Clinical Pathway Specification at what Grain?

This relates to Dr. George Lundbery's video editorial available in yesterday's blog post here. According to his explanation the right clinical pathway (regarding a specific condition in his example) depends upon the stability of the patient. Apparently physicians are continuing to follow evidence-based practice when the patient has not been stabilized but then are not shifting to the less costly equally effective evidence-based practice when the patient has become stable. So what is at issue is the grain of the specification of what is the best evidence-based practice. I imagine that if the less costly practice was to be followed on both stable and unstablized patients, physicians would more likely conform. As it is, their conformance requires an adjustment in practice during the course of the clinical pathway.

What I am thinking now is that if clinical pathways are written at a high grain (relatively few dimensions of criteria) conformance by physicians is likely to be high. But as additional dimensions are added to the criteria (such as stability of the patient) rates of conformance are likely to drop because conformity becomes more difficult. As the specificity of the pathways becomes higher conformity will become more and more labor intensive and cognitively demanding. This will clearly lead to automated systems and physicians will be asked to input a lot of data, surrendering judgment to the expert system software. It will become increasingly time consuming to document why the physician disagrees with the output of the system and physicians will feel a loss of autonomy as their role becomes more nearly that of highly credentialed technicians.

There is a differences between pay-for-performance and pay-for-conformity. Under pay-for-performance judgment remains within the physician's discretion. Financial rewards are based upon outcomes rather than processes. Under pay for comformity, most judgment shifts to the automated system. I am not advocating anything here. The grain of the specification of clinical pathways and the distinction between pay-for-performance and pay-for-compliance have many implications I hope to explore in future posts.

Reflecting on An Information Technology Implementation Challenge

This is an initial reflection upon an assigned reading by Ann Scheck McAlearney in our textbook Health Services Management, Cases, Readings and Commentary (9th) by Kovner, McAlearney and Neuhauser. The title of the case is, "An Information Implementation Challenge." The focal character is Dr. Dan Johnson who has been appointed CEO of a hospital system. Johnson favors the adoption of new information systems including a computerized provider order entry (CPOE) system and or a more comprehensive electronic health record (EHR) system. The hospital system presently runs on paper-based systems and those systems are working. Dr. Johnson, a physician, is getting push-back from physicians and the supervisor of the medical records department. He has done his homework and can cite evidence that automated systems are better once through the period of deployment and transition. The case sets up a discussion of the challenges of transformational leadership. Those who are resisting a change have also collected "data" indicating that early adoption is problematic. Dr. Johnson favors early adoption and is planning his next steps carefully. He wants this to happen sooner rather than later. He realizes that if he pushes too hard he risks alienating good people whose work the success of the hospital system depends upon. He is inviting people to become part of a working group, but the key players he needs on board have strong reservations.

What is at stake is the future of the hospital system and the future of Dr. Johnson's career as an administrator. While some younger employees and physicians appear open to use of electronic devices the culture of the organization is not aligned with Dr. Johnson's plans. I see problems with all the "obvious" solutions. A likely future scenario is that he pushes forward quickly, the plan fails, the hospital system falters, and Dr. Johnson is forced to leave. The incremental approach (what Charles Lindblom termed, "muddling through") is not likely to be acceptable to Dr. Johnson. Sometimes you can't get from "here" to, "there" incrementally, and moving slowly becomes an excuse for not moving. Johnson should look for allies in other high places in the organization but he may not find any. It would be better if the energy for this initiative had emerged from within the organization and he had been "recruited" by others to become a sponsor. So far, his attempts to reason with people appear to not be successful. He is apparently not working from an external mandate that requires this change at this time. He is likely to call a meeting and find himself the lone voice in support of this idea.

I think Johnson has to assess the situation and consider that this fight may not worth the effort. Dr. Bernadine Healy, former president of the Red Cross, took on the culture of that organization trying to make needed changes and wound up sacrificing her career. If Johnson is indeed a lone voice in the culture of this hospital system he may be best for him to find another professional opportunity now. When reason is pitted against fear reason is likely to lose. The people who resist change are not bad, selfish or dumb. They prefer the known to the unknown. We all have a natural attachment to known ways of doing things, even if we realize that the status quo is not ideal. Concerns about job loss or spending less time in direct patient care are realistic concerns. Automation involves process reengineering which often results in reducing the number of employees and modifying the responsibilities of those who remain. Physicians rightfully value their autonomy and resist changes that may force them to explain some of the decisions they make regarding their patients. Transformation is costly and requires faith that the gain will ultimately be worth the pain.

It appears from the case study that Johnson has the ability to listen. It is necessary to listen in order to gain empathy for others. The key is to create an alignment of interests if possible. I am not recommending a political approach such as Nancy Pelosi collecting Congressional votes for healthcare reform one deal at a time. But I question that Johnson can win this one based on evidence-based management alone. He must address peoploe's fears, including possible job loss and possible reductions in professional autonomy. The external environment of healthcare organizations is changing rapidly. Organizations must adapt. By adapting they have some ability to affect environmental changes. A failure to adapt is risky. I am remembering the movie, "Other People's Money." Clinging to a dying organization is futile. As a physician Johnson had to make difficult decisions involving the best interests of patients. Now as an administrator he must make difficult decisions involving the best interests of a hospital system. He has to assess what is possible and what may not be possible. He has to assess how important the future of this particular hospital system is to him. It is not selfish to walk away from one situation to join another organization more ready to accept one's heart-felt beliefs. I believe Johnson needs some internal allies to be able to make this change.

There is an episode of the original Star Trek series in which Captain Kirk materializes in some strange parallel universe by a malfunction of the transporter. Spock and other team members in that other universe are evil deriveratives of the characters we know. Spock of the other university figures out what has happened and arranges for Kirk and others to return to the right universe. The following dialog is part of this episode named, "Mirror, Mirror."

KIRK: You're a man of integrity in both universes, Mister Spock.
SPOCK: You must return to your universe. I must have my captain back. I shall operate the transporter. You have two minutes and ten seconds.
KIRK: In that time I have something to say. How long before the Halkan prediction of galactic revolt is realised?
SPOCK: Approximately two hundred and forty years.
KIRK: The inevitable outcome?
SPOCK: The Empire shall be overthrown, of course.
KIRK: The illogic of waste, Mister Spock. The waste of lives, potential, resources, time. I submit to you that your Empire is illogical because it cannot endure. I submit that you are illogical to be a willing part of it.
SPOCK: You have one minute and twenty three seconds.
KIRK: If change is inevitable, predictable, beneficial, doesn't logic demand that you be a part of it?
SPOCK: One man cannot summon the future.
KIRK: But one man can change the present. Be the captain of this Enterprise, Mister Spock. Find a logical reason for sparing the Halkans and make it stick. Push till it gives. You can defend yourself better than any man in the fleet.
SCOTT: Captain, get in the chamber!
KIRK: What about it, Spock?
SPOCK: A man must also have the power.
KIRK: In my cabin is a device that will make you invincible.
SPOCK: Indeed?
KIRK: What will it be? Past or future? Tyranny or freedom? It's up to you.
SPOCK: It is time.
KIRK: In every revolution, there's one man with a vision.
SPOCK: Captain Kirk, I shall consider it.
(He beams them away.)

http://www.chakoteya.net/StarTrek/39.htm

Cultures change slowly, but they can change. One voice can possibly initiate a change if joined by other voices. In the case study, Johnson may find a way to change the culture of the organization he leads. Johnson has power but his power is derived from the support of those he leads. He appears to have the sensitivities needed to understand the situation in a systematic way. Logic may gain its end and his vision may be realized.