Improving Quality and Efficiency of Care through Clinical Pathways with Dr. Andrew Buchert

Clinical Pathways: Driving High-Reliability and High-Value Care | Pubmed.gov

What is a clinical pathway? Development of a definition to inform the debate | Pubmed.gov

Clinical pathways as a quality strategy | NIH National Library of Medicine

Health Informatics | The University of Pittsburgh School of Medicine Department of Pediatrics

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Voiceover: This podcast is for informational and educational purposes only. It is not medical care or advice. Clinicians should rely on their own medical judgements when advising their patients. Patients in need of medical care should consult their personal care provider.

Welcome to That's Pediatrics, where we sit down with physicians, scientists, and experts to discuss the latest discoveries and innovations in pediatric healthcare.

Dr. Allison “Alli” Williams: Hey, I'm Alli Williams, a pediatric hospitalist here at Children's Hospital of Pittsburgh.

Dr. Sameer Agnihotri: I'm Sameer Agnihotri, an assistant professor in the Department of Urological Surgery.

Dr. Williams: And today we are so excited to be joined by Dr. Andrew Buchert. Dr. Andrew Buchert is a member of the Paul C. Gaffney Division of Pediatric Hospital Medicine, but in addition to all of the wonderful clinical work that he does here through the hospitalist role and his clinician educator role, he is a champion of quality improvement and providing high value clinical care to our patient population here at Children's. Thank you so much for joining us.

Dr. Andrew Buchert: Thanks for having me.

Dr. Williams: It looks like from reading your bio, that you've trained in various different places, and so Sameer and I always like to start with kind of an easy, fun question, and since you've been so many places, I was wondering if you could tell me one of your favorite things about Pittsburgh.

Dr. Buchert: That is a great question. I would say my most favorite thing about Pittsburgh is that you get all four seasons. I love having some winter, some fall, some spring, and some summer, and where I came from in the South it's summer for a lot of the year, and then winter is a little more fall-ish, sometimes spring-ish, so it's great to have all four seasons. I love having a mix of some snow and some good sunny weather.

Dr. Williams: Yeah. As a southerner myself, I joke that the South is usually hot, hot, and Christmas are the seasons that you get down there. So, it's truly nice to have that here in Pittsburgh.

So your role here is not only as a clinician through our hospitalist division, but you're also one of the leaders of our clinical pathways. And we would love to talk to you more about that and how it started. So I guess the first question would be, how did these pathways come about and why do we have them?

Dr. Buchert: Yeah, it's a really interesting question actually, because long before I was even here and involved in this in any way here at UPMC Children's, the teams that had been working on guidelines actually had a long history of putting together algorithms of care and coordinating with an interdisciplinary way algorithms that were used to drive care for common as well as less common diagnoses.

So starting in the early 2000s, they started to rapidly build up this list of diagnoses with algorithms associated with them. And by probably about 2010 or so, they already had 100 to 150 of these. And so when myself and then the team that I built as we got started with this around, it was probably about 2015 or so when we started this, we walked into a scenario that was very, very helpful because we had the groundwork.

And the other really key part about this is that the culture here has always been, what's the guideline, what's the pathway, what's the algorithm of care, and so it's been a longstanding culture amongst our trainees and our faculty and our nurses to really look for that guideline of care.

And so one of the biggest questions that I have gotten as I share this around the country is, how do you get buy in? How do you get your faculty and your teams to want to do this? And I always say that it's actually been really easy here because that's always been our culture. And in fact, we actually have the opposite problem, that everybody wants a guideline or a pathway for everything. And it's a great problem to have, but we have to triage that sometimes.

Dr. Williams: And so you've used the term both guideline and pathway. Are those the same things or are they different in different ways?

Dr. Buchert: Yeah, I'm glad you asked that. So when we first started this, we had what we referred to as guidelines, which was essentially an algorithm of care. And as we began this transition to what we're now calling pathways, we really felt that there was an opportunity to take those existing guidelines, or as we build new guidelines, build in more than just an algorithm of care. And so as we have transitioned to what we now call pathways, it's an algorithm which is the existing guideline or a guideline like we used to have, but we now add to that a narrative that's an educational narrative that is provider and nursing focused. We add patient and family focused educational material that's provided to patients and families, both sometimes on admissions, sometimes at discharge. And then we've also built in measurement. And really that differentiator building in measurement of tracking, how are we doing with adherence to this and what's the impact of it, is what we differentiate now as a true pathway as opposed to a guideline, which is still more of an algorithm of care without that extra component.

Dr. Agnihotri: That's so exciting. Is there an example you can give us of when a clinical scenario requires a pathway?

Dr. Buchert: Yeah, that's a great question. So we have pathways for a lot of our common diagnoses. One of the ones that jumps out at me that I think is a great example of this is we recently built a G-tube pathway. So this is a G-tube maintenance and care and troubleshooting pathway that actually started with our surgical division that's been very involved with some of our initial pathways wanting to standardize the G-tube placement process, which we did. And then as we did that, we realized that there's a whole lot of troubleshooting and maintenance that happens with G-tubes down the road, that some of it happens within the emergency department or while patients are admitted, some of it happens in primary care offices, some of it happens in the surgeon's clinic space, but there's a huge opportunity for us to really standardize these elements of how do you take care of a patient's G-tube going forward, and then sharing that out with the primary care providers, including those outside of our system, as well as with other community resources, such as school nurses.

And so we built a comprehensive pathway that includes those initial elements of standardizing that procedure of how do you go about evaluating for a G-tube and placing a G-tube and the post-operative care and feeding initiation. But then we added in all of the maintenance that goes along with that and troubleshooting, and we've shared this with our community liaisons and our primary care providers as, here's an instruction manual for when you see a patient in your office whose G-tube has some granulation tissue or is leaking, or if you're not sure if it's infected or not. Here's pictures and here's guidelines of what the surgical team would do so that you can provide this care in the office and hopefully keep kids out of the hospital if they don't have to be in the hospital. It's really the right care at the right time at the right place.

Dr. Agnihotri: Right. And this is so fascinating. One question I have is, pardon the puns and stuff, but how do you take an alternate pathway? And what happens if you have a roadblock in your current pathway?

Dr. Buchert: Yeah, that's a great question. So we actually build in what we call on ramps and off ramps. So we build in inclusion criteria and exclusion criteria, so from the outset, we try to make it very clear which patients should follow the pathway and which patients really wouldn't qualify for this pathway to start with. And then as you go about the pathway, we build in these off ramps. So if a patient hits a certain roadblock and there's something that doesn't fit what we're describing in that algorithm of care, then you would exit that pathway, and then we build in what those next steps are, which may be consult pediatric surgery or send to the emergency department depending on that setting of care.

Dr. Williams: And are these pathways that we make with the on ramps and off ramps, are they monitored regularly to know if we're having too many patients go off pathway and maybe that pathway is not the best pathway for the patients?

Dr. Buchert: Yeah. So, all of our pathways that we built in that measurement component, really that's exactly why we did that. So we have behind the scenes some very innovative, comprehensive dashboards that our analytics team builds for each of our pathways, and those dashboards are designed to pull data from the electronic medical record to help us to track the outcomes that we want to track for each pathway, and we really rely on the clinical champions to tell us what those outcomes are, but then also allow us to really track some of those other secondary adherence metrics that come along with it, such as what you described. Are we using the pathway enough? Are we exiting the pathway enough? Are there patients who would qualify for it who aren't actually going down that pathway of care? And then we also look at some of the secondary outcomes such as, are these patients returning to the ED? Are they being readmitted?

So it really helps us to measure the success of that. And I would add that one of the key components of that measurement that we do is a lot of institutions pull that from orders, so if you order certain care it goes to the dashboard. We actually pull from the orders because we're curious to see what the order is, but we also pull the outcome of that care. So an example would be a patient who's getting albuterol. If albuterol is ordered, we can pull that, but what we're actually looking for is from the MAR, from the medication administration record, was that patient actually getting albuterol? Was it actually administered? So we actually look at the care that was actually administered as opposed to the care that was just intended.

Dr. Williams: So is that then, because some of this sounds like it's computerized, but that must be person centric then to look in the MAR?

Dr. Buchert: So we can build in logic behind the scenes that actually pulls all of that out of the EMR and then puts it on a dashboard, so we can see that this was ordered and then was it actually followed through on and actually delivered to that patient?

Dr. Williams: Wow. My gosh. That's very cool.

Dr. Agnihotri: This is so cool and very important. Can you give us a little bit of information in terms of the research behind this? Do you need more funding and how does one develop these pipelines and the optimization? It's so important and vital, but it seems like it's also a lot of time and investment to build these.

Dr. Buchert: Yeah, yeah, it definitely is. So as we started this, we were fortunate that we had a significant investment that was a partnership between UPMC Children's and the University of Pittsburgh School of Medicine. And under the Department of Pediatrics, we actually established a division of health informatics that Dr. Suresh, who is our chief medical information officer, actually runs that division. And so by building that, we were able to actually bring in some of the analysts and the really technical people who do the building of the dashboards and the logic under that division to be able to support those team members and expand over time.

The other thing we've been able to do is we have a team of primarily nursing informaticists who serve as liaisons and pathway coordinators, and are really the primary people now who are interacting with the front lines as we build these pathways. Our team probably consists of about, I would say, six people right now who do this, with myself overseeing them from a medical director perspective and really setting that strategy of what we do.

We always can use more people because, like I mentioned earlier, the triage of being able to build all these pathways really does take a lot of person time and coordinating of discussions and meetings. And when we first started this, it would take about six months to go from the idea outset to the launch of a pathway. We're now down to about three months, but it's still a lot that goes into that and we're really working on our capacity to be able to do multiple ones concurrently. And we do a pretty good job of that, but there's always opportunity to bring in more folks, so we're always looking for other people who are interested in helping to make an investment in this so that we can continue to expand this team.

Because we think that particularly as we start focusing more on pathways that we're sharing with our primary care providers and our school nurses, and really fulfilling our population health mission, we're going to need to be even more robust with pulling in data as well as partners outside of our immediate healthcare organization to be able to continue to move forward. So it's really exciting, but definitely looking for further investment to help us with our innovation.

Dr. Williams: It sounds like you could have a pathway for almost anything. And you had mentioned like 110, 115, when you even first got here. How do you decide what qualifies to need a pathway or that should have a pathway?

Dr. Buchert: Yeah, that's a great question. So when we first hear of an idea, we'll often look at the volume of patients that are going to be impacted by this, as well as the degree of the change in practice, if there's a change in practice, or how important that reduction of variation is going to be, there are certainly instances where just an algorithm is more than enough. There are patients that we may not see these diagnosis very frequently and so just having a really good algorithm that we build and have available is all that we need. And then there are the patients that we know we see a lot of them and there's opportunities to improve the care that we provide to them, both within our walls as well as across the continuum of care, particularly our chronic diagnoses like asthma and diabetes. Those are really the ones where a comprehensive pathway is the key.

The other thing we've learned is that the process that we use, and really going back to the culture that our organization has of looking for a pathway, that's really helped us with other ideas as well. So an example is hyperbilirubinemia. There once was a time where a lot of these babies went to the NICU and we realized that we didn't need to send all these babies to the NICU, and so building in a way that we could very rapidly triage which babies did need that higher level of care versus which babies could we adequately manage on the acute care floor, using the pathway approach was really the best way to implement that. And we've actually used that with several other hospital wide initiatives. That building it into a pathway approach is the best way sometimes to reach our frontline staff and really drive that change in care that we're looking to drive.

Dr. Williams: And I bet that had huge implications, not only for hospital length of stay, but also for that one in particular family financial burden and insurance costs as well, ICU versus acute care for.

Dr. Buchert: Absolutely. And even looking at our own internal hospital costs, which we also look at very closely as a part of our pathways, it's just one of the metrics that we look at, each year now we have about 1.8-$2 million that we save year over year with our pathways that we've implemented so far.

Dr. Agnihotri: Wow. You lightly touched upon this with collaborations locally. These pathways, are there conferences? Are there international or national collaborations to strengthen your pathways? And have you helped other institutes with pathway implementation?

Dr. Buchert: Yeah, we've definitely helped other institutions with this. We've been very active with sharing this work throughout the country, both via Children's Hospital Association, myself, and some members of my team have presented numerous times through CHA and the quality world. I sit on some of the quality groups within CHA and have been able to continue to share this over time.

We've been a part of a few collaboratives that have started up recently. There was one a couple of years ago that started out of Texas Children's that was a national collaborative around developing pathways at multiple children's hospitals. And so we shared our process and our approach and that went into that collaborative, that really led to a lot of work at some of the other hospitals.

We've actually, myself and some of my team members, have published a couple of textbook chapters around this, particularly focused specifically as pathways as a way of driving pediatric safety and quality, and that's really been used as well to share the approach that we use and share the messaging of this.

And it's probably about a couple times a month that I get emails from other children's hospitals asking to learn more about our team and our approach. In fact, there's one from another children's hospital, smaller children's hospital in this state, that we're trying to schedule some time to have a discussion and share some of our approach as they start to build their team. So it's been very well received. It's exciting.

Dr. Agnihotri: That's fantastic.

Dr. Williams: That's amazing. Where do our providers find all of this information then to start using these pathways?

Dr. Buchert: So one of the really fortunate things about UPMC is that the Infonet is a great way to share and have this information available throughout the entire organization and have it instantly accessible. So all of our pathways and guidelines live on the Infonet. We actually have a specific page where they live, however, the best way to access them is at whatever your Infonet homepage happens to be, which could be your personal homepage on your computer desktop in your office, or, if you're on a clinical desktop, and whether you're here at Children's or up at UPMC Hamot or in an office somewhere in one of our CCP offices, whatever that homepage happens to be, on the search bar, if you type in a common pediatric diagnosis, asthma, cellulitis, hyperbilirubinemia, jaundice, any of those, or any diagnosis you can think of, our pathway or guideline is going to be one of the first search results that pops up when you do that, and you'll have all the material right there in front of you.

We also link to it within our Children's EMR, but we think that having it on Infonet helps us to rapidly share this across our entire system.

Dr. Williams: So then how does the information get to the school nurses as well? Is this something that we have to print and share with them? How do they have access to this?

Dr. Buchert: Yeah, we're working on the evolution of that. And the way that it happens right now is that we have a separate, it happens to be a Google Drive, but it's a separate drive that's accessible to the school nurses because they're outside of our system, and so we're able to upload those pathways and guidelines that are relevant to them. And actually many of them, they have their own version that's very specific to what they do in the school, but we're able to have all of that on that Google Drive.

We're actually looking at ways to have this more accessible in a more public way, because we think it's important to share this. So those conversations are ongoing and we're hoping to have this even more available to our community partners outside of the UPMC firewall.

Dr. Agnihotri: That sounds fantastic.

Dr. Williams: That's exactly what I was thinking, because you had mentioned PCPs earlier too, and even if they know what the inpatient criteria is for certain diagnoses and can help determine whether a patient needs to come here or not. For example, for cellulitis, if you had them on the first line medication that wasn't working, and then, what is the second line, when do they need to come to the hospital, what are those areas where it's the most worrisome, could be really helpful for patients and providers.

Dr. Buchert: Absolutely. And in fact, that actually gets to one of the other outcomes that we've seen with this is really improving the experience for patients and families, but also for providers. We've seen that sometimes very well intentioned providers might set an expectation that is not exactly what happens here at Children's, or vice versa. We might set an expectation that's not exactly what that school nurse is able to do, and the patient and the family might feel like they're hearing different information.

And even within providers within the organization, I always say that we often say the same thing, but in different ways and so it sounds different, and standardizing the verbiage that we use, standardizing the educational materials, really helps all of us, our providers, our nurses, and everyone in the care continuum to say the same things in very similar ways so patients and families hear that it's the same. But from a provider perspective, it also helps to avoid sometimes those awkward situations where you're seeing a patient and their beloved pediatrician has told them that these things might happen and those things aren't necessarily going to happen and you feel a little bit stuck.

And so we really have heard that it's helped to provide the increased wellness from a provider perspective, as well, to know that those expectations are being set at the outset and that we're all hearing the same things said in the same way.

Dr. Williams: I imagine it's great for trainees here too, as we have so many different residents, and we have residents visiting from family practices, family practice residencies, we have our own pediatric residents, surgical residents, et cetera, so they can learn from these as well.

Dr. Buchert: Absolutely. And in fact, one of the things we always say to our visiting resident is if they're visiting from a UPMC hospital, we make sure they know how to access these in their own practice. And if they're visiting from a non-UPMC hospital, we always tell them that we want them to take these with them so that they have them available now, and that we're working to get them more publicly available, but also it's a good way for them to know that we're always here to help them and they can always call us and we're happy to walk them through our pathway or our guideline when they are out in their own practice in the community.

Dr. Agnihotri: You touched upon this a little lightly, maybe you could expand a bit more, but by standardizing and harmonizing these pathways, it seems that patient care is going to improve tremendously. And so as a medical director, do you have a short-term goal and a longterm goal in terms of getting these pathways more standardized, out to more communities to improve medicine?

Dr. Buchert: Yeah, absolutely. So our really high level goals are really twofold. The first is high value care, and that really is the absolute safest, highest quality, most cost effective care that happens across the entire continuum. And then our secondary goal is building our population health approach, making sure the right care is happening at the right time in the right place for everyone always.

And putting those two together really helps us to build those metrics that we track. And so some of that is related to continuing to expand our pathways. We have a goal of every year adding an additional 8 to 10 pathways. We have a goal of continuing to expand where those pathways reach along the entire continuum, making sure that most of our pathways as we go forward are not just internal pathways, but really do have those partnerships along the entire continuum, and continuing to drive the value and the experience that we seek.

So all those things really go into where we see ourselves. We see ourselves down the road as having a pathway or a guideline for pretty much everything that we might see here and continuing to share those with our other partners outside of the organization as well. So we still feel that we're early into it, even though we now have about 220 pathways and guidelines combined as of a month or so ago.

Dr. Williams: I feel like you can't get more than 220, but if for some reason I can think of one that I would want as a pathway, then what would I do as a provider? How do I get this pathway in process?

Dr. Buchert: First step is to send me an email. That's the easiest way to do it. And then I'll send that to my team and they'll be in touch with you. On the Infonet page, when you've pull up one of our pathways, you'll find the name and email of other members of my team, and you can also email them and they're also happy to get this process started. But just get in touch with us and we'll have a conversation and go from there.

Dr. Williams: That sounds great. Thank you so much, Dr. Buchert for coming in today and telling us all about these pathways. And for those of you that have any ideas or are interested in participating, or maybe joining his team as he could always use expansion, please feel free to email him. And thank you all for listening to That's Pediatrics.

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