A brief history of pathways
April 1, 1998 2 minutes read
A brief history of pathways
From case management plans to Care Maps
The first clinical pathways, developed in 1985 by a team of clinicians at New England Medical Center (NEMC) in Boston, represented one of the first attempts to streamline and standardize patient care without jeopardizing patient outcomes. Pathways were developed in four significant phases:
· Case management plans.
These were bulky documents, some as long as 40 pages, that attempted to describe a basic time frame, projected outcomes, and the various responsibilities of different disciplines in caring for a patient. Structured by DRG or ICD-9 code, these were interesting academic documents, but too long to be usable in a practical clinical way, says Karen Zander, RN, MS, CS, FAAN, principal and co-owner of the Center for Case Management in South Natick, MA, and a member of the original pathway development team at NEMC.
· Time lines.
The second generation of pathways at NEMC involved mapping outcomes and intermediate clinical goals against a set time frame. "It was a way of trying to look in a snapshot at clinical progressions," Zander says. "They weren't usable either, but they were a study of what patients had in common and how you could track a patient across time."
· Critical pathways.
At this point, the team laid out actual tasks, interventions, and processes against time. It was at this stage that NEMC's work went public. "This was the one that everybody grabbed onto and said `Ah! This is great!'" Zander says. Ironically, she notes, the concept was already familiar to industrial engineers, who had developed similar systems as early as the 1950s.
But for the first time, clinicians had access to a document that could be understood by administrators and finance officers alike. "Finally, we had a way of describing care - of describing some very abstract, nebulous concepts - against time, and that was the breakthrough," Zander says. But it was still an incomplete tool: It couldn't be used as a documentation tool because it was still essentially just a task chart, "like a to-do list," she says.
· Care Maps.
The fourth generation of clinical pathways at NEMC took the radical step of incorporating critical pathways into the medical record, with a built-in system for documentation and analyzing variances.
(Editor's Note: When Zander left NEMC to found the Center for Case Management, she took the term Care Map with her and now owns its trademark. "Care Map" should not be used interchangeably with the generic term "clinical pathway.")
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