Vías clínicas: un viaje para mejorar los resultados, la eficiencia y la previsibilidad en la atención médica

Clinical Pathways: a journey to improve outcomes, efficiency, and predictability in healthcare

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Lengthy waiting lists for elective surgery are a daily struggle for patients and a headache for hospital managers. On one hand, they postpone the expected benefits of treatment, while pain and disability remain; on the other hand, delaying the procedures can have a significant impact on a facility’s financial security. In this article, we’ll be exploring the main causes and consequences of this reality in worldwide healthcare systems.

Before going further, there are some facts that we kindly ask you to keep in mind:

If nothing changes, those figures will keep spreading in the upcoming times with some major details pressing ahead: an expected always growing demand contrasting with the health workers shortage are fostering the perfect storm for healthcare systems.

Well, that’s why recruitment and retention efforts are key - but insufficient – drivers to handle such a complex challenge. New productivity enhancing and patient engagement strategies, linked with optimized processes will differentiate those providers able to increase capacity from those who will keep their patients and staff held hostage of lengthy processes and waiting times.

An unprecedented backlog is leading the way…

Long waiting times for elective (non-urgent) surgery have been a longstanding issue, dating back well before the pandemic, but COVID-19 has had a drastic impact on surgical delays, as providers have been forced to prioritize emergency and critical care cases. This shift in resources has resulted in a significant backlog of non-emergency procedures, including surgeries.

A study published in the British Journal of Surgery makes it explicit: 

28 million elective surgeries worldwide have been cancelled or postponed in 2020

 In the same year, surgery waiting times increased by about two months on average.

… and waiting times are turning the spotlights on hospitals (for bad reasons)

Anyone working in a healthcare facility knows that surgical waiting times are a “everyone’s reality”:

And we could keep listing… It is not unique, but it is crucial to understand the leading causes of surgical waiting times and to implement innovative strategies to mitigate them as soon as possible.

Finding the root causes for lengthy waiting lists in surgery 

The root causes of surgical waiting times can be attributed to a variety of factors. Most commonly, it is due to a lack of resources, such as insufficient staff and equipment, poor coordination between different hospital departments and administrative issues can also contribute to waiting times, as well as the sheer number of patients requiring care.

Starting with human resources. It’s well known that health systems are facing a severe shortage of workers due to two major reasons – retirement and turnover – and the second one has been aggravating with growing rates of healthcare workers burned-out. Guess what: perioperative professionals are included in this challenging scenario.

While a current global shortage of 199,000 surgeons and 87,000 anesthesiologists is already reported,

 USA statistics show that, at the present time, more than half of anesthesiologists are 55 years old or older.

a new wave of physician retirements is imminent

At the same time, the world’s population aged 60 years and older is expected to total 2.1 billion in 2050,

 representing an additional risk factor for multiple chronic diseases. The global demand for cancer surgery is expected to increase from 9.1 million to 13.8 million procedures over the next 20 years, and the surgical workforce will need to increase 47%.

Focusing exclusively this reasoning line, sounds obvious that human and technical resources availability are the number one bottleneck for surgical waiting times, but what about the surgeries that are supposed to happen, block hospital facilities and healthcare professionals’ agendas and are cancelled at the last minute?

Cancellations: the hidden face of surgery waiting times

Let’s put it plain: cancellations cost up to €450 million per year…

Evidence reports highly variable elective day of surgery (DOS) cancellation rates from 5% in Finland

It's easy to understand that if an operating room is expected to be working and it changes unexpectedly, there are heavy efficiency losses and waiting times will not reduce – quit the contrary. What is much more difficult to understand is why it happens due to preventable reasons.

…And around 80% of cancellations are preventable

Besides the lack of resources, such as staff or equipment issues previously mentioned as drivers for waiting times, the reasons why a surgery may be canceled include an unforeseen medical issue, such as a sudden infection or complication; the patient's condition not being suitable for the procedure; or the patient not being able to meet the pre-surgery requirements.

In this regard, recent prospective epidemiological study in NHS hospitals states that clinical reasons are responsible for 33% of historical cancellations and 28% of contemporaneous cancellations.

 This include cancellations due to poor preparation or unexpected deterioration in patient health.

Well, what this means in practice is that around 30% of

 cancellations happen due to clinical reasons that could beneficiate from more accurate risk-stratification 

and/or better coordination between different teams and/or care levels.

Once again, it’s not only about having more resources, but also about changing processes to improve the way things are done and make sure that those people are delivering their best.

Last, but not least, increased anxiety levels, often due to a lack of communication and information from the practice staff, are reported by 50% of patients,

resulting in them postponing or canceling the surgery altogether. All in all, preoperative instructions not being followed, lack of OR availability due to administrative issues, or patients simply not showing up, make up 70%

 of surgery cancellations. And all of them are preventable reasons.

patient engagement and navigation enablers’ strategies

, able to reduce either doubts or wrong behaviors that threaten surgery’s viability, 

have their say when it comes to reduce intra-operative cancellations

, consequently reducing – or at least not rising – surgical waiting times.

If you want to keep on top of efficiency tips to increase your OR capacity, read the next blog post. If you prefer to have a conversation about how to reduce cancellations and surgical waiting times, 

How much are hospitals loosing due to inadequate navigation and  cancellations? 

How much are hospitals loosing due to inadequate care navigation and intra-operative cancellations? 

Article co-authored by David Rodrigues and Eduardo Freire Rodrigues

The COVID-19 pandemic has challenged the practice of 

 (EBM) due to two major reasons: uncertainty due to the lack of evidence available, and the sense of urgency that emerged. How could healthcare agencies take this opportunity to shift from EBM to evidence informed decision-making (EIDM) in health? Which role do clinical standards and real-world evidence play in this shift?

 aim to ensure that every patient receives high quality and adequate care. This is usually achieved through agreed guidelines that support physicians and healthcare workers to improve the 

are the basis of an objective evaluation process that can help healthcare organizations measure, assess, and improve performance, through key performance indicators.

 Considering Archie Cochrane’s distinction between efficiency and efficacy in healthcare, clinical standards take on both purposes: setting the ideal conditions to maximize the beneficial change of a given intervention in the most inexpensive way.

Clinical standards are one of the available instruments to disseminate evidence-based medicine (EBM), which is currently defined as “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients”.

 The two principles that rule EBM sustain that: 

COVID-19: the urgency to find hybrid models for evidence production and translation into clinical standards

Traditional knowledge translation models, understood as “the exchange, synthesis, and effective communication of reliable and relevant research results (…) so that effective interventions are used more widely”,

 typically take many years of research. In a pandemic, which by its very nature develops and evolves rapidly, the great challenge is how to speed up this process, which is not at all compatible with the classical methodologies, not only because of speed but also because of uncertainty.

With the advent of the COVID-19 pandemic, health authorities – used to produce clinical standards based on robust and reliable evidence and methodologies – came across a new reality: evidence production was, at the very beginning, sparse, and, later, massive. However, due to the expedited thirst for information, still presenting wide differences in terms of 

Therefore, the COVID-19 pandemic has challenged our understanding and the use of EBM: the complex systems theory has been recently proposed to reflect epidemics as biosocial events,

 composed of complex and dynamic relationships in the real world which need to be addressed by a variety of methods, going beyond clinical trials, and dealing with information that is systematically more fragile and temporary.

FDA defines real-world evidence (RWE) as data about potential benefits or risks of a medical product derived from analysis of real-world data (RWD), such as big data, patient-generated data, data from registries, or electronic health records. RWE advocates state that this approach reflects more accurately what happens outside a controlled research environment. However, Schünemann outlines some risks that should not be neglected:

The future – and already the present – belongs to 

, able to incorporate distinct types of evidence:

 scientific (codified) evidence – both from clinical trial and RWE-, tacit (also known as colloquial evidence, since it often includes opinions, expertise, lessons learned, organizational tradition of policymakers, clinicians, patients, or citizens), global and local evidence. A structured assessment is still required as the basis for EIDM, but it is not enough. Development of living guidelines incorporating RWD/RWE, and data on values, available resources (including digital) and organizational factors are a way forward to face rapidly evolving scientific knowledge and a critical need to ensure compliance.

Reimagining clinical standards’ target: engaging civil society in evidence-based behaviors at post COVID-19

In relation to the people for which clinical standards are suitable, the pandemic caused two different effects. On one hand, healthcare professionals changed their perspective on clinical standards, and on the other hand, new (lay) audiences become aware of clinical standards’ importance.

 in the absence of unambiguous evidence, as reported by Simon Carley, -

“the nature of a pandemic is to push clinicians into a position where they must make decisions that are both time-critical and information light”

 - healthcare professionals changed the lenses through which they look at clinical standards, from a purely economic perspective bounding individual decision-making to a useful tool to approach a new condition surrounded by uncertainty. 

Moreover, COVID-19 demonstrated that these recommendations should overtake the physical frontiers of healthcare providers to guide social behaviors and drive political decisions. Perhaps like no other major event in recent memory, the pandemic has exposed synergies between science and policy, as scientists have played a key role in providing scientific advice to national and local governments on what to do at each moment. Usually in the background, epidemiologists were leading actors throughout the pandemic, since public authorities needed information on a real-time basis to track the incidence evolution, disease severity and health system impact, and the potential effect of interventions – e.g. testing strategies, vaccination rollout, nationwide lockdown, circulation restrictions, occupancy limits in public transport or cultural events.

Therefore, the COVID-19 pandemic brought to the fore 

 as a discourse of methods that inform the policy process, advocates a more rigorous, and systematic approach, on the premise that policy decisions should be better informed by available evidence and should include rational analysis. On this matter, a Global Commission on Evidence to Address Societal Challenges

 led by McMaster University made a wakeup call for decisive action by multiple stakeholders to ensure that evidence is consistently used to address societal challenges.

Finally, it should not go unnoticed that the success of many pandemic-related policies also depended on the public’s compliance with clinical standards. Evidence became a daily discussion matter not only for healthcare professionals but also for the general society. This represents another transformational shift, aligned with Huber et al. definition of health as:

This perspective stresses the traditional doctor-patient relationship and perceives citizens as active agents of change capable of navigating the health system.

Clinical standards should therefore evolve to establish the cornerstones for self-management support interventions, defined as “the care taken by individuals towards their own health and wellbeing: it comprises the actions they take to lead a healthy lifestyle; 

to meet their social, emotional and psychological needs

and has the potential to improve the efficiency of health services by reducing unnecessary primary care or hospital visits.

Clinical standards supporting the shift from evidence-based medicine to evidence-informed decision

Despite the information disorder phenomenon, the rise of “anecdotal medicine”,

 and the challenges imposed on the two distinctive domains of the evidence ecosystem - evidence creation and evidence application - both from a public health perspective and direct clinical care - scientific response to the pandemic has been remarkable. In an article for Nature, Helen Pearson stressed out that:

During health emergencies, when time is limited, scientific uncertainties and political pressures are high, and irrefutable evidence to support a decision may be lacking, decision-makers must consider the scientific evidence together with other political and social imperatives, such as the need to maintain the national economy, security, education, and the need of individuals to work to meet their daily needs.

 However, as health emergencies are fortunately non-routine events, training for this kind of decision making is usually lacking.

In this regard, the pandemic emphasized the need to switch from evidence-based medicine to 

. That is to say, decisions should be made putting together research evidence with public health expertise, resources, and knowledge about community health issues and local context, to make policy and programming decisions. In other words, policymaking – and not only clinical decisions – is made considering the 

most relevant, high-quality qualitative or quantitative evidence

 available, among other dimensions such as: community health status reports to determine the magnitude of a particular health issue in the local setting, the needs and interests of community members, the current political climate, and the financial and human resources available.

 from people engaged with decision making for the COVID-19 pandemic need to be disseminated as a heritage for future public health emergencies. In this article, we focused on 

clinical standards as a tool to support evidence-informed decision

, which asks for a revision of their development and dissemination process intending to:

 to discover more on how UpHill has been providing 

 to help the medical community and the work done during COVID-19 pandemic to 

Evidence-informed health: post COVID-19 lessons

Associate Professor in Health Management and Leadership at FCS-UBI, ISCTE-IUL, ISCSP-ULisboa

Introduction to eHealth in the context of national and EU challenges

To better understand current trends and directions of eHealth in the European Union (EU) there are three fundamental referential and what are three more specific, yet very relevant, tendencies or lines of work being explored right now. The three fundamental referential documents are:

Although different the lines of focus that these document outline, they obviously intersect with each other in more than one way. They also have relevant differences namely regarding proponents, commitments, and target audiences. All of them, currently condition lines of work in EU funding for research and developments, for interoperability and harmonization efforts, as well as eHealth implementation projects more broadly.

Such conditioning is not just at EU level, like for example cross-border eHealth Digital Services like country-to-country exchange of ePrescriptions, but actually and increasingly, at national level. This is very important trend to analyze as, in the EU, health is a prerogative of member states, ie. it is not part of the treaties that establish the EU. However, thought the fact that there are cross-border movement of goods, services and citizens, there is not just a growing need for harmonization and interoperability, but actually since the publication of the, so called, Cross-border care directive (DIRECTIVE 2011/24/EU), there are also legal imperatives for cooperation.

The Digital Single Market (DSM) also acts as a powerful enabler as communications and digital markets are regulated at EU level and via that way influence and cooperation is needed and justified increasingly in the areas of eHealth and Digital Transformation. Regarding the Digital Single Market Strategy, it is built on three pillars. These have influenced many calls and ongoing support actions. With regards to eHealth it has meant an important energy in standardization work as one of the challenges is the lack of interoperability in the many existing technologies and applications, which limits the “single” digital market, dividing it into language or country markets. The downside of this is larger costs for healthcare providers as they face low competition, severe vendor lock-in and difficulties in switching systems if they so desire.  The MWP 2018-2021, and its support Joint Action (eHAction) have four areas of work of which “overcoming implementation challenges” included efforts related to interoperability, e-skills for professionals, data protection and data security and evaluation, which are highly relevant.

Finally, in 25th April 2018, following a mid-term review of the DSM strategy, the European Commission felt a need to focus some of the aspects and principles of the DSM, into the specificities of modern health and future health and care in the Union. The Communication highlights the importance of advancing the Digital Transformation of Health and Care (DTHC), laying out three priorities to be followed in the coming years. This is very useful document for eHealth and Digital Health strategic planning and its three outlined priorities, to some extents relate directly to the three pillars of the DSM. Of higher relevance to this paper is pilar 1: “Citizens’ secure access to electronic health records (EHRs) and the possibility to share their records across borders, and the use of e-prescriptions”. In sequence we saw the publication of the Recommendation on the European Eletronic Health Record exchange format (EHRxF), based on which the eHealth Network approved important recommendations on the Interoperability ecosystem and funding criteria linking for the first time funding of projects and structural funds to interoperability solutions and harmonization efforts and setting the grounds for conditioning EU funding in the future Multi-Annual Financial Framework (MFF 2021-2027).  The three recent tendencies of focus from the European Commission that trigger action in EU Member States, and which deserve special attention by health leaders are:

These are not isolated items, but rather new focus of attention within the scope of the strategies presented before. These trends are somehow future looking, necessary research and development efforts, but link to interoperability of systems and information in health as they all have two things in common: i) need for large volumes of interoperable datasets, and ii) high quality of the data, with regards to its semantic interoperability and its capacity to be a true capture of health reality.

LOST Interoperability framework, LOST-IIS, and healthcare guide for interoperability

Many years ago, the EU has adopted the famous European Interoperability Framework, which has been further refined and adapted to health into 6 layers, but the famous four, 

LOST) interoperability layers are still the best way to explain interoperability to non-technical people.

Finally, however, I have argued that the famous LOST interoperability framework should be enhanced with two final ‘I’s’ and an ‘S’, which would stand for:

A LOST-IIS approach to digital health is needed at all levels: from Global to National, and from National to local and institutional. Through a holistic global and sustained approach to digital health worldwide, I believe we will see digital health as the only way forward for Universal Health Coverage, for fair and balanced healthcare transformation. Such transformation starts in healthcare organizations but also extends to digital solutions providers who benefit from participating in forums such as, per example, HL7 Chapter Portugal or its equivalents in other countries.

Interoperability challenges and (re)Emerging Technologies

At present, the main ehealth interoperability challenges are:

Interoperability is much more than technical interoperability; the organizational dimensions are perhaps the least appreciated and ill-managed by healthcare organizations. Multidisciplinary boundary-spanning capacities are needed to consult and help healthcare organizations excel in how they integrate with others and integrate their services, value circles and, at the end of the day, deliver or foster better health and care.

Levels of interoperability in healthcare

Efforts to improve healthcare quality and providers’ efficiency have resulted in 

the production of practice guidelines and implementation of clinical pathways

. According to a 2019 European Observatory on Health Systems and Policies’ report, the use of clinical pathways has been growing in Europe since the 1990s, beginning in the United Kingdom, and spreading to most European countries. However, the European Pathways Association (EPA) concluded that, within the last decade, their use was low and mainly in acute care settings. The same document reveals that 

experienced professionals rank improvement of care quality and efficiency among the most important features of clinical pathways.

rapid access to evidence-based resources for professionals to support decision-making, treatment, care planning, referral, and follow-up. 

improve communication and teamwork in multidisciplinary teams

. Last, but not least, clinical pathways have also been reported to 

mitigate risk, be effective in improving patient care outcomes and reduce cognitive overload

A more recent study, conducted within the Department of Pediatrics of the University of Colorado School of Medicine, discloses physicians’ thoughts about clinical pathways’ benefits, covering all the above-mentioned areas. Thus:

Why measure the impact of clinical pathways?

Measuring clinical pathways’ impact provides decision-makers and healthcare teams a means for comparing outcomes resulting from standardized processes implementations within or across organizations, thus, being able to:

Essentially, monitor and measure how reality conforms with the clinical pathway promotes the identification of training needs, the quantification of HCPs' performance and medical processes improvement. Actually, if not properly adhered to, clinical pathways implementation will most likely be unsuccessful in enhancing the quality of the care provided.

How to measure: clinical compliance vs. clinical outcomes

Healthcare organizations that already measure clinical compliance with a pathway usually have an incorrect, not updated, or oversimplified view of the actual conduct in a patient careflow. 

Quality measurement has focused mainly on clinical isolated outcomes of care in specific settings (e.g. length of stay, costs, infection rate, etc.). Although these measurements provide valuable information, the diagnostic and therapeutic actions must be considered as well, that is to say compliance measure.

To achieve all the aforementioned goals, you need more than to look at the results. It is often the case that a hospital measures an outcome, but don’t know which decisions led to that particular result and, by widening the time frame, results fluctuate randomly.

By comparing the collected data with the prevailing clinical pathways, it is possible to identify where the care given has deviated from the expected and quantify the compliance level. 

In practice, hospitals have information systems to capture the treatment behaviors and the details of a patient treatment journey. By comparing such data with the regulations of a clinical pathway, it is possible to assess the compliance of healthcare professionals to the expected course of care and understand the main deviations.

All in all, which actions were missed should be identified and understood, but also the ones executed even though are not recommended, performed in the incorrect order, or within the improper timing.

Our role is to bring actionable clinical pathways to hospitals, making them available for healthcare professionals to train and decide. Therefore, reducing the time it takes for scientific innovation to have an impact in care settings, improving patient outcomes, and making organizations more predictable in terms of costs and results.

Measuring the impact of clinical pathways

The provision of quality hospital services depends on the suitable and efficient execution of processes, understood as a series of activities aimed to diagnose, treat and prevent diseases and improve a patient’s health. Changes in processes – such as the adherence to the Enhanced Recovery After Surgery protocol 

 or the prompt administration of appropriate antibiotics in the management of patients with sepsis 

 – have proven its worth to improve outcomes.

, executed by different types of professionals, and can vary from one organization to another, according to the resources and infrastructures available. However, reality often deviates from the clinical practice guidelines. That’s why, in this article, we are going to explore process mining - a method for Business Process Management (BPM) and analysis, focused on extracting knowledge from data generated and stored in corporate information systems in order to analyze executed processes – and its applicability in healthcare.

First things first: what does process mining mean and what does this concept brings to healthcare?

Process mining is gaining increasing attention in healthcare. Adopted in the domain of BPM, it is useful to extract knowledge and non-trivial information from the process executions, to discover, monitor, and improve processes. It provides a comprehensive set of tools to return fact-based insights and, thus, to support process improvement.

In short, process mining applied to healthcare involves 3 variables: 

A literature review performed by Rojas et al. identified and classified the most relevant common aspects in which the application of process mining is useful in healthcare. Today, we would like to highlight the following:

That being so, process mining ensures that not only the healthcare processes are well-understood, but also allows to achieve a high level of process efficiency. Healthcare organizations can 

 whether certain practices were really followed, and 

 into resource utilization and performance-related aspects. At this point, we’ve arrived at the three main current types of process mining: 

The first two dimensions mentioned – discovery and conformance checking – can be applied to implement and evaluate clinical pathways compliance. In a first moment to design or redesign processes within a healthcare unit, and after for performance analysis and conformance checking.

This perspective is particularly interesting when it comes to assessing the compliance between a 

 - the term assigned to the evidence-based medical treatment processes of operational nature that healthcare professionals should act in accordance with - and the real medical behaviors.

Clinical pathways provide detailed guidance for each stage in the management of a patient (treatments and interventions), but multiple variances may still unavoidably occur due to individual complexities and subjectivity. 

 Due to the gap observed between what is stated by updated scientific evidence and effective care settings, clinical pathway compliance checking is of utmost importance in the healthcare environment.

For this purpose, when applying process mining techniques and technologies, healthcare organizations are able to compare a given process model with all process executions in reality. The objective is to output a set of compliance metrics to measure the observed deviations. Gathering insights on the actual clinical practice is receiving increasing attention, due to the potential of the information extracted. In the mentioned scenario, clinical pathways compliance analysis is the process of discovering knowledge about how clinical activities impact the patients careﬂow and using the discovered knowledge for: 

Despite the difficulties due to the richer diversity and complexity of medical behaviors over other business processes, discovering process models and analyzing their performance provides relevant opportunities for extracting knowledge out of the abundant information recorded in a hospital’s EHR.

Process mining in healthcare management

Como empresa de software y contenidos médicos que ha estado trabajando codo con codo con los principales hospitales y empresas farmacéuticas de Europa, en este libro electrónico compartimos algunas reflexiones teóricas y consejos prácticos para ayudarle a conseguir coherencia, aportando vías clínicas procesables a su unidad sanitaria.