1. Introduction
Web-based technologies have recently been brought into the field of medical information.
Much web-based education for patients, nurses and physicians has been developed. Web-based information can also be a tool of communication among patients, nurses and physicians. Many advantages of web-based technologies have been reported.
Many strategies have been used by organizations to improve the quality of medical care.
Quality-oriented methods focus mainly on decreasing system failure and unnecessary variations in patient care practices, and enhance collaboration among the health care team members.
Thereafter, many clinical pathways have been reported as tools for use in clinical process management. The development and implementation of clinical pathways in caring for patients are still enthusiastically supported.
Favorable results of paper-based implementation of a clinical pathway for radical nephrectomy were reported in 2000.
When implementing a web-based clinical pathway for radical nephrectomy, a nurse must review the daily activities of the patient and make records on the pathway. Although most nurses are familiar with computer technology, the functional limitations of inexperienced nurses remain a problem. Designing a usable web-based clinical pathway for nurses is challenging. The design of a system for implementing a web-based clinical 160
pathway should focus on increasing its functional accessibility.
This investigation evaluates the effect of using the web-based clinical pathway for radical nephrectomy, on the approach to patients, admission charges and the quality of medical care. The results of implementing the web-based clinical pathway were compared to those of the paper-based pathway, and the advantages of web-based clinical pathway implementation were described.
2. Method
Patients with renal cell carcinoma, who underwent radical nephrectomy between May 1999 and August 2001, were enrolled into this study. Patients were divided into two groups - (1) those treated according to the paper-based clinical pathway from May 1999 to June 2000, and (2) those treated according to the web-based clinical pathway from July 2000 to August 2001.
The paper-based clinical pathway for radical nephrectomy was developed and formalized by the clinical pathway development team in April 1997. From July 2000, a web-based clinical pathway on Internet using ASP (active server pages) and SQL Server 2000 has been developed (Fig. 1). Seven databases were used to create the clinical pathway. The architecture of the program is shown in Fig.2.
Fig. 1. The web-based clinical pathway
Fig. 2. The architecture of web-based clinical pathway
This web-based pathway includes consultation, laboratory tests, treatment, medication, activity, nutrition, elimination, education, psychosocial support, and discharge plan (Fig. 3). The nurse reviewed the daily activities of the patient, which were recorded on the web-based clinical pathway.
Fig. 3. The web-based clinical pathway for radical nephrectomy
Correctable, uncorrectable, and undetected variances were measured. The correctable variances are those that can be corrected immediately without an effect on health outcomes.
Uncorrectable variances are those that cannot be corrected or are obsolete. Undetected variances were defined as those discovered after a patient was discharged from the hospital. Variance detection time was defined as the period from scheduling time to the time when the variance was
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identified. Variance detection time was determined to compare the efficiency of the detection of variances between the two groups.
After the patients were discharged from the hospital, the nurse completed the web-based clinical pathway.
The results of the analysis and the variance data were stored on the web server. Six quality indicators were measured to evaluate the effect of the use of the web-based clinical pathway on the quality of care.
These six quality indicators included 1) the percentage of patients to whom fluid was intravenously administered for over one day following starting a diet postoperatively; 2) the percentage of patients with Foley catheterization for over three days postoperatively; 3) the percentage of patients with drainage tube insertion for over five days; 4) the percentage of patients with complications; 5) the percentage of in-hospital mortality; and 6) the percentage of patients readmitted within two weeks.
The differences between the average length of hospital stay, average admission charges, and quality indicators of the two groups were determined. The independent Student’s t-test was used to determine the statistical significance of the differences between the two groups.
The Chi-squared test was used to determine the differences among the variances. Statistical analysis was performed using a commercial software. A p value below 0.05 was considered to be statistically significant.
3. Results
Sixty-one consecutive patients were treated for radical nephrectomy according to the paper-based clinical pathway from May 1999 to June 2000 (group 1) and 63 consecutive patients were treated for radical nephrectomy according to the web-based clinical pathway from July 2000 to August 2001 (group 2). The proportions of men and women, mean patient age, and admission charges did not significantly differ between the two groups (Table 1).
Table 1. Demographic characteristics of patients, length of hospital stay (LOS), and admission charges
for two groups
Group 1 Group 2 P*
charges (NT$)
77512 75178 0.7330
*P for the comparison of values between gr. 1 & 2.
The total number of variances did not significantly (p = 0.299) differ between the two groups. The most common variances were patient-related in both groups. The number of correctable and uncorrectable variances did also not significantly differ between the two groups. However, the number of undetected variances in group 2 was significantly (p = 0.0193) less than that in group 1.
Group 2 included only three undetected variances.
The mean variance detection time in group 2 was 0.48 days, and significantly (p = 0.0162) less than that in group 1 (Table 2).
Table 2. Patients with variances from the paper-based (group 1) and web-based (group 2) clinical pathways
Group 1 Group 2 P*
Total number of variances
54 42 0.2990 Total number of
patients with variances
20(32.8%) 15(23.8%) 0.4070
Patient-related variances
25(46.3%) 22(52.4%) 0.5956 Physician-related
variances
17(31.5%) 10(23.8%) 0.1073 Hospital-related
variances
11(20.4%) 9(21.4%) 0.5743 Discharge
variances
1(1.8%) 1(2.4%) 0.9818 Correctable
variances
26(48.2%) 25(59.5%) 0.7698 Uncorrectable
variances
16(29.6%) 14(33.3%) 0.6059 Undetected
variances
12(22.2%) 3(7.2%) 0.0193**
Average variance detection time (days)
0.79 0.48 0.0162**
*P for the comparison of values between gr. 1 & 2.
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**Statistically significant differences between the two groups.
After implementation, six quality indicators of the web-based clinical pathway did not significantly differ from those of the paper-based pathway. Table 3 shows the quality indicators of both groups.
Table 3. Quality indicators for both groups Quality Indicator Group 1 Group 2 P*
Percentage of patients who had intravenously administered fluid for over one day after starting a diet postoperatively
16.4%(10) 15.9%(10) 0.7637
Percentage of patients who underwent Foley catheterization for over three days postoperatively
32.8%(20) 25.4%(16) 0.2172
Percentage of patients who underwent drainage tube insertion for over five days
36.1%(22) 20.6%(13) 0.1069
Percentage of patients with complications
4.9%(3) 3.2%(2)
Percentage of in-hospital
mortality
0 0
Percentage of patients readmitted within 2 weeks
0 0
*P for the comparison of values between gr. 1 & 2.
4. Discussion
The World Wide Web (WWW) has proven to be very successful. The turnaround time and cost can be considerably reduced via the WWW service, and may enhance completion rates.Over the last several years, web-based surveys, web-based clinical monitoring systems for elderly patients, web-based materials for medical education and web-based distance education programs have been reported to show good results.
However, the web-based implementation of clinical pathways has not been reported. Accordingly, this study reports and evaluates the implementation of a
web-based clinical pathway for radical nephrectomy.
Clinical pathways outline laboratory test, medication, therapy and nursing care plan that are essential to obtain a desired health outcome .The clinical pathway has recently been reported as useable as a tool for monitoring health outcomes and has emerged as a successful strategy for improving the quality and cost-effectiveness of medical care.Many clinical pathways have been used at various medical centers.A patient, family and hospital can all benefit from the continuous implementation of clinical pathways. At the authors' hospital, the first clinical pathway for transurethral prostatectomy was implemented in February 1995. Since April 1997, 18 clinical pathways for urological operations were implemented at our department. This research reveals that implementing clinical pathways can improve practice by reducing the length of the hospital stay and admission charges, and by improving the quality of medical care.In 2000, continued implementation of the paper-based clinical pathway for radical nephrectomy improved the physician’s practice was reported.Consequently, we developed and implemented a web-based clinical pathway for radical nephrectomy in July 2000 and compared the results to those obtained by implementing the paper-based clinical pathway.
Regular nurses in the urological ward were relevantly trained before the web-based clinical pathway for radical nephrectomy was implemented.
Physicians and health care staff were orientated to familiarize them with the web-based pathway.
Nurses were continually trained throughout the year of the study to facilitate implementation.
In implementing the paper-based clinical pathway, a clinical pathway special sheet and a variance-reporting sheet were included in the patient chart to track daily activities and record deviations from the pathway.However, this chart was sometimes used by a doctor. The ward nurse
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assigned to a patient had to wait for the chart when she wanted to record the patient's activity on the pathway form. Using the web-based clinical pathway, the pathway special form and variance-reporting form were always on the Internet. The personal computer at the nurse station was used only to implement the web-based clinical pathway. The nurse could record and review daily activities on this form on the web at any time. A web-based clinical pathway is clearly more convenient to the ward nurse than a paper-based pathway.
The demographic characteristics of patients for whom the web-based clinical pathway was implemented, are the same as those of the patients for whom the paper-based pathway was implemented. The authors' previous report showed that continued implementation of the paper-based clinical pathway for radical nephrectomy can improve a physician’s practice by reducing the length of hospital stay and admission charges to below those before the paper-based clinical pathway was implemented.In this study, the length of hospital stay and the admission charges in group 2 were less than those in group 1, although the difference was not significant. Therefore, implementing a web-based clinical pathway can reduce the length of hospital stay and admission charges, as much as the paper-based clinical pathway.
Implementing clinical pathways is a complex and multifaceted task. The variances from clinical pathways must be analyzed to evaluate their effectiveness and identify areas that must be changed. Consequently, computerizing patient outcomes and variances in the pathways are important in implementing web-based clinical pathways. In the authors' experience variances from the paper-based clinical pathway declined significantly after continued implementation. The total number of variances, the number of patients with variances, and the causes of variances were did not significantly differ between the two groups. The numbers of correctable and uncorrectable variances also did not significantly differ between the two groups.
Implementing a web-based clinical pathway for radical
nephrectomy can yield the same variances as paper-based implementation. However, the number of undetected variances from the web-based clinical pathway was significantly less than that from the paper-based pathway. The variance detection time in the web-based clinical pathway group was also significantly less than that of the paper-based clinical pathway group. Implementing the web-based clinical pathway is more accurate and faster than implementing the paper- based clinical pathway in detection of variances. The advantages of the WWW are very obvious in implementing the web-based clinical pathway.
Improving the quality of care is the main goal of implementing clinical pathways. The improvement in the quality of care due to implementing a paper-based clinical pathway was prove n in the previous reports. This study found that implementing a web-based clinical pathway for radical nephrectomy improved the quality of care as much as the paper-based clinical pathway.
After implementing the we b-based clinical pathway for radical nephrectomy, the nurses, physicians and health care staff became familiar with the relevant web-based technologies. A universal record which incorporates patient input, nursing input, administrative input and physician input will be the desired aim for an integrated care pathway. The results of web-based implementation can be disseminated to improve health care outcomes in the institution. Based on the implementation of a web-based clinical pathway, a web-based decision support system for creating, implementing and evaluating the clinical pathway may be developed in the future.
Implementing web-based clinical pathways for radical nephrectomy offer many advantages over the paper-based clinical pathway. These include the following.
1. A clinical pathway special sheet and a variance-reporting sheet need not be prepared for any patient.
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2. Nurses can record patients' daily activities at any time in web-based implementation and they do not need to wait for the chart if a doctor is using it, as is the case in paper-based implementation.
3. Any variances are easily and quickly detected.
4. Web-based implementation positive ly influences the length of hospital stay, admission charges and quality, as does the paper-based clinical pathway.
5. Nurses complete the clinical pathway and can send it to the clinical pathway development team by pressing a single key.
6. The data are captured directly in electronic format, facilitating and accelerating analysis.
The only two disadvantages of implementing the web-based clinical pathway are the following.
1. Nurses must be keyboard and Internet literate.
2. Nurses cannot record the patients’ activities at the point of care. However, this disadvantage can be overcome by creating the web-based clinical pathway on a palmtop or hand-held computer.
The results of this study reveal that implementing a web-based clinical pathway for radical nephrectomy can improve health outcomes by reducing the length of hospital stay and admission charges, and improving the quality of medical care as much as implementing the paper-based clinical pathway. Furthermore, the web-based pathway is more accurate and faster than paper-based implementation in detection of variances.
Availability
The web-based clinical pathway can be reviewed at http://www.bmido.com/CPSSI_0531/default.asp
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