Care pathways: from clinical pathways to care innovation

This is the first issue of the International Journal of Care Pathways (IJCP) that has been edited by the European Pathway Association team. The European Pathway Association (ivzw) is an international not-for-profit association. The goal of our association is to perform international research, to organize international knowledge sharing, to support international collaboration and to advise policy-makers on care pathways. Therefore, in this issue, we have decided to focus on presenting different international experiences on care pathways inside and outside Europe. The articles in this issue of the IJCP originate from a conference that took place on 28 May 2009 in Leuven, Belgium, held to mark 10 years of care pathways in Belgium. The conference was a landmark in showing that the developments in care pathways, although still quite recent, are growing fast. Kathy Bower, principal and co-owner of the Center for Case Management in the USA, was one of the first keynote speakers, and talked about the very first beginnings of care pathways, 25 years ago, in the New England Medical Center (now Tufts Medical Center) in 1984. Their origin coincided with the onset of Diagnosis Related Groups (DRGs) in the USA as a method of cost-containment. DRGs were used to define homogeneous patient groups for which a prospective payment rate was set. It forced managers and clinicians to start organizing the care they were providing. In Belgium, research on care pathways began in 1996, mainly based on the experiences in the USA and in the meantime also in the UK. It was the basis for launching the Belgian–Dutch Clinical Pathway Network (www.nkp. be) in March 1999. The Network was defined as a knowledge-sharing network between academia and health-care facilities. The aim of the Network was to improve the effectiveness of developing, implementing and evaluating care pathways. The Network started with eight corporate members (all hospitals). In 2009, the number of members increased to up to more than 100 health-care organizations, broadening the scope from hospitals to home care organizations, rehabilitation centres and mental health organizations. The number of care pathways that are in development or up and running in these organizations has grown to more than 1000 different projects. The top of this list is led by conditions with a high predictive flow of care such as total hip and knee arthroplasty and normal delivery. But the list of conditions for which care pathways have been built is long and varies from simple to complex procedures, and high to low predictability. About 9% of all care pathways are crossing the boundary of their own organization, mainly in bridging the continuum between primary and secondary care. The Network in 2000 was mainly focusing on Flemish acute hospital care. As there was interest from the Netherlands and French-speaking Belgian hospitals, the Network looked for collaboration with the Dutch Institute for Quality improvement and the Université Catholic de Louvain as care pathway facilitating centres, for The Netherlands and the French-speaking region of Belgium, respectively. In 2004 the European Pathway Association (www.E-P-A.org) was launched and opened the way for international collaboration. It was exactly this Belgian and international history line that the Leuven conference of May 2009 was planned to show, as there has been incredible development during these last 10 years in pathways. At the same time, the actual care pathways do not look familiar anymore to their relatives from the early days. Although the first aim of care pathways was costcontainment, the actual focus is on quality and safety. Cost-efficiency has almost become the byproduct of wellorganized care. The main purpose is to give the right care to meet the needs of patients. Although the care pathways of the early days were very focused in bringing a team together and enhancing communication and coordination, the new care pathways are focused on integrating guidelines and evidence-based care. The care pathway is seen more and more as a means to how guidelines can be put in practice by interdisciplinary teams. The care pathway approach realize that interdisciplinary teams, often varying from a few to more than 100 members, will have the same focus, where roles are discussed and set, communication channels are discussed and most importantly, where they adhere to the same evidence-based standards. During the conference Thomas Rotter, research fellow and lead of the German–Australian Cochrane group, gave a first overview of the results of their work. Massimiliano Panella, professor in Public Health at the University of Piemonte Orientale ‘Amedeo Avogadro’ and president of the European Pathway Association, shows in his paper in this issue, the effect of working with a well-designed pathway, built based on state-of-the-art evidence on mortality and patient outcomes. The early care pathways were put on paper, which sometimes led to more administrative burden for health professionals. The new pathways of the future will be digital. They will require uniform digital platforms, communication and documentation standards, and integration of care pathways in patient records and clinical documentation systems, determining access rights. Ricard Rosique, head of the medical department of B-Braun in Spain, shows in his paper in this issue how these digital systems can be designed and work. The early pathways put a lot of their effort in organizing care by defining the team members’ role, but it still depended highly on the individual professional if these arrangements were to be put in practice. These pathways were not embedded in systems. The new care pathways will code these organizational arrangements into the systems, such as scheduling and workflow systems. Professor Martin Elliot, a paediatric