With UpToDate Advanced, physicians can streamline care at different points using UpToDate Pathways for interactive decision-making workflows and Lab Interpretation for evaluating abnormal test results and deciding next steps, which can be a major source of variations in care. UpToDate Advanced equips providers with continuously updated decision pathways that optimize decisions at the point of care by providing recommendations tailored for specific patients helping to achieve effective care.
Journal of Clinical Pathways spoke with Priti Shah, vice president of product and solutions at Clinical Effectiveness, Wolters Kluwer Health, and Anne Travis, MD, senior director, advanced clinical decision support–editorial at UpToDate, Wolters Kluwer Health, to gain a better understanding of the UpToDate Advanced Pathways tool, how it can enhance care and outcomes, and their thoughts for the future of the tool.
JCP: Ms Shah, what makes UpToDate Advanced different from UpToDate and why was there a need to create this new clinical decision support tool?
Ms Shah: Today, UpToDate is used by over 1.5 million clinicians worldwide; we have thousands of health care institutions depending on UpToDate. When speaking to all these clients, what the chief medical officers and the chief medical information officers have shared with us is that they’re really trying to tackle the problem of reducing unwanted variability in care and also, obviously, the associated cost that goes along with it as they’re trying to optimize patient care. In the process of trying to tackle these issues, they put some guidelines in place—basically engaging multidisciplinary clinical committees to come together, create these guidelines, get agreements, and then they disseminated the guidelines, for example, in a binder or online, for their clinicians to use. As you can imagine, those guidelines probably never get updated on time or get used at the point of care. So these clients came to us and said, “Can you help us out with that?” We felt like that was absolutely an opportunity for us to really help them solve this problem, and that’s where this whole concept of creating clinical pathways was born.
In the simplest terms, what we did was take our core knowledge that already existed in UpToDate and started identifying those clinical conditions that have the highest amount of variability. We also looked at our search logs within UpToDate to see the most common searches and then cross-referenced it with those conditions that impacted quality measures through The Medicare Access and CHIP Reauthorization Act and the Merit-Based Incentive Payment System, thereby creating our table of contents for clinical pathways. Basically, these pathways are interactive guidelines that can proactively guide a clinician at the point of care in their decision-making.
That is the historical perspective as to what was the need, how we came up with this tool, and why we believe it has been really successful even with the short launch so far. We announced it at the Healthcare Information and Management Systems Society conference, but we were in beta testing in 2017—we are very, very encouraged with the progress that we see.
Dr Travis: I can give some additional insight into how the content differs from the traditional UpToDate product. The main thing is, as Ms Shah mentioned, that our Pathways are based on our UpToDate content, so there is nothing that you’re going to find in a Pathway that we don’t also cover within UpToDate. But in UpToDate, we go into a lot of depth and detail around different disorders and findings—going through multiple topics could take you a while to get to the answer that you need. And, as we all know, clinicians have very little time during their work day, so the quicker that we can get people answers, the better. A matter of one minute may matter to a clinician. So what we’ve done is to create Pathways in important clinical areas; in particular, where there is unwanted variability of care, we have tried to identify the specific questions that a clinician is likely to have and to then bring together all of the information from different parts of UpToDate into one pathway to help the clinician get to their answer extremely quickly.
The other thing that the Pathways do is, in addition to helping users get to answers faster, we include a decision summary that clinicians can use to facilitate their documentation. This keeps a record of their pathway navigation, answers, and the logic behind the different decision making.
Finally, because our UpToDate Pathways are based on UpToDate content, there are many links back to the core UpToDate content, so that if clinicians want more details (eg, they want to see the references behind the evidence-based recommendations), it is easy for them to find additional information. We also link to drug information through our Lexicomp monographs as well as patient education topics that are within UpToDate that clinicians can print or email to their patients, so that they have some additional information for after the visit.
JCP: Since UpToDate Advanced was launched, what early feedback have you received from providers who have used it—positive and/or negative feedback?
Ms Shah: As I mentioned earlier, we were in active beta testing all of 2017, and then we officially launched it in 2018. So we have had a good pool of end users as well as customers that we have been actively surveying and having interviews with. I’m really pleased to say that 100% of the users have said that the Pathways were valuable in getting them the clinical answers that they needed. Eighty-four percent said that the Pathways had really helped them validate their knowledge about managing a particular condition. Sixty-eight percent said that the Pathways helped them learn something new about managing that condition for their patients, and then about 58% said that they helped them manage a patient condition that they were not frequently managing. These are all of the things we were setting out to achieve with our Pathways.
In terms of other feedback, I think what our customers want is more pathways. Right now, we have roughly about 42 pathways live, and our goal is to absolutely continue getting more published. Those 42 pathways primarily focus on outpatient conditions, but we do hae some inpatient ones. I will have Dr Travis share with you what our goals are in terms of building out a table of contents.
But before I pass it on to her, another piece of feedback that we’ve been getting from our customers is that, right now, these pathways launch from within UpToDate. So, when you conduct a search, say for atrial fibrillation (AF), the Pathways are going to appear in that search result if there is one available for that condition. You can also navigate to these pathways through the top banner, but, ultimately, the vision that our end users want is to get these pathways integrated into the electrionic health records (EHRs)—to get these pathways pre-populated with patient information, to automate those orders directly into order-in baskets, to automatically populate the patient notes within the EHR. That’s where our customers want to take us, and it is definitely where we are intending to go with this product.
Dr Travis: As we mentioned, initially we had been focused heavily on questions that are likely to present in a primary care or internal medicine setting, and we have thus far limited ourselves to adult medicine. We have observed that the pathways that seem to be the most popular are the ones related to choosing antibiotics for patients with community-acquired pneumonia who are being treated as outpatients; the evaluation of hyponatremia (which isn’t surprising because it’s one of those things that all physicians learned in medical school and promptly forgot); and the Pathway related to AF, ie, helping clinicians decide which patients with AF need anticoagulation (this is a more complicated question than it might appear because some patients, even though they have AF, are at relatively low risk for stroke, which is the thing that you worry about as a consequence of AF, but you also have to take into account what their bleeding risk is).
So, after considering what pathway users have found helpful thus far, we have continued to try to develop more pathways for outpatient primary care and internal medicine, but we are also looking to expand into care that may be delivered in the emergency room or in inpatient care and areas outside of internal medicine. For example, we have been developing pathways around things like evaluating patients who might have a pulmonary embolism.
JCP: Can you explain how Lab Interpretation is incorporated into UpToDate Advanced Pathways?
Ms Shah: UpToDate Advanced was a package made up of our UpToDate Pathways as well as our Lab Interpretation product. Lab interpretations are basically a new content type that we have introduced to, once again, try to help the clinician make a call on how they should interpret a lab result that they just got. What do the values indicate to them? What should the next follow-up test be? So, we are trying to address those same clinical condition questions. We decided to package it together because both, when used in conjunction with UpToDate, really help reduce the variations in care that we’re trying to tackle with this product.
So, in terms of how our table of contents for Lab Interpretation has started to develop, we focus on lab tests where clinicians tend to make a misjudgment, or where they might be confused as to is the next step that they should take—these considerations are what has shaped the table of contents for the Lab Interpretation monographs.
JCP: What other important points would you like to make for our audience about UpToDate or any of the components of UpToDate Advanced Pathways?
Ms Shah: I’d love to take this opportunity to share with you where we’re going to take our clinical pathways in the future. As I mentioned briefly, our goal is to get our Pathways deeply integrated into the EHR workflow for the clinician. Our hope is to leverage the evolving standards of SMART on FHIR (Fast Healthcare Interoperability Resources) and CDS Hooks so that we can begin silently nudging the physician to help guide them based on the EHR patient data—we want to have greater intelligence for decision-making built into the EHR. Thus, when the physician is gently nudged about a clinical decision, they can launch the related pathway, they can get the answer, and based on the decision made, we can also help directly populate the orders basket with the right order and support documentation of that decision in the EHR patient record. In other words, we want to partner more closely with our customers to help them reduce variability in care and, in general, increase the amount of value that they get out of UpToDate in any of its forms.
Dr Travis: I would add that we are also trying to make sure that our Pathways are as user-friendly as possible. As we mentioned, the goal here is really for them to be used at the point of care—to help a clinician when caring for a patient in real time. Thus, in addition to providing our Pathways through desktop applications, we’ve also extended them to be available both on smart phones and tablets, so that clinicians can take the Pathways with them and really use the Pathways anywhere that they need to.