databases: Embase and Medline using Ovid, to identify publications on clinical pathways used for cardiovascular diseases. The search was conducted between December 3, 2016 and January 6, 2017, and was focused on the concept of clinical pathways. The strategy combined two concepts: (1) cardiovascular diseases and (2) clinical pathway. Of the cardiovascular diseases concept, terms were used involving the cardiovascular system including the heart, blood vessels, and the pericardium. Of the clinical pathway concept, multiple synonyms were used, as those were deemed relevant. The search was formulated by two researchers (SM and RA). All other tasks were performed by one researcher (RA). The whole search query can be found in appendix A.
We included studies that met the following inclusion criteria: 1) Full text available in English, 2) study population is cardiac disease of any type, 3) clinical pathways are a main subject of the paper (clinical pathways or a synonym was mentioned in the title or abstract), and 4) evaluated pathways that are computerized including computerized order entry systems. Paper-based pathways were excluded. Data extraction was done by tabulation of the following information into a data extraction form in a spreadsheet: study characteristics (e.g. title, author(s), publication year, country, target group, and what type of computerized pathway), the study objective and methodologies used, and the results and conclusion of the studies.
2.3
Results
The results of the search are summarized in Figure 1. Ten articles were included in the analysis based on the inclusion criteria. The studies dated from 2007 – 2016. During the screening phase, we excluded all articles that were not targeted on cardiovascular diseases and evaluated a clinical pathway (n = 1144).
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Finally, during the eligibility phase, we excluded all articles that had no full text available (n = 25), and that were not focused on a computerized pathway (n = 55).
Figure 1: PRISMA flow diagram of this review
Characteristics of included studies
The characteristics of the studies are described in Table 1. The 10 studies were conducted in six countries, including two studies from The Netherlands. Of the 11 cardiovascular diseases included in our search, six have been addressed by the included studies: congestive heart failure, acute decompensated heart failure, chronic heart failure, atrial fibrillation, acute myocardial infarction, and unstable angina. The included studies involved a hospital information system, clinical patient order sets (n = 3), usage of electronic health tools, a clinical pathway based on clinical decision support, and concepts which described tools that can be used to develop [20], implement [21, 22], or evaluate [23] clinical pathways (n = 4).
12 Table 1: Charateristics of included studies
Study Country Study design Clinical Pathway description
Target group Results
Wagenaar KP et al. (2015) [29] The Netherlands Protocol for a three-arm parallel RCT A Clinical Pathway with the E-Vita platform and the heartfailurematters website. Congestive Heart failure Results not available yet. Shabo A et al. (2016) [21]
Italy Case study An interplay between Asbru Computer-interpretable guideline (CIG), and Activity Workflows via the MobiGuide’s Patient Health Record. Atrial fibrillation Proof-of-concept. Park YS et al. (2016) [25] Korea Retrospective observational cohort study A multidisciplinary Clinical Pathway based on Clinical CPOE system, known as FIRST. Acute myocardial infarction Clinical Pathway found to be effectively improve door-to-date interval and door-to-balloon times. Huang Z et al. (2014) [23]
China Case study A rule-based Clinical Pathway compliance checking system. Unstable Angina Proof of concept Yu Y et al. (2014) [20] Unknown Description of methods An end-to-end web-based Care pathway Workbench for care pathway development. Congestive heart failure Proof of concept Mei J et al. (2014) [22] China Description of methods A Clinical Pathway logical model based on Case Management Model and Notation. Congestive heart failure Proof of concept.
13 Garin N et al. (2012) [26] Switzerland Retrospective cohort study A computerized Clinical Pathway including order sets for each stage of the hospital stay. Congestive heart failure Implementation of Clinical Pathway was associated with improved guidelines adherence and reduced risk of death or readmission after discharge. Valente M et al. (2010) [24] The Netherlands Retrospective cohort study An electro cardioversion digital Clinical Pathway with a feature to allow automatic communication with the primary care thrombosis service. Atrial fibrillation Implementation of Clinical Pathway resulted in a significant reduction in walk-through times. Gardetto NJ et al. (2008) [27] The United States Qualitative study A user-friendly computerized Clinical Pathway that provides order sets for treatment.
Acute decompensated heart failure Clinical Pathway perceived to be effective. Leslie SJ and Denvir MA (2007) [28] Unknown Qualitative study A computerized decision support system (CDSS) based on published guidelines, papers, and consensus of clinical practice. Chronic heart failure Potential value of and barriers to CDSS.
Channels for clinical pathway
Hospital Information System
One study, performed by Valente, reported the effectiveness of a computerized clinical pathway that was introduced into a hospital information system (HIS) in a local hospital in The Netherlands. This was a pathway for electro-cardioversion in atrial fibrillation and consisted of a predefined path running from admission to discharge [24]. It also included all actions outlined in national guidelines. The pathway was evaluated from a patient perspective where satisfaction and safety were primary concerns. Evaluation was done during the development- and implementation phase [24].
Computerized order sets
Three studies evaluated the effectiveness of a clinical pathway that included predetermined order sets for the treatment of patients with a cardiovascular disease. Firstly, Park implemented a multidisciplinary clinical pathway for ST-segment elevation myocardial infarction, that was based on a Computerized Physician Order Entry (CPOE) [25]. It was designed to reduce unnecessary in-hospital time delays, such as the time between first admission and completion of an ECG (door-to-data interval). The CPOE system was used for activation or deactivation of a treatment program, consultation, entering predetermined order sets (e.g. medical orders for blood tests, ordering an ECG), providing protocols and guidelines, and to assess treatment efficacy. Secondly, Garin implemented a clinical pathway within a computer-assisted prescription tool for patients with dyspnea and principal diagnosis of heart failure.
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It was designed to encourage physicians to perform appropriate diagnosis (e.g. monitoring patient’s weight, obtaining an echocardiogram and specialized advice to the patient) and to prescribe appropriate medications [26]. The pathway included predetermined order sets for each phase of the hospital stay, and must be fulfilled before going to the next phase. The third study, conducted by Gardetto, reported the development of a clinical pathway that included standard order sets for patients with acute decompensated heart failure (ADHF) who presented to the emergency department [27]. The pathway was based on care processes, clinical guidelines, and best care practices to assist care providers in the treatment process. The system provided physicians with a set of standard medications, consults, patient education, and heart failure discharge instructions.
Clinical Decision Support Software
Another study, done by Leslie, discussed the potential value of clinical decision support software (CDSS) in the treatment of patients with chronic heart failure [28]. Leslie stated that a clinical pathway is unable to provide patient-specific management advice. Therefore, they developed a CDSS that could be able to provide tailored management that was based on published guidelines and papers combined with expert advice. The CDSS included a series of yes/no diagrams for diagnosis, initiation, and treatment.
eHealth
One study, performed by Wagenaar, aimed to assess the effects of an adjusted Clinical Pathway incorporated with two different e-health tools, which replaced routine face-to-face consultations with heart failure nurses at an outpatient clinic in patient with heart failure. The tools comprised a website with information targeted at patients and their family/carers, and an interactive platform for disease management. A first report of the representativeness of patients, who participated in this study, showed that participants were younger, more often male, and wealthier and healthier than those who declined to participate [29]. At the time of this literature review, results regarding the effectiveness of the incorporation of e-health tools was not available yet.
Effectiveness of clinical pathways
Mortality rates
Two studies measured the outcomes of mortality rates [25, 26]. The study conducted by Garin, assessed a trend towards fewer deaths of patients who were included in the pathway (p=0.06) [26]. In addition, the relative risk of death within 90 days after discharge was reduced by 28%. The other study, performed by Park, assessed no difference in in-hospital and 30-days mortality rates [26]. In addition, Garin reported that the patients included in the pathway, were more likely to have a reduced left ventricular ejection fraction (LVEF). This improved by 12.4% and was associated with lower risk of death [26].
Length of stay
One study measured the length of stay of patients included in the pathway as a secondary outcome. The study assessed no improvement in the length of stay compared to a control group (median length of stay of 11 days in both groups) [26].
Adherence to guidelines and ease of use
Four studies assessed outcomes in adherence to clinical guidelines [24, 26, 27, 28]. Three studies assessed closer adherence to clinical guidelines in the pathway [24, 26, 28] and one study reported that the pathway assisted as a measurement tool in tracking adherence to guidelines [27]. Furthermore, inclusion of a clinical pathway could improve adherence to prescription of medications for in-hospital patients with heart failure [26].
Patient satisfaction and patient safety
One study assessed improvement in patient satisfaction and patient safety outcomes [24]. The study reported that the overall patient satisfaction after implementation increased by 5%, from 86% to 91%, compared with the development phase. Measured quality indicators for patient safety showed also improvements. Adequate levels of anticoagulation were achieved by the scheduled date with a 96%
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successful-rate, respectively. The implementation of the pathway also resulted in a significant reduction in walk-through times [24].
Complexity
Leslie reported that the clinical pathway based on the CDSS could only provide tailored advice up to a point reflecting a number of heart failure patients, because patients may presented in various ways having comorbidities, different social circumstances, and responses to medications. It became more complex to provide patient-specific management advice as the number of those combinations increases. Furthermore, Leslie encountered several barriers regarding the implementation of their tool including low computer skills among health professionals, and a lack of complexity within CDSS in addressing the wider nonmedical needs of patients [28].
Barriers and facilitators
Eight studies reported about barriers and facilitators for implementing a clinical pathway [20, 21, 22, 23, 24, 25, 27, 28]. We found six barriers and four facilitators. The barriers and facilitators are summarized in the table (Table 2) below.
Table 2 Barriers and facilitators for implementing a clinical pathway that are addressed by the included studies.
Barriers Facilitators
1. Clinical pathways has not gained widespread usage [28];
2. Very few hospitals have the ability and resources to develop a pathway [21, 24]; 3. Multiple stakeholders with different
behaviours are involved along the care continuum [21, 23, 24];
4. Multiple guidelines and many best practices from different sources are available [20];
5. Clinical pathways are often not flexible and lack ad hoc variations in execution of clinical tasks [22];
6. Heart failure is complex, having a large evidence base, and a high prevalence [28].
1. Workflows that are shared by all stakeholders with agreed-upon representations of the guidelines and workflows [21, 23];
2. Making use of standardized and simple protocols [25];
3. Usage of a multidisciplinary team approach [24, 25];
4. Many published guidelines and papers are available [27, 28].
Concepts that can be used to develop, implement, or evaluate a clinical pathway.
Four of the included studies addressed concepts that can be used to develop, implement, or to evaluate clinical pathways [20, 21, 22, 23]. Yu described an end-to-end web-based platform called a ‘Care Plan Workbench’, that allows users to create a pathway with synthesized evidence from clinical practice guidelines and patient data, conforming to Case Management Model and Notation (CMMN). The workbench consisted of two parts: (1) a management component allowing the user to create, edit, save, and transform a pathway; and (2) analytics components, which allows the user to extract elements from the guidelines and perform a variation analysis. However, Yu did not report on the effectiveness of the workbench. Mei advocated to also adopt CMMN to implement clinical pathways. According to Mei, CMMN helps to address the flexibility problem of traditional process modelling, in which a process model restricts the sequences of activities with predefined decision logics [22, 30]. Mei proposed a CMMN-based clinical pathway model, with an extension of CMMN with decision tasks. Those tasks were predictive models to provide decision support for diagnosis, prognosis, and treatment. In this study, the proposed model has not been evaluated. Furthermore, it is difficult to orchestrate clinical and organizational actions because clinical practice guidelines are not well integrated into clinicians’ native organisational workflows [22]. Therefore, another study, done by Schabo, addressed proof-of-concept
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implementation of integrating digital representations of clinical pathways with organizational workflows [21]. It concerned the creation of an interplay between guidelines and business process management (BPM) languages and their engines. Schabo stated that the integration of such concepts is challenging along the care continuum because multiple stakeholders are involved. Therefore, they points to the need to move towards an asynchronous execution of work processes that is shared by all stakeholders, with agreed-upon representations of the guidelines and workflows [21]. Huang advocated that it is more important to look into treatment behaviours of the pathway rather than only assess the outcome of the pathway [23]. Therefore, Huang presented an online rule-based clinical pathway compliance checking system to timely assess treatment behaviours in patient care flow, and support online compliance checking between actual treatment and the designed treatment regulations. The system can create an independent representation of the state of the pathway and treatment behaviours performed on patients in their care flow. This proposed system is demonstrated through a case study in a general hospital in China. However, Huang has not reported the results of that case study.
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2.4
Discussion and conclusions
Principal findings
In this study, we found that computerized clinical pathways are tentatively implemented, but they have not been used widely yet: of the 11 cardiovascular diseases included in our search, six have been addressed by pathways. We also found four different channels through which a pathway can be implemented. Furthermore, studies show that improvement in care outcomes can be made through the inclusion of pathways, including fewer deaths and readmission rates [25, 26], closer adherence to clinical guidelines [24. 26, 28] and higher patient satisfaction and patient safety [24]. There are concepts that can be used to develop, implement, or to evaluate a pathway, though these concepts are not evaluated yet. We found six barriers and four facilitators for implementing pathways in the literature, such as the challenge of addressing the needs of many stakeholders (barrier), and the many clinical guidelines available describing good quality of care (facilitator).
There are barriers and facilitators for implementing pathways. We found six different barriers and four different facilitators.
Strengths and limitations
To avoid missing articles, we first identified all articles mentioning cardiology and pathways, and then identified computerized pathways. That makes it unlikely that articles about computerized pathways will be missed. In addition, we searched for specific cardiovascular diseases as well as cardiovascular disease as a concept. That gave the smallest chance of missing relevant articles.
In this scoping review, the decision was made to only include relevant studies of which the full text articles were available and downloadable from the databases. However, we also found studies that could potentially be relevant, but which we not included because no full texts were available. Umans et al. for example, addressed the development and implementation of a critical pathway for atrial fibrillation [31, 32]. Thus, some potentially relevant studies were excluded. Furthermore, we included articles that reported on clinical pathways based on a computerized decision support systems and clinical patient order entry systems. We require that they use one of the synonyms for “clinical pathway”. Some systems may have the same functionality as a clinical pathway, but not be called a clinical pathway. Finally, only one researcher performed the actual search. Different relevant articles could come up if the search was repeated independently by another researcher, because that researcher could have a different view on the articles. Therefore, process for selecting studies and determining eligibility should be stated in consensus between reviewers [33].
Implications
Although some included studies show that clinical pathways tend to be effective, we imply that they still need to be fully evaluated. We suggest that this could be caused, because of the different barriers that may arise when implementing pathways. In addition, there are no standardized methods for de development and implementation of pathways, and the concepts we found were not evaluated yet. However, graphically expressing the workflow of a cardiologist using CMMN or BPMN seems to be a workable method to develop a clinical pathway [22], which can be useful for developers and implementers.
Future work
Future study could include to design a clinical pathway informed by the findings of this scoping review. In this regard, researchers and developers could make use of different concepts to design it. further research could be done to determine which concepts are most suitable for designing a pathway. Also, pathways have been used with some success for some cardiovascular diseases but not others. Future work could investigate whether pathways can improve care for these other conditions.
Conclusion
We conclude that evidence for the effectiveness of computerized pathways is limited, but studies indicate that it is a promising approach to improve care outcomes. Additionally, although there are no
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best practices, knowledge of barriers and facilitators and concepts that were suggested in the literature can be used to develop, implement and evaluate pathways.
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Chapter III
Expert interviews: Workflow of the cardiologist
3.1
Introduction
Close adherence to clinical practice guidelines can be challenging because guidelines can be inconvenient to use and patients with cardiovascular diseases may present in different ways. The methodology of clinical pathways comprises the ability to better comply with clinical practice guidelines [23, 31]. However, it is unclear to what extent the workflow of cardiologists complies with the guidelines and what cardiologists believe they need to improve compliance to the guidelines. Therefore, we performed interviews with cardiologists to find out how their current workflow looks like, if it corresponds to the guidelines, and what they believe is needed to improve compliance to clinical practice guidelines for cardiology.
3.2 Methods
Participants
We recruited a sample of cardiologists from different non-academic hospitals in The Netherlands who were using the same electronic patient record system. Participants were invited to take part in the study only if they were familiar with that system. The first researcher carried out the recruitment by email. We scheduled the interviews individually to best accommodate participant’s availability.
Data collection methods
A semi-structured interview protocol was prepared listed open questions, which served as a checklist to make sure that all relevant topics were covered during the interviews. The protocol in detail can be found in appendix B. The protocol was structured into four themes: 1) acceptance of clinical pathways, 2) Scenario 1, 3) Scenario 2, 4) Barriers and facilitators for registration. The focus of the first theme was to question the cardiologists their opinion about clinical pathways, and whether they believe pathways are helpful in performing their work processes more efficiently. The focus of theme two and theme three was to find out what workflow the cardiologists currently follow. For each theme, a scenario was formulated to make the questions about workflow more concrete. The following two scenarios were formulated:
1) Scenario 1: What happens if a patient likely to have heart failure gets a GP referral to the hospital?
2) Scenario 2: What happens if a patient, who has already been treated in the hospital due to other illness than heart failure, gets a GP referral because the GP suspects that the patient has heart failure?
Finally, the focus of the last theme was to question the cardiologists what parts in the current electronic patient record system is easy to use, but also what is hard to use to do their registration. We discussed the four themes with each participant in chronological order. Participants were allowed to raise relevant issues not covered by the interview protocol. Participants were informed about the purpose and content of the interview and agreed to participate by email. All interviews were taken face-to-face.
Data capture, coding, and analysis
The interviews were audio recorded and transcribed verbatim. We started our analysis with open coding the interviews, aiming to exam, compare, and conceptualize and categorize the data. After that, we identified relationships among the list of open codes through the process of axial coding by categorizing the codes into defined terms. Finally, we tabulated the defined terms to figure out the core categories that includes all of the data.
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3.3 Results
Of 11 cardiologists from six different hospitals who were contacted, five cardiologists and one representative consented to participate. The representative was an information-communication advisor who was also familiar with the information system and the work processes of the cardiologists. We arranged the results into four themes:
1. Workflow
2. Opinions towards current system 3. Opinion on clinical pathways 4. Demands
The first theme ‘Workflow’ gives a description of the results about how the current workflow of the participants looks like. In this theme, we also included the point of views on clinical practice guidelines, because we believe it is an important complement, because it gives an idea why the participants follow a certain workflow. The second theme ‘opinion towards current system’ gives a report of the results about the participants’ opinion towards the current electronic patient record they use. The third theme gives the results of the participants’ opinion on clinical pathways. In the last theme ‘needs’, we reported the needs of the participants that they believe is needed to improve the current patient record.
Workflow
All participants appear to follow the same clinical workflow process (e.g., starting with the referral from the GP, performing different diagnostic tests, if needed ordering follow-up tests, interpreting the results of the diagnosis, then starting the treatment or discharge the patient if heart failure is unlikely). How the workflow looks like depends on the completeness of the referral (i.e. what diagnostic tests are already done by the GP and what tests are still need to be done), and whether the case is acute or non-acute. Furthermore, all participants generally follow the same diagnostic process, including performing a physical examination, ECG, echography, and blood tests including a NT-proB-type Natriuretic Peptide (BNP) test. The treatment process is often a combination between a treatment done by a cardiologist, e.g. medication treatment, and a life style consult, e.g an exercise program or a reduced calorie diet, done by a nurse.
Four participants commented that their workflow is patient centered, meaning that they adjust their processes based on what the patient wants and needs. One participant noted that their function is shifting towards a more supporting role: “This is very important, because you need to discuss with the patient
what he or she wants. We are more like information providers like, well, these are the available treatment options. This is the available medication with different side effects, this and this. I think this is how you could look at our job”. Finally, all participants adhere to the national agreements for heart
failure described in the LTA.
Point of view clinical practice guidelines
All participants argued that the guidelines help to determine which diagnostic test or treatment they should follow. However, it is not required to follow the guidelines, which means that cardiologists are able to deviate from what is recommended. One commented: “Guidelines are kind of a cook book,
which is how you should look at it. You can deviate from that guideline, but in general, it tells you how you should treat a patient”. In addition, participants stated that it is essential to give well-considered
argumentation when they want to deviate from the guidelines.
When asked what kind of information participants need to document, most participants responded that they need to document a complete status of the patient (e.g. results of ECG, physical examination or updating medication), and if needed a complete resignation or referral letter. However, two participants commented there is no authority who checks what information they document or what their argumentation is when they deviate from the guidelines: “From our profession, we need to perform our
documentation carefully. However, nobody tells what I need to document”. The other stated: “Actually, when I deviate from the guidelines, I need to register why I deviate from those guidelines. Will it be checked? No”.
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Opinions towards current system
The presentation of test values can be found in Table 3. The table lists the facilitators and barriers regarding the current electronic patient record system and their frequencies of occurrence.
Table 3 Advantages and disadvantages current system
Facilitators Frequency
(n = 6)
Barriers Frequency
(n = 6) - Presentation and
registration of test values - Different tabs - Uniformity - Registration treatment limitations - Availability of information - Displaying right information - Form flexibility 2 2 1 1 1 1 1 - Lack of interoperability - Not user-friendly - Lot of clicks - Redundant information - Plain text
- Lack of proper Search function - No feedback 6 6 4 3 2 1 1 Facilitators
Seven facilitators with respect to the current system were observed. Two participants argued that the
presentation of test values such as an electrocardiogram and the registration of blood values, functions
very well because it is not documented as plain text. They indicated that this helps to do their registration: “The CHEST VASC score, you need to register that and actually that works fine in the
system”. Furthermore, two participants stated that the different tabs help them to give a better overview
of all the information that they see on the screen. Added to that, without taking into account how it is presented, one participant noted that there is a lot of patient related information available on the system. That makes the system uniform without any subdivision by department or speciality. Another facilitator is the Registration of treatment limitations. One participant stated: “Treatment limitations are essential
to document in the system. I can show you how easy that is. Resuscitate, you choose that and then it is done. So, that is easy to document”. Moreover, a facilitator of the current system was that it displayed the right information in case of calamities. Finally, one participant argued that the availability of
different digital forms makes it helpful to do the registration, because cardiologists have different preferences concerning the way they document findings. One may wants to type everything, while the other wants to select items from a list or wants a combination between typing and selecting (form
flexibility).
Barriers
We observed seven barriers. All participants argued that a lack of interoperability between different sub-systems is the most important barrier of the current system. One argued: “the most important
bottleneck is the lack of interoperability between different sub-systems. For example, a heart failure patient underwent blood tests, an echocardiography, and a chest x-ray. I see these three tests on the right side of the screen, under results. I see them everywhere, but eventually it needs to be imported on the left, in the medical record of the patient”. The participants argued that interoperability between
sub-systems is essential to improve treatments and to optimize collaboration between other health professionals such as a general practitioner. A cardiologist argued: “Interoperability is essential,
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to know what the current medication is… It could be that the general practitioner has prescribed other medication that is not shown in this system. That is because there is no interoperability”.
Furthermore, the participants argued about the user-friendliness of the system. Four participants argued that they spend a lot of time clicking around to find what they need: “If I would like to request a result,
then I need to go here and after that to here. So relatively, you spend a lot of time clicking”, according
to a cardiologist. Adding to that, participants can only request a specific diagnostic or schedule an appointment with another health professional one at a time, which makes it time consuming as well. Three participants stated that redundant information makes it hard to keep a clean overview of the important information. Two participants commented that plain text makes it hard to find specific data. One complained: “… I want to look at disease specific data, but then I encounter a problem, because
usually that disease specific data is entered as plain text. That is inconvenient”.
Finally, two different comments with respect to the functionalities of the system were found. One participant complained the lack of a proper search function to search for specific data in plain text. Another participant indicated that the system does not give any feedback to the cardiologist when an employee at the polyclinic finishes a task.
Opinions on clinical pathways
Although none of the participants were using clinical pathways, we found eight advantages and three disadvantages of using pathways. The advantages and disadvantages are listed in Table 4.
Most participants argued that a pathway is applicable to non-acute heart failure patients, because in most of the cases, they often follow the same care process. In addition, three participants stated that it can also help to improve quality of care- and work processes. Finally, pathways could also help to give
guidance and keep track of processes, and to compare their treatment outcomes with other healthcare
professionals.
All participants argued about the potential complexity of pathways. One argued: “You should exclude
care that is too complex… If you have a heart failure patient in an academic setting with three different rare co-morbidities, then you should not use a pathway. Therefore, a pathway is helpful for cases that are the same and recurrent”.
Table 4 Advantages and disadvantages of Clinical pathway
Advantage Frequency (n = 6) Disadvantages Frequency (n = 6)
To improve quality of care 3 Complexity 6 To standardize work processes 3 Not generalizable 1 To optimize work processes 2 New concept 1 To give guidance 2 To give patient value-oriented care 2 To improve the current system 1 To keep track of processes 1 To compare treatments 1 Requirements
All participants advocated that the ability to deviate from the clinical pathway with well-defined argumentation is the most important requirement. Furthermore, they argued that it is essential to define the scope and write out the complete workflow in collaboration with the end-users.
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Needs
When asked about participants’ opinion regarding their current system, they argued what they think is needed to improve their registration process. It resulted in a list of needs that we clustered into four main subjects as shown in Table 5. In total, 23 different needs were observed. The most frequent advocated needs were focused on collaboration improvements and system interoperability.
Table 5 Needs of the participants for improving their registration process
Need Frequency (n = 6)
Collaboration
1) System interoperability;
2) Better collaboration with colleagues; 3) Developers should collaborate with
end-users;
4) Developers should provide better services;
5) Supporting better communication with patients. 3 2 2 1 1 Standardization
1) Standardizing work processes;
2) Predetermined appointment/follow-up sets;
3) A complete clinical pathway from referral till revalidation;
4) Support to give best recommendations.
2 2 1 1
Essential information
1) Show only relevant information; 2) Disease focused information;
3) Continuously up to date information; 4) One structured overview of relevant
information. 2 1 1 1 Functionality
1) Good search function; 2) Mark off layout; 3) Structured information;
4) Supporting different clinical pathways; 5) Ability to change patient status if
needed;
6) Alert when deviating from guidelines; 7) Able to create digital forms;
8) Phrase-express functionality; 9) A hyperlink to clinical guidelines; 10) Improvement in availability of test
results. 1 1 1 1 1 1 1 1 1 1
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3.4 Discussion and Conclusions
Principal findings
In this study, we interviewed cardiologists from different local hospitals to explore how their current workflows look like, what their opinion is on electronic patient record system to do their registration, and to what extent they believe that clinical pathways are helpful to improve their workflow and registration process.
We found that all participants generally follow similar workflows that only may differ depending on whether it is an acute- or non-acute patient, and what diagnostic tests are already done by the GP. Herein, clinical practice guidelines are helpful to determine the right treatment, but should always be overruled if needed. We found seven facilitators and seven barriers of using the current information system. Participants were more critical towards their current system. All participants argued bad interoperability and lack of user-friendliness as the most important barrier of the current system. We also found 23 needs that should be encountered according to the participants, in order to improve the current system. Finally, all participants see clinical pathways as a potential solution to improve their work processes. In total, we found eight advantages and three disadvantages of using clinical pathways for cardiology.
Strengths and limitations
One of the strengths of this study is that we prepared an interview protocol that gave guidance and focus when performing the interviews. Furthermore, most participants (5/6) were cardiologists specialized in heart failure, which is the focus group of this research. The participants were able to explain how a workflow of a cardiologist looks like and they gave valuable thoughts on how clinical pathways can help them to improve their workflow. In addition, this study gives important insights into the strengths and limitations of-, and what is needed to improve the current electronic patient record system, because all participants have already been working with the system.
A limitation of this study is that most participants had limited amount of time to do the interview. Therefore, we were not able to discuss their current workflow in dept. Furthermore, since the questions were semi-structured, participants tended to discuss things more than what was asked. They were more likely to discuss about the disadvantages of the current system rather than about their own workflow. Another limitation is that we were only able to interview five cardiologists from two different local hospitals and one representative from another local hospital who did not work at the department of cardiology. This might imply why the cardiologists generally follow the same workflow.
Implications
This study can be useful when developers want to check whether the workflow of a cardiologist is congruent with the clinical practice guidelines. The finding that cardiologists follow the same workflow, and that cardiologists are willing to use clinical pathways, can be useful for developers when developing a clinical pathway based on clinical practice guidelines. The methodology used in this study can also be adapted and used to study other guidelines and specialisms. Furthermore, this study provides valuable insights into the advantages and limitations of the current information system. It gives a better understanding of the workflows and what parts of the current system users like and do not like. It can help to determine what the barriers and facilitators are for registration. Thus, this may enable developers to improve the current system so that registration processes can be improved.
Future work
Future work could include interviewing cardiologists about how they believe the design of a clinical pathway should look like. Furthermore, it could also include interviewing other care providers who are also involved in the treatment process of a patient with heart failure, like a nurse.
Conclusion
We conclude that the workflow of the cardiologist generally matches with the clinical guidelines, but may differ if the cardiologist, based on the person’s own experiences, disagrees with the guidelines.
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This may influence the acceptance of a clinical pathway when the end-users are not able to overrule it. Furthermore, although pathways are not suitable for complex workflows (e.g. treatment of a patient with a rare disease), it can improve quality of care and optimize work processes in cases such as non-acute heart failure patients.
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Chapter IV
Development of a computerized clinical pathway that can
be incorporated into the electronic health record
4.1
Introduction
In the previous chapters, we described what is known about clinical pathways for cardiovascular diseases. Clinical pathways have potential to improve care. We then gathered clinicians’ views on the workflow and how a pathway might improve it. Thus, the aim of this chapter is to make use of these findings to create a new computerized clinical pathway that can be implemented in an electronic patient record system.
4.2
Materials and Methods
Materials
We used the Business Process Modelling Notation (BPMN) technique for designing process of the pathway. BPMN is a worldwide standard to model processes. It is a graphical notation to understand and optimise business processes [34]. It represents the sequence of steps and decisions needed to perform a certain process, for example the care process of heart failure treatment. It is based on flowchart techniques, which is used within Unified Modelling Language to create an activity diagram. We used the Bizagi Process Modeller tool for designing the pathway. Bizagi modelling tool is a freeware application in which processes and documentation behind those processes can be modelled using a drag and drop interface [35]. A created process can be exported to XML Process Definition Language (XPDL), which was the supported format by the electronic patient record system we used to test the model.
Methods
First, we designed a workflow algorithm, based on the interview results. This algorithm was used as a basis to design the pathway. The ESC clinical practice guidelines were used as a reference to check whether all processes were in the algorithm. Then, we translated the designed algorithm into a BPM model. It was required to construct the model into four layers: Process → Phase → Activity → Task to make it able to integrate it into the electronic patient record system. The first layer ‘Process’ was an overview of the whole workflow. The second layer was a description of the different phases within that process. The third layer described the activities that should be followed within each phase, and the fourth layer was a description of the specific tasks that need to be followed to finish each activity. The following example gives an idea how the four layers are related to each other:
Process “Sick” has three Phases: Assessment, Treatment, and Evaluation. Phase “Assessment” has four Activities: Intake, Physical examination, Request laboratory tests, and determine treatment. Finally, activity “Intake” has four Tasks: Intake interview with patient, writing intake report, set up referral form, register time spent.
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4.3
Results
Algorithm workflow cardiologist.
The algorithm for the diagnosis of heart failure in the non-acute setting is shown in Figure 2. The algorithm starts with a referral from the patient’s general practitioner. The cardiologist evaluates the referral based on what diagnostic tests the general practitioner already performed. Following on this evaluation, the cardiologist assesses the heart failure probability by performing an ECG, echocardiography, and blood tests (including a BNP test). An evaluation of the patients’ prior clinical history and a physical examination will also be performed if this information is not known. If all test results are normal and thus heart failure is unlikely, the cardiologist sends the results and conclusion back to the General Practitioner. If heart failure is confirmed based on all available data, the cardiologist determines aetiology and starts the appropriate treatment.
Figure 2: Algorithm for the diagnosis of Heart failure (non-acute setting)
Business Process Model
The BPM model is described below. Each paragraph describes and explains the four different layers. The process of the whole workflow is depicted in Figure 3. It includes four phases, seven activities and in total 14 tasks. Each phase and its tasks should be executed before going to the next phase. The decision is made to not specify each task in sub tasks to keep it executable.
The first phase (Evaluation of Referral GP) has only one activity in which the cardiologist should decide what diagnostic tests should be performed (see Figure 4, left upper corner). The second phase (Assessment heart failure probability) is divided into three activities: ECG, Echocardiography, and Blood tests, each consisting of one task (see Figure 4). The third phase is split up into two activities: Assessment Test Results (see Figure 5), and Consultation (see Figure 6). During this first activity, the cardiologist should assess the diagnostic test results and predetermine heart failure probability. During the consultation phase, one of the two decisions could be made: sending a letter back to the GP because
Referral from General Practitioner
(Non-acute)
Evaluation of the referral
If HF confirmed Assessment of HF probability - ECG - Echocardiography - Blood tests Referral back to GP
Start appropriate treatment
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heart failure is not confirmed, or determining the appropriate treatment, because heart failure is confirmed. We decided to stop the pathway after the decision is made to send a letter back to the GP. If heart failure is confirmed, the cardiologist should determine and start the appropriate treatment (see
Figure 7).
Figure 3: The process of the whole workflow
Figure 4: Activities: Evaluating the referral (upper left), ECG (upper right), Echocardiography (lower left), Blood tests (lower right)
29 Figure 5: Activity: Assessment Test Results
Figure 6: Activity: Consultation
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4.4 Discussion and conclusions
Principal findings
With the use of a Business Process Modelling tool, we developed a computerized clinical pathway for cardiology that can be implemented into an electronic patient record system. The pathway only includes an algorithm for the diagnostic process of heart failure in the non-acute setting and correctly reflects the clinical guidelines. Additionally, it addresses the concern of cardiologists found in the interviews that a pathway may get too complex if patients present with different comorbidities. Therefore, this pathway is intended to support and guide the cardiologist in the diagnosing process and is designed for non-acute cases that are recurrent.
Strengths and limitations
This study provides a first impression and potential benefit of the usage of a BPM modelling tool to develop a digital clinical pathway. It provides an algorithm of what the whole workflow of the cardiologist generally looks like. The tool allows the user to define limitless tasks. The algorithm can be exported into a format that can be used for an Electronic Patient Record. A limitation of this pathway is that cardiologists are allowed to skip tasks, but they cannot undo their actions. In addition, due to lack of availability of cardiologists during the development process, the algorithm is not been verified by cardiologists.
Implications
This pathway can help to reduce workflow variability, because all tasks are predefined and based on the workflow of the cardiologists. Furthermore, BPM modelling is a workable method to create a pathway based on clinical practice guidelines. However, as a cardiologist’s workflow becomes more patient centered, it becomes more important to listen to the patients’ needs, rather than only follow certain guidelines. The development process of a pathway is therefore not straightforward. We imply that the pathway should also incorporate tasks that are based on what a patient need.
Future work
First of all, the BPM modelling tool had a steep learning curve and we have not tested the usability of it. Therefore, we suggest that future work should include a usability evaluation of modelling tools, including the tool we used. Secondly, the clinical pathway remains to be tested by end-users. Also, the pathway could be used as a basis for the development of pathways for other heart diseases. The method we used, using different layers, gives developers an idea how they could define all tasks in a structured manner. Finally, as mentioned in chapter four, we made use of a freeware modelling tool to design our pathway because it was compatible with a specific electronic patient record system. However, it is not known what the requirements for a modelling tool should be to make it compatible with any other record system. Therefore, future work should include investigating all relevant factors needed for a successful integration between modelling tools and health systems.
Conclusion
A Business Process Modelling tool can be used to translate workflows and clinical practice guidelines into a digital clinical pathway. However, it depends on the hospital information system whether it can be implemented into that system. Also, patients with heart failure may present in various ways, who will need patient-specific treatment [28]. Therefore, the development process of a pathway is not straightforward.
