Background: Clinical decision making pathways (pathways) embedded within electronic medical record (EMR) systems are an innovative tool intended to assist providers in diagnosing and managing patient conditions. Pathways provide clinical decision trees with the ability access online risk score calculators and select orders for lab and imaging tests, medications, and consultations. Studies have shown that use of pathways can decrease cost and length of stay without negatively affecting patient physical functioning improvement or increasing readmissions1. Pathways are associated with a decrease in hospital complications and improved documentation2. A quality improvement study was conducted in a teaching hospital. This study sought to understand hospitalist interactions with pathways, something that has not been previously reviewed in published literature, in order to improve the interface and increase overall usage of pathways across providers.
Methods: Quantitative review of pathway openings were utilized to identify hospitalists with at least one pathway opening between July 2018 to May 2020. Providers received a high, moderate, or low user designation based on overall tertials of pathways openings (N=77; high n=24; moderate n=23; low=17). Semi-structured qualitative interviews were conducted with a sample from each group and with developers (n=16; high=4; moderate=6; low=4; developer=2). Three interview guides were established. Interviews were assessed for themes relating to user experience, perspective and expectations.
Results: Findings were consistent with prior internal studies indicating pathway usage depended on patient diagnosis and available pathways. Counter to initial assumptions of this study, higher clinical full-time equivalent was not associated with higher pathway usage. Providers expect pathways to be easy to locate and navigate, aesthetically pleasing, evidence-based, up to date, and efficient. They also would like pathways to convey standards of care, be useful as teaching tools, contain links to resources, and allow for orders to be easily placed. This differed from actual interface with pathways as pathways: were not as up to date as other resources, added additional steps to the ordering process and were therefore not efficient, would not change an experienced physician’s practice, and were not an established habit. Discordance exists between user and developer expectation of pathway interface. Developers indicate pathways would be most useful for experienced staff who used many pathways. Users indicated pathways would be most useful for new staff learning organizational processes. Providers reported expecting that pathways were intended to improve efficiency of care while this was not identified by developers as an expectation. Providers view the 2020 addition of a COVID-19 pathway as beneficial in addressing a novel and rapidly changing condition. However, providers were quick to clarify themselves as users of the COVID-19 pathway specifically and did not identify as a pathway user otherwise.
Conclusions: Even among high users, providers did not report consistent use of pathways. Discrepancy exists between developer intentions and expectations of providers. Opportunity exists in establishing pathway use as a norm for providers, creating comprehensive marketing campaigns to increase exposure to providers, and to optimize pathway functionality to improve utility to providers based on the information learned.