But take a look anyway, if you have an interest in process improvement in hospitals. This is a collection of my best posts on this topic.

Monday, November 27, 2006

What Works -- Part 2 -- Clinical Pathways

The Whipple procedure is a complicated and difficult surgical procedure. It is also called a pancreaticoduodenectomy, and it generally encompasses the removal of the gallbladder, common bile duct, part of the duodenum, and the head of the pancreas.This operation was first described by Dr. Alan O. Whipple of New York Memorial Hospital (now Memorial Sloan-Kettering).

The surgeons at BIDMC have developed a "clinical pathway" to guide themselves, related physician specialists, nurses, case managers and other involved in performing Whipples and taking care of patients before, during, and after this surgery. The clinical pathway is intended to assist physicians in clinical decision making by describing a range of generally acceptable interventions and outcomes. In other fields, it might be called a "decision tree." The guidelines attempt to define practices that meet the needs of most patients under most circumstances. While the physician must remain alert to deviations from the expected, the use of the clinical pathway can bring greater predictability to the entire treatment process in many cases.

The introduction of the clinical pathway for Whipple procedures at BIDMC has had very positive results. Here is a summary of the data pre- and post-clinical pathway.

Pre-clinical pathway period: October 2001-January 2004 -- 64 patients (42% male)
Post-clinical pathway period: February 2002-October 2006 -- 121 patients (53% male)

Age distribution: Mean for both periods = 64 (comparable range of ages)

ASA class of patients (degree of disease/difficulty)
Pre-clinical pathway: I (1.6%); II (51.6%); III (46.8%); IV (0%)
Post-clinical pathway: I(0.8%); II (39.7%); III (54.5%); IV (5.0%)

Pre-clinical pathway mortality = 1 death (1.6%)
Post-clinical pathway mortality = 2 deaths (1.7%)

Pre-clinical pathway ICU admissions = 8 patients (12.5%)
Post-clinical pathway ICU admissions = 16 patients (13.2%)

Pre-clinical pathway of stay/cost = 10.8 days/$23,536
Post-clinical pathway length of stay/cost = 9.8 days/$19,999

Pre-clinical pathway readmission/reoperation = 4 (6.3%)/4 (6.3%)
Post-clinical pathway readmission/reoperation = 10 (8.3%)/7 (5.8%)
(Both readmission and reoperation are measured within 30 days.)

To put all this into English, after the introduction of the clinical pathway, nothwithstanding a greater percentage of sicker patients, cost and length of stay decreased without negatively affecting mortality, readmission, or reoperation rates.
Patients and families also like the new pathway because they receive a roadmap of what to expect and when to expect it, and they can literally follow their own progress by looking at a chart on the wall of their room.

I don't mean to suggest that we are the only place to have clinical pathways, but they remain less prevalent than you might think. This is but one example to show how effective they can be when well designed and implemented by the entire medical team.

Friday, November 24, 2006

What Works -- Part 1 -- PatientSite

The first in a series of innovations that work (!) and make a difference in patients' lives:

A recent story on MSNBC called "Tired of waiting for the doctor?" made reference to PatientSite, our user-friendly, personalized electronic communications link between patients and their doctors, using a secure website:

Most patients have experienced playing phone-tag to get test results. That’s at least partly because of the traditional paper-based method of relaying information. Test results are transcribed onto paper, then given to the doctor, who then phones or snail-mails them to patients.

At Boston’s Beth Israel Deaconess Medical Center, patients can get test results electronically the same time as the doctor through a private online account called PatientSite. “There is no waiting for paper printouts to arrive by mail,” said Dr. John Halamka. All test results show up on the site, except those involving diagnosing cancer or HIV, “assuming that this news should be delivered in person,” he said.

PatientSite has been up and running for many years, well ahead of most of the industry. Patients like the fact that they can use it for a variety of routine functions -- from requesting prescription renewals, to making appointments and getting referrals, to viewing their own electronic medical records, including medications, allergies and test results, radiology reports and electrocardiograms. Doctors like it, too, because it frees them up to spend person-to-person time with patients on more important matters.

The long-term success of PatientSite also means that it can be used to study other new ways to improve care. Here is an example funded by the Robert Wood Johnson Foundation.

Try out the demo!