This year again, I took part to the annual meeting of the Japanese Society of Clinical Pathway on December 9-10.  This year, it took place in Tokyo, at the prestigious Keio Plaza Hotel in Shinjuku and the chairman was Prof. Fukui of St Luke International Hospital.

The theme of the 12th edition was: the Future of Multi-Disciplinary Team Care.

The main topics covered this year were mostly recurring with respect to previous years:
1. Critical Indicators (CI) or Quality Indicators (QI)
2. Analysis of Variance, and Outcome Master
3. Pathway of Regional Cooperation
4. Multi-disciplinary Team
5. DPC (diagnosis procedure combination) and Clinical Pathway

Moreover, this year, 2 special guests were invited:
Prof. Shigeaki Hinohara, who turned 100 years old this year, and delivered a powerful message on stage, about the concept of Team Based Learning.  Truely amazing.
Prof. Junichiro Kawaguchi, professor of aerospacial research at Kyoko University, who talked about a completely unrelated topic (apparently, at least): the amazing story of Hayabusa, the spacecraft which made a 7 year trip into space before landing back on Earth, after multiple technical troubles.

And last but not least, this year’s conference also covered the terrible earthquake of Tohoku (Northern Japan) and its consequences in the medical world.

The attendence was more than 2,400 people, less than average, but not too bad considering the difficult year it was for Japan.

Here are a few notes I took.

Critical Indicators (CI) or Quality Indicators (QI)

  • There are 3 types of CI: regarding structure, process and outcome.
  • CI can be used to improve the quality of healthcare by repeating the PDCA cycle (Plan - Do - Check - Act).
  • Variance analysis allows to find which factors negatively/positively influence CI/QI.
  • Quantitative improvement is easy to grasp (e.g. reduce the length of stay in hospital), but qualitative improvement is more complex (e.g. influence of adding or removing a process step).
  • St. Luke Intl. Hosp. publishes every year a book summarizing dozens of CI’s, mostly process-related.

Analysis of Variance, and Outcome Master

  • “Variance” is, broadly speaking, a “deviation from the plan”. It can be an outcome not reached, but reaching an outcome earlier or later than planned is also a variance (although it can be “positive variance”). Adding/changing/removing an step in the process is also an occurrence of variance.
  • There are many ways to record variance, the most exhaustive way being referred as “all variance”; every deviation is recorded (Prof. Katsuo is a proponent of “all variance” recording). Other ways are “gateway” and “sentinel”, which only record some occurrences.
  • Proper recording of variance should describe the content (WHAT happened) and the reason (WHY it happened).
  • Although recording variance as “free text” is possible, it makes its analysis impractical. It is more efficient to create a “master” for variance content and reasons and assign a code to each one. This relates to the work of Prof. Soejima who compiled a BOM (basic outcome master) which tries to unify vocabulary for describing outcomes.

Pathway of Regional Cooperation

  • Several diseases, which must be taken care of in both acute and chronic stages, are well-suited for regional cooperation clinical pathway.
  • The current situation is that, although big hospitals (and even clinics) may be equipped with high-end information systems, they are not well interconnected, and there is a whole (the biggest) part of the actors (including small medical centers, home nurses, home helpers, …) which is not connected together. It is therefore very common to exchange information through paper (fax) or more recently by sending Excel sheets back and forth via e-mail.
  • Examples of systems enabling electronic data exchange for regional collaboration pathways are “Zaitaku Dr. Net”, “Net 4 U” (VPN network), as well as custom solutions (such as K-MIX, Kagawa Medical Information eXchange)
  • The success of regional collaboration pathways relies on involving all actors including the attending physician, primary care doctor, nurses, home helpers, nutritionist, and last but not least, the patient and family. It is critical that all actors have a common view, and understand what are the goals (outcomes) of each step of the pathway.

Multi-disciplinary Team

  • This was the main theme of this year’s conference.
  • In his special talk, Prof. Hinohara suggested that for a team to work well together, they first should learn together (Team Based Learning).
  • Team dynamics: forming, storming, norming, performing. It is important to understand which stage the team is in.
  • The multi-disciplinary team includes all actors. In the “old” model, the doctor was at the center, playing the main role; today, not only doctors and nurses, but pharmacists, radiology technicians, examination technicians, nutritionists, physiotherapists,…
  • Concrete examples where multi-disciplinary team care was studied: breast cancer care, nutrition screening test before leaving hospital, education of diabetic patients,…

DPC and Clinical Pathway

  • DPC (diagnosis procedure combination) is a standard of the Japanese Ministry of Health Labor and Welfare (MHLW), which defines codification of all medical acts using 14-digit codes.
  • DPC codes contain various information including disease, medical act or prescription, and complication.
  • DPC is primarily used for accounting, but it appears to be very useful to obtain various information through data mining.
  • DPC is not specifically related to Clinical Pathway, but it can be used in relation with CP, e.g. to infer current medical processes, to find out variability in processes, to detect variance, etc
  • Several ways were proposed to visually show CP information extracted from DPC data and ways to improve CP (through PDCA cycle) by looking at these data.

Clinical pathway and effective recording

Interesting side track about use of IT to improve hospital workflow.

  • POTV (Problem Oriented Timeline View) is a “timeline” plot of various EHR data with capability to “zoom out” in the time scale and view the whole patient’s life
  • WATATUMI, an Android app on the nice and lightweight Samsung Galaxys tablet replacing an old and expensive PDA (Pocket@iEX) as a bed side terminal allowing among other patient identification (bracelet reading) and recording of vitals
  • Discussion about how electronic CP software reduced error and double encoding, and made nurse record easier.

Lessons from clinical pathway introduction

Some nice alternative ways to mainstream CP software:

  • Use of Yaghee document management system to compensate for shortcomings of the “NEC Megaoak HR” CP software, and efficiently record variance.
  • Presentation of a custom CP software called “Flexi Path” (Nagano Hospital) which allows to not set a fixed duration for each step, but have a unit transition logic based on events or patient condition. This reminded me the PCAPS (patient condition adaptive pathway system).

The conference was concluded by a free discussion with doctors involved in the big Tohoku earthquake of March 11. Many witnessed what they did just after the earthquake, and how they adapted to the very serious situation that followed. Some difficult questions that arise:

  • As a doctor/nurse, should you go and find your family before taking care of your patients?
  • Should the non-patient refugees be welcomed in the hospital?

This was again a very interesting conference, with highly motivated participants. It is extremely interesting to meet with doctors who are not only experts in their field, but are also constantly preoccupied by making healthcare better, not concerned by their own interest.