A Process-Centered Approach to the Description of Clinical Pathways—Forms and Determinants
Abstract
:1. Introduction
- It is the patient, not the disease, who is being treated;
- The treatment process should include the patient and their closest relatives;
- Different clinical and extra-clinical pathways (management, support, logistics, and others) should comprise a cohesive system;
- Clinical pathways should be reflected in IT systems, used on an ongoing basis by physicians and other relevant personnel.
2. Related Works
2.1. Business Processes
- Structured (static, predictable, repetitive) processes—as described above, processes which can be described in detail, in advance, and optimized, due to the pre-defined conditions of all decisions taken at the time of implementation;
- Semi-structured processes, further divided into:
- Structured processes with ad hoc exceptions—processes for which detailed description is possible before the commencement of implementation, and determination of decisions, as a result of which, ad hoc individual tasks not provided for in the process description, can be realized.
- Unstructured processes with pre-defined fragments—processes, for which it is possible, to clearly define goals and the roles of participants, and to describe in detail, the fragments, with which implementation must comply, within the imposed standards.
- Unstructured (unpredictable) processes, where it is possible to define the aims of the process, but is impossible to define as a priority, the exact steps to be taken, in order to successfully execute the process.
- The first principle: comprehensiveness and continuity;
- The second principle: process execution should guarantee evolutionary flexibility;
- The third principle: processes are considered completed, only after having been documented.
2.2. Clinical Pathways as Processes
- Analysis of related works in order to determine the best clinical practice for each medical condition and incorporating it into the CPs;
- Definition of the care process in each CP;
- Creation of the multi-disciplinary teams and granting ownership of each pathway disciplines involved in the care process;
- Invitation of all medical professions to comment on each pathway before their implementation;
- Incorporation of CPs into the patients’ medical records;
- Implementation of the regular feedback loop to all health professionals involved in the CP.
- Patients and their closest relatives,
- Students of medicine and inexperienced doctors making first steps in a given speciality.
- Presenting the planned and performed CPs in a way that is tailored to the requirements of the performers;
- Possibility to present and enter data in the place where the clinical pathway is being executed, that is, at the patient’s bedside, in a clinic, ER, ambulance, or even in the patient’s home;
- An ergonomic approach to data entry, which is cognizant of the limitations faced at each specific phase of the process, with the use of robotic process automation and elements of artificial intelligence, such as voice recognition, image recognition, and recognition of handwriting.
2.3. Analysis of Existing Forms of Describing Clinical Pathways
2.4. Proposal of a Process-Based Approach to Describing Clinical Pathways
- Cumbersome (a size of even A0, i.e., 1 meter in width and height!);
- Cluttered (a large number of small objects and a plethora of interconnections);
- Too complex (includes a large amount of information, which is not pertinent to the specific patient).
- Standard procedures dividing processes into hierarchical levels: maps, process models, and action charts with information, with the adequate level of detail and adequate scope of subject matter [61];
- Standard goals and rules of dividing the entire process into sub-processes on specific levels, and a clear presentation of their interrelations [61];
- Notation of description of processes, independent of the country in question, the geographical area, and the IT tool used to model processes (e.g., Business Process Model and Notation—BPMN) [42].
3. Materials and Methods
- Patient diagnosis and the formulation of a treatment plan (patient diagnosis; preparation of an individual treatment plan (ITP);
- Patient treatment, including eventual modifications to the ITP (modification of the individual treatment plan; adding a step to the individual treatment plan; preparation of a medical treatment/procedure; reminder on the necessity of performing a step of the individual treatment plan; confirmation of the performance of a step of the individual treatment plan; analysis of the performed diagnostic–therapeutic process);
- Ex-post evaluation of the finished treatment (analysis of the course of a finished diagnostic–therapeutic process of an individual patient; comparative analysis of a finished diagnostic–therapeutic process and the clinical pathway; comparative analysis of multiple finished diagnostic–therapeutic processes and the clinical pathway; statistical analysis of finished diagnostic–therapeutic processes; statistical analysis of finished diagnostic–therapeutic processes).
- Clearer form of patient data, making it easier to make correct clinical decisions;
- Possibility of evaluating the treatment on an ongoing basis;
- Possibility of modifying planned ongoing actions on an ongoing basis;
- Possibility of analyzing use resources and the degree of their productivity;
- Limiting mistakes in treatment by monitoring;
- Possibility of easier comparative analysis with the use of anonymized data on the treatment of other patients;
- Better control over the operations of the organization.
4. Results
5. Discussion
6. Conclusions
- The possibility to analyze the treatment on an ongoing basis (27%);
- The possibility to dynamically modify planned and ongoing actions (23%).
6.1. Theoretical Contribution
6.2. Practical Implication
- The level of description;
- The character of the processes (the field that is being modeled), and the group of recipients; but also
- The phases of the process execution.
- Updating the medical knowledge contained in them based on the latest achievements of medicine, passing from Clinical Guidelines for Individual Treatment Plan (ITP) [12];
- Updating information on medical procedures that can be implemented within the health care unit, based on the common ontology underlying the CPs;
- Accumulation of knowledge on the basis of implemented or completed diagnostic and therapeutic processes thanks to the use of process mining techniques and the collection of data on clinical decisions taken and their impact on the course and results of therapy.
6.3. Limitations with Future Research Directions
- Analysis of preferences of users of CP presentation form conducted on a wide group of their users (doctors, nurses and other medical personnel);
- The identification of determinants for the description and presentation of CPs in different phases of their execution, on stationary and mobile devices;
- Development of a standard CPs integration format with ontologies describing resources and possible medical procedures, as well as knowledge bases or Evidence Based Medicine (EBM);
- The preparation of guidelines, with respect to the user interface for creators of HIS/EMR systems, as well as, more generally, creators of IT systems supporting dynamic BPM;
- Development and practical verification of the methodology and tools for gathering knowledge based on the implemented CPs and its use for ongoing support of the doctor’s work in the field of clinical decision-making.
Author Contributions
Acknowledgments
Conflicts of Interest
References
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Administration and Supervision Priorities | Physicians’ Requirements (Expectations) |
---|---|
The standardization of diagnostic and therapeutic processes on the basis of acquired knowledge. | Adapting such processes to the situation at hand and obtaining new knowledge from each subsequent performance. |
Planning and strict control over performance. | Empowering physicians to make independent clinical decisions. |
Cost optimization of the performed processes. | Allowing for the accommodation of a given performance to the needs of the individual patient. |
Form of Description and Presentation of CPs/Phase or Group of Performed Actions | Verbal Description | Structured Description | Block Diagram | Table | Checklist | Process Diagram | Gantt Diagram | 3D Process Map | Total No. Points |
---|---|---|---|---|---|---|---|---|---|
patient diagnosis | 2 | 7 | 4 | 6 | 18 | 6 | 0 | 1 | 44 |
preparation of an individual treatment plan (ITP) | 3 | 6 | 5 | 4 | 19 | 2 | 0 | 3 | 42 |
Total: The form of description of CPs in the initial diagnosis and treatment planning phase | 5 | 13 | 9 | 10 | 37 | 8 | 0 | 4 | 86 |
6% | 15% | 10% | 12% | 43% | 9% | 0% | 5% | ||
modification of the individual treatment plan | 2 | 3 | 3 | 3 | 16 | 5 | 0 | 0 | 32 |
adding a step to the individual treatment plan | 9 | 6 | 4 | 7 | 11 | 7 | 0 | 0 | 44 |
preparation of a medical treatment/procedure | 0 | 6 | 12 | 3 | 12 | 11 | 0 | 0 | 44 |
reminder on the necessity of performing a step of the individual treatment plan | 6 | 11 | 9 | 3 | 10 | 3 | 0 | 0 | 42 |
confirmation of the performance of a step of the individual treatment plan | 6 | 11 | 5 | 3 | 9 | 8 | 0 | 0 | 42 |
analysis of the performed diagnostic-therapeutic process | 0 | 10 | 3 | 7 | 3 | 3 | 10 | 2 | 38 |
Total: The form of decription of CPs in the patient treatment phase | 23 | 47 | 36 | 26 | 61 | 37 | 10 | 2 | 242 |
10% | 19% | 14.9% | 11% | 25% | 15.3% | 4% | 1% | ||
analysis of the course of a finished diagnostic-therapeutic process of an individual patient | 0 | 0 | 3 | 6 | 7 | 5 | 11 | 9 | 41 |
comparative analysis of a finished diagnostic-therapeutic process and the clinical pathway | 0 | 2 | 0 | 6 | 5 | 5 | 12 | 8 | 38 |
comparative analysis of multiple finished diagnostic-therapeutic processes and the clinical pathway | 0 | 2 | 2 | 8 | 2 | 10 | 11 | 3 | 38 |
statistical analysis of finished diagnostic-therapeutic processes | 0 | 5 | 0 | 4 | 2 | 7 | 12 | 8 | 38 |
statistical analysis of finished diagnostic-therapeutic processes | 0 | 5 | 0 | 1 | 5 | 7 | 12 | 5 | 35 |
Total: The form of description of CPs in the ex-post evaluation phase | 0 | 14 | 5 | 25 | 21 | 34 | 58 | 33 | 190 |
0% | 7% | 3% | 13% | 11% | 18% | 31% | 17% | ||
Total: The form of description of CPs expected by physicians | 28 | 74 | 50 | 61 | 119 | 79 | 68 | 39 | 518 |
5% | 14% | 10% | 12% | 23% | 15% | 13% | 8% |
Determinants of the Selection of the Form of Description of CPs/Phase or Group of Performed Actions | Clearer Form of Patient Data, Making it Easier to Make Correct Clinical Decisions | Possibility of Evaluating the Treatment on an Ongoing Basis | Possibility of Modifying Planned and Ongoing Actions on an Ongoing Basis | Possibility of Analysing Used Resources and the Degree of Their Productivity | Limiting Mistakes in Treatment by Monitoring | Possibility of Easier Comparative Analysis with the Use of Anonymized Data on the Treatment of Other Patients | Better Control over the Operations of the Organization | Total No. Points |
---|---|---|---|---|---|---|---|---|
patient diagnosis | 9 | 9 | 4 | 0 | 1 | 0 | 2 | 25 |
preparation of an individual treatment plan | 12 | 12 | 8 | 3 | 1 | 0 | 3 | 39 |
Total: The form of description of CPs in the initial diagnosis and treatment planning phase | 21 | 21 | 12 | 3 | 2 | 0 | 5 | 64 |
33% | 33% | 19% | 5% | 3% | 0% | 8% | ||
modification of the individual treatment plan | 10 | 11 | 14 | 0 | 4 | 0 | 3 | 42 |
adding a step to the individual treatment plan | 10 | 9 | 12 | 0 | 2 | 1 | 2 | 36 |
preparation of a medical treatment/procedure | 9 | 11 | 9 | 0 | 7 | 2 | 2 | 40 |
reminder on the necessity of performing a step of the individual treatment plan | 7 | 11 | 10 | 0 | 9 | 0 | 1 | 38 |
confirmation of the performance of a step of the individual treatment plan | 10 | 14 | 6 | 2 | 3 | 1 | 2 | 38 |
analysis of the performed diagnostic-therapeutic process | 3 | 14 | 10 | 4 | 2 | 3 | 6 | 42 |
Total: The form of decription of CPs in the patient treatment phase | 49 | 70 | 61 | 6 | 27 | 7 | 16 | 236 |
21% | 30% | 26% | 3% | 11% | 3% | 7% | ||
analysis of the course of a finished diagnostic-therapeutic process of an individual patient | 0 | 9 | 9 | 6 | 5 | 3 | 7 | 39 |
comparative analysis of a finished diagnostic-therapeutic process and the clinical pathway | 0 | 6 | 6 | 7 | 7 | 7 | 3 | 36 |
comparative analysis of multiple finished diagnostic-therapeutic processes and the clinical pathway | 0 | 9 | 9 | 6 | 6 | 6 | 3 | 39 |
statistical analysis of finished diagnostic-therapeutic processes | 0 | 9 | 7 | 4 | 7 | 5 | 4 | 36 |
statistical analysis of finished diagnostic-therapeutic processes | 2 | 9 | 6 | 6 | 5 | 5 | 3 | 36 |
Total: The form of description of CPs in the ex-post evaluation phase | 2 | 42 | 37 | 29 | 30 | 26 | 20 | 186 |
1% | 23% | 20% | 16% | 16% | 14% | 11% | ||
Total: The form of description of CPs expected by physicians | 72 | 133 | 110 | 38 | 59 | 33 | 41 | 486 |
15% | 27% | 23% | 8% | 12% | 7% | 8% |
Phase of the CP Lifecycle | Main Features of the Context of Executing the CP | The Preferred Form of Description of the CP | Determinants of the Choice of the Preferred Form of the CP Description and Presentation by Physicians | |
---|---|---|---|---|
I | Initial diagnosis and treatment planning | Usually the lack of direct time constraints. The possibility of consulting and modifying treatment plans multiple times. | 1. Checklist 2. Structured description 3. Table | 1. The possibility of analyzing the treatment on an ongoing basis. 2. Clearer form of patient data, making it easier to make correct clinical decisions. 3. The possibility of dynamically modifying planned and ongoing actions. |
II | Patient treatment | Time constraints (or very strong time constraints). The necessity of tailoring the prepare treatment plan to the course of a specific treatment, including unpredictable developments. Responsibility (the undertaken actions are often irreversible). | 1. Checklist 2. Structured description 3. Process diagram | 1. The possibility of analyzing the treatment on an ongoing basis. 2. The possibility of dynamically modifying planned and ongoing actions. 3. Clearer form of patient data, making it easier to make correct clinical decisions. |
III | Ex-post evaluation of finished treatments | No time constraints. The possibilit of consulting and modifying or supplementing the results of analyses multiple times. | 1. Gantt diagram 2. Process diagram 3. Table | 1. The possibility of analyzing the treatment on an ongoing basis. 2. The possibility of dynamically modifying planned and ongoing actions. 3. The possibility of analysing used resources and the degree of their productivity |
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Szelągowski, M.; Berniak-Woźny, J. A Process-Centered Approach to the Description of Clinical Pathways—Forms and Determinants. Int. J. Environ. Res. Public Health 2019, 16, 2638. https://doi.org/10.3390/ijerph16152638
Szelągowski M, Berniak-Woźny J. A Process-Centered Approach to the Description of Clinical Pathways—Forms and Determinants. International Journal of Environmental Research and Public Health. 2019; 16(15):2638. https://doi.org/10.3390/ijerph16152638
Chicago/Turabian StyleSzelągowski, Marek, and Justyna Berniak-Woźny. 2019. "A Process-Centered Approach to the Description of Clinical Pathways—Forms and Determinants" International Journal of Environmental Research and Public Health 16, no. 15: 2638. https://doi.org/10.3390/ijerph16152638