The effectiveness of tools for clinical pathways

232 Pages·2015·4.29 MB·English

The effectiveness of clinical pathway management software
Master thesis in partial fulfillment of the requirements for the degree of
Master of Science
in the subject of
Business informatics

Utrecht University
Utrecht, The Netherlands
October 2015

Graduate student:
Name: Mariëlle Floor Aarnoutse
Student number: 3469662
Address: Cambridgelaan 375, 3584 DB, Utrecht
Email: [email protected]
Phone: [phone]

Supervisor:
Name: Dr. Ronald Batenburg
Department: Information and Computing Sciences
Company: Utrecht University
Email: [email protected]

Second supervisor:
Name: Prof. Dr. Sjaak Brinkkemper
Department: Information and Computing Sciences
Company: Utrecht University
Email: [email protected]

External supervisor:
Name: Dr. Marieke Vissers
Department: Dienst Informatie Technologie
Company: UMC Utrecht
Email: [email protected]

I
A
BSTRACT

Background
Clinical pathways are known to lead to extensive benefits for all involved parties in hospital
environments. Since several years IT supported clinical pathways (in this study: clinical pathway
management software) are known to be developed. Few studies research the additional benefits of
these software programs. Especially the effectiveness of clinical pathway management software for
healthcare professionals remains underexposed.
Aims
The aim of this study is to provide a research-based conclusion about the effectiveness of clinical
pathway management software for healthcare professionals. This is done by answering the main
research question: Can clinical pathway management software be effective for healthcare
professionals in hospital environments?
Methods
The research method consists of two parts: a desk-research in the form of a literature study and field
research in the form of a single-case study. The main part of the literature study is guided by the
process of a systematic literature review. Additional information about the case study is found in an
unstructured way. The case study is held in four of the seven departments of the Utrecht Medical
Center who work with the newly developed clinical pathway management software program, named
Check-It. The participants in this study are asked about the perceived effectiveness in surveys as well
as semi-structured interviews.
Findings
The systematic literature review showed that IT is known to be important for hospitals and also
thought to be of importance for clinical pathways. Clinical pathway management software can lead
to the opportunity to deliver faster and better information, economic benefits, and a higher patient
satisfaction. The case study showed that Check-It is perceived effective in two of the four researched
departments. These outcomes are dependent on the environment they work in. Healthcare
professionals in departments with a positive attitude towards a (new) system and who collectively
use the system, are more inclined to profit from Check-It. There are also strong indications that
Check-It is more effective for ‘physicians and medical specialists’ than for other healthcare
professionals in the hospital environment. This particular clinical pathway management program
leads among others to less forgotten tasks, makes it easier to work due to pre filled orders and letters,
leads to a better overview, but is also perceived as not flexible enough.
Conclusion
Clinical pathway management software can be effective for healthcare professionals in hospital
environments. However, this depends on the environment the software is used in.

II
A
CKNOWLEDGEMENTS

“Scientific research is one of the most exciting and rewarding of occupations” Frederick Sanger once
said. Now this thesis is done, I can finally feel myself agreeing with him. While the road had several
bumps and bends, the result presented before you is something that is exciting as well as rewarding
for me. Months of hard work have resulted in this stack of paper, which will hopefully also bring
some excitement and even a reward in the form of an extension of knowledge for you, as its reader.
Of course I cannot let the acknowledgements pass without a few words of heartfelt thanks to the
people surrounding me and supporting me throughout the process. Especially my external
supervisor Marieke Vissers for her constant enthusiasm and all her help within the UMCU. Ronald
Batenburg, for his useful guidance during the bi-weekly feedback sessions and guiding me through
the scientific part of this study. Last but not least, Sjaak Brinkkemper for being a critical and valued
reader on the moments that matter the most. Mom, dad, friends, family: thanks for believing in me
and being there when you needed to be.
All that’s left for me to say now is enjoy reading!

Floor Aarnoutse
Utrecht, October 2015

III
T C
ABLE OF ONTENTS
Abstract ____________________________________________________________________ II
Acknowledgements __________________________________________________________ III
List of Figures _____________________________________________________________ VII
List of Tables _______________________________________________________________ IX
Glossary of abbreviations ______________________________________________________ XI
1. Introduction _____________________________________________________________ 1
1.1 Problem definition _____________________________________________________ 1
1.2 Problem statement and objective __________________________________________ 4
1.3 Research questions _____________________________________________________ 6
1.4 Relevance ____________________________________________________________ 7
1.5 Thesis overview _______________________________________________________ 8
2. Research method _________________________________________________________ 10
2.1 Literature study ______________________________________________________ 10
2.2 Case study __________________________________________________________ 12
2.3 Research process _____________________________________________________ 16
3. Systematic literature review _________________________________________________ 20
4. Hospital information systems ________________________________________________ 25
4.1 Hospitals and IT _____________________________________________________ 25
4.2 E-health and the hospital environment ____________________________________ 29
4.3 Systems in a hospital environment ________________________________________ 31
4.4 Hospital information systems ____________________________________________ 33
4.5 Components of hospital information systems _______________________________ 34
4.6 Hospital information system architecture ___________________________________ 38
4.7 Conclusion __________________________________________________________ 39
5. Clinical pathways _________________________________________________________ 41
5.1 Introduction to clinical pathways _________________________________________ 41
5.2 Clinical pathway history ________________________________________________ 42
5.3 Clinical pathway concept explanation ______________________________________ 44
5.4 Clinical pathway effects ________________________________________________ 50
5.5 Clinical pathway management ___________________________________________ 58
5.6 Clinical pathways and IT _______________________________________________ 61
5.7 Conclusion __________________________________________________________ 63
IV
6. Check-It and the hospital environment of the case study ___________________________ 65
6.1 UMCU’s hospital environment __________________________________________ 65
6.2 Check-It ____________________________________________________________ 71
7. Case study operationalization ________________________________________________ 77
7.1 Surveys ____________________________________________________________ 79
7.2 Interviews __________________________________________________________ 82
7.3 Structure case study reports _____________________________________________ 84
8. Case study results: Pediatric pulmonology ______________________________________ 86
8.1 Introduction ________________________________________________________ 86
8.2 Pretest _____________________________________________________________ 87
8.3 Posttest 1 ___________________________________________________________ 91
8.4 Posttest 2 ___________________________________________________________ 97
8.5 Differences between tests _____________________________________________ 103
8.6 Conclusion for pediatric pulmonology ____________________________________ 107
9. Case study results: Vascular surgery __________________________________________ 109
9.1 Introduction _______________________________________________________ 109
9.2 Pretest ____________________________________________________________ 110
9.3 Posttest 1 __________________________________________________________ 114
9.4 Posttest 2 __________________________________________________________ 115
9.5 Conclusion for vascular surgery _________________________________________ 116
10. Case study results: Dermatology and allergology ______________________________ 118
10.1 Introduction _______________________________________________________ 118
10.2 Posttest ___________________________________________________________ 119
10.3 Conclusion for dermatology and allergology _______________________________ 125
11. Case study results: Ophthalmology ________________________________________ 126
11.1 Introduction _______________________________________________________ 126
11.2 Posttest ___________________________________________________________ 127
11.3 Conclusion for ophthalmology __________________________________________ 133
12. Case study results: Four departments compared ______________________________ 134
12.1 Introduction _______________________________________________________ 134
12.2 Vascular surgery vs. pediatric pulmonology ________________________________ 134
12.3 Pediatric pulmonology vs. dermatology and allergology vs. ophthalmology ________ 138
12.4 Case study conclusion ________________________________________________ 147
13. Conclusion __________________________________________________________ 150
V
14. Discussion ___________________________________________________________ 156
Bibliography _______________________________________________________________ 158
Appendix A: Clinical pathway chest pain _________________________________________ 176
Appendix B: Original PRISMA flow diagram ______________________________________ 177
Appendix C: Original TAM questions ___________________________________________ 178
Appendix D: SLR search keys__________________________________________________ 180
Scholar _________________________________________________________________ 180
PubMed ________________________________________________________________ 182
Appendix E: Numbers per search key____________________________________________ 187
Appendix F: SLR results ______________________________________________________ 191
Appendix G: Domain reference model hospitals of i-Ziekenhuis _______________________ 193
Appendix H: Systems at the UMCU _____________________________________________ 194
Appendix I: Surveys _________________________________________________________ 197
Pretest - vascular surgery and pediatric pulmonary ________________________________ 197
Posttest 1 & 2 - vascular surgery and pediatric pulmonology _________________________ 201
Posttest – dermatology and allergology and ophthalmology _________________________ 205
Appendix J: Combined pediatric pulmonology results _______________________________ 209
Appendix K: SPSS results _____________________________________________________ 211
Appendix L: Interview comparison _____________________________________________ 219

VI
L F
IST OF IGURES
Figure 1: Process from job-specific guidelines to CP's _________________________________ 2
Figure 2: Clinical Pathway Management ____________________________________________ 3
Figure 3: Venn diagram research elements __________________________________________ 5
Figure 4: Research division ______________________________________________________ 7
Figure 5: Thesis overview _______________________________________________________ 9
Figure 6: Test timelines ________________________________________________________ 14
Figure 7: Technology Acceptance Model. Adopted from Wu, Li, and Fu (2011) _____________ 16
Figure 8: Iterative steps for field research. Reprinted from Edmondson and McManus (2007) __ 17
Figure 9: Research method PDD ________________________________________________ 18
Figure 10: Number of SLR-papers per year ________________________________________ 23
Figure 11: SLR results _________________________________________________________ 24
Figure 12: Venn diagram focused on hospital software ________________________________ 25
Figure 13: Systems classification according to Norris (2002) ____________________________ 31
Figure 14: Systems classificaton according to Hannah Ball, and Edwards (2006) ____________ 32
Figure 15: Three HIS subsystems. Reprinted from Degoulet (2014) ______________________ 35
Figure 16: Conceptual model of HISs. Reprinted from Reichertz (2006) __________________ 39
Figure 17: Venn diagram focused on clinical pathways ________________________________ 41
Figure 18: From medical guidelines to actual treatment. Adopted from Lenz and Reichert (2007) 50
Figure 19: 7-phased model for CPM. Reprinted from Vanhaecht et al. (2012) ______________ 59
Figure 20: Organizational chart UMCU ___________________________________________ 66
Figure 21: Global consistency processes ___________________________________________ 67
Figure 22: Domain reference model hospitals of i-Ziekenhuis, adjusted for the UMCU _______ 68
Figure 23: IT systems at the UMCU ______________________________________________ 69
Figure 24: Check-It screenshot: getting started ______________________________________ 72
Figure25: Check-It screenshot: Check-It tab ________________________________________ 72
Figure 26: Check-It screenshot: patient dossier ______________________________________ 73
Figure 27: Check-It mapped to the IT systems overview of the UMCU ___________________ 75
Figure 28: Check-It in the conceptual model of HISs _________________________________ 76
Figure 29: Venn diagram focused on healthcare professionals __________________________ 77
Figure 30: Coding process _____________________________________________________ 83
Figure 31: Figure template TAM questions _________________________________________ 85
Figure 32: Participant’s functions at pediatric pulmonology ____________________________ 87
Figure 33: Mean objective grades pretest - department of pediatric pulmonology (N=8) ______ 87
Figure 34: Mean Check-It expectation grade pretest - department of pediatric pulmonology (N=8)
__________________________________________________________________________ 88
Figure 35: Mean TAM results pretest - department of pediatric pulmonology (N=8) _________ 89
Figure 36: Mean objective grade posttest 1 – department of pediatric pulmonology (N=8) ____ 92
Figure 37: Mean Check-It department contribution grade posttest 1 - department of pediatric
pulmonology (N=8) __________________________________________________________ 92
Figure 38: Mean Check-It personal contribution grade posttest 1- department of pediatric
pulmonology (N=8) __________________________________________________________ 93
Figure 39: Mean TAM results posttest 1 - department of pediatric pulmonology (N=8) _______ 94
VII
Figure 40: Mean objective grade posttest 2 – department of pediatric pulmonology (N=6) ____ 97
Figure 41: Mean Check-It department contribution grade posttest 2 - department of pediatric
pulmonology (N=6) __________________________________________________________ 98
Figure 42: Mean Check-It personal contribution grade posttest 2- department of pediatric
pulmonology (N=6) __________________________________________________________ 99
Figure 43: Mean TAM results posttest 2 - department of pediatric pulmonology (N=6) ______ 100
Figure 44: Department effectiveness score – department of pediatric pulmonology _________ 104
Figure 45: Department grade per objective – department of pediatric pulmonology _________ 105
Figure 46: Personal effectiveness score – department of pediatric pulmonology ____________ 106
Figure 47: Personal grade per objective – department of pediatric pulmonology ____________ 107
Figure 48: Participant’s functions at vascular surgery ________________________________ 109
Figure 49: Mean objective grades pretest - department of vascular surgery (N=10) _________ 110
Figure 50: Mean Check-It expectation grade pretest - department of vascular surgery (N=10) _ 111
Figure 51: Mean TAM results pretest - department of vascular surgery (N=10) ____________ 112
Figure 52: Participant’s functions at dermatology and allergology _______________________ 118
Figure 53: Mean objective grades pretest - department of dermatology and allergology (N=9) _ 119
Figure 54: Mean Check-It department contribution grade - department of dermatology and
allergology (N=9) ___________________________________________________________ 120
Figure 55: Mean Check-It personal contribution grade - department of dermatology and allergology
(N=9) ____________________________________________________________________ 121
Figure 56: Mean TAM results pretest - department of dermatology and allergology (N=9) ____ 122
Figure 57: Participant’s functions at ophthalmology _________________________________ 126
Figure 58: Mean objective grades pretest - department of ophthalmology (N=15) __________ 127
Figure 59: Mean Check-It department contribution grade - department of ophthalmology (N=15)
_________________________________________________________________________ 128
Figure 60: Mean Check-It personal contribution grade - department of ophthalmology (N=15) 129
Figure 61: Mean TAM results pretest - department of ophthalmology (N=15) _____________ 130
Figure 62: Participant’s functions _______________________________________________ 134
Figure 63: Mean Check-It effectiveness scores – department of pediatric pulmonology and vascular
surgery ___________________________________________________________________ 135
Figure 64: Mean Check-It expected contribution grades – department of pediatric pulmonology and
vascular surgery ____________________________________________________________ 136
Figure 65: TAM questions combined – department of vascular surgery and pediatric pulmonology
_________________________________________________________________________ 137
Figure 66: Department effectiveness matrix _______________________________________ 139
Figure 67: total healthcare professional role overview ________________________________ 140
Figure 68: heathcare professional group effectieveness matrix _________________________ 141
Figure 69: Flowchart CP chest pain. Adopted from Huiskes and Schrijvers (2010) __________ 176
Figure 70: Original PRISMA statement. Reprinted from Prisma Statement (n.d.) ___________ 177
Figure 71: SLR results SQ1 ____________________________________________________ 191
Figure 72: SLR results SQ2, 3, 4 ________________________________________________ 192
Figure 73: Domain reference model hospitals of i-Ziekenhuis _________________________ 193

VIII
L T
IST OF ABLES
Table 1: Check-It departments __________________________________________________ 12
Table 2: SLR search keys ______________________________________________________ 21
Table 3: Healthcare compared to other sectors. Adopted from Avison and Young (2007) _____ 31
Table 4: Frequency of management theories used in Dutch hospitals. Reprinted from van Lent,
Sanders and van Harten (2012). _________________________________________________ 44
Table 5: Difference between clinical pathways and guidelines ___________________________ 49
Table 6: Potential positive CP effects _____________________________________________ 51
Table 7: Positive CP effects ____________________________________________________ 53
Table 8: Potential negative CP effects _____________________________________________ 53
Table 9: Negative CP effects ____________________________________________________ 54
Table 10: Proven CP effects ____________________________________________________ 55
Table 11: Clinical pathway pitfalls. Adopted from Resnick (2014) ________________________ 57
Table 12: CPM approaches _____________________________________________________ 60
Table 13: Healthcare professional division _________________________________________ 78
Table 14: Interview results Check-It effects pretest – department of pediatric pulmonology ____ 90
Table 15: Interview results Check-It effects posttest 1 – department of pediatric pulmonology _ 96
Table 16: Interview results Check-It effects posttest 2 – department of pediatric pulmonology 101
Table 17: Interview results improvement points posttest 2 – department of pediatric pulmonology
_________________________________________________________________________ 103
Table 18: Interview results Check-It effects pretest – department of vascular surgery ________ 113
Table 19: Interview results Check-It effects – department of dermatology and allergology ____ 123
Table 20: Interview results improvement points – department of dermatology and allergology 125
Table 21: Interview results Check-It effects – Department of ophthalmology _____________ 131
Table 22: Interview results improvement points – department of opthalmology ____________ 133
Table 23: Mean objective grades – department of pediatric pulmonology and vascular surgery _ 135
Table 24: Effectiveness scores per department _____________________________________ 138
Table 25: Effectiveness scores per healthcare professional group _______________________ 140
Table 26: Personal effectiveness score per healthcare professional group per department _____ 142
Table 27: TAM score per cluster/construct per department ___________________________ 143
Table 28: Combined interview statements ________________________________________ 145
Table 29: Combined improvement points _________________________________________ 146
Table 30: Overview departmental outcomes _______________________________________ 148
Table 31: Numbers per search key ______________________________________________ 187
Table 32: Mean objective grades - department of pediatric pulmonology _________________ 209
Table 33: mean Check-It department contribution grade - department of pediatric pulmonology
_________________________________________________________________________ 209
Table 34: Mean Check-It personal contribution grade – department of pediatric pulmonology 209
Table 35: TAM results - Department of pediatric pulmonology ________________________ 210
Table 36: Paired samples t-test for the department efficiency score – pediatric pulmonology __ 211
Table 37: Paired samples t-test for the personal efficiency score – pediatric pulmonology ____ 211
Table 38: Independent samples t-test for the expected perceived efficiency score – pediatric
pulmonology vs. vascular surgery _______________________________________________ 212
IX