I had the recent privilege to observe and learn first-hand about an exemplary functioning learning health system (LHS) that has been developed and enhanced over the past two decades in Japan. This system was initiated and has continued to flourish through the tireless leadership of Dr. Hidehisa Soejima at the Saisekai Kumamoto Hospital, which has received and maintained a coveted Gold Seal of Approval from the Joint Commission International (JCI) since 2013. I would encourage everyone to hear Dr. Soejima speak about this fine example of an LHS and how it improves research and benefits patients. He will be coming from Japan to present at the Bridging Clinical Research and Health Care Collaborative on 5 March 2019, National Academy of Sciences, Washington, DC. (See www.bridgingclinical.com.)
A ‘learning health system’ is defined by the National Academy of Medicine as “…one in which science, informatics, incentives and culture are aligned for continuous improvement and innovation, with best practices seamlessly embedded in the delivery process and new knowledge captured as an integral by-product of the delivery experience”. A related concept that supports LHSs is that of Clinical Pathways (also known as Integrated Care Pathways and Critical Pathways), which were actually described in ~ 1985 in a publication by Zander, Bower and Etheredge. These Clinical Pathways or ICPs are essentially care plans or medical protocols through which process management methodology is applied to healthcare. The forces that have garnered interest in ICPs over the years include health care economics that require more efficient use of resources, quality improvement initiatives and evidence-based best practices, implementing electronic health records and involving patients and their families as partners. [Zander, K. Journal of ICPs, “Integrated Care Pathways: Eleven International Trends” (2002)] They have been used in at least 23 countries to varying degrees.
Dr. Soejima, having learned of Clinical Pathways from Zander, introduced this concept within his hospital in Japan in ~ 1996 to improve medical quality. He has been improving upon it ever since, taking it from a paper-based process to an electronic system that now offers all hospital employees graphs and analytic views displaying results of their applied Clinical Pathways. Since 2011, he has been the chairperson of the Japanese Society of Clinical Pathway (JSCP).
The Japanese word kaizen means continuous improvement. Applying kaizen principles to Clinical Pathways and integrating new technology to obtain structured digital health information, Dr. Soejima and his colleagues can now boast a hospital-wide system that significantly improves the functioning of the hospital and improves patient outcomes at lower costs. Interest has spread throughout the Japan and a recent grant from Japan’s AMED (which is similar to the U.S. NIH) will fund extension of Dr. Soejima’s Electronic Clinical Pathways approach and technology to additional hospitals.
Dr. Soejima is a humble individual who has transformed the way healthcare is delivered, measured and managed at Saiseikai Kumamoto Hospital. He confessed that he is somewhat different from most doctors, who generally do not like standardization and comparisons; he believes that collecting quality measures in a standard format and benchmarking against other clinicians leads to professionalism. Clinical Pathways have now been embraced by all team members at Saiseikai Kumamoto Hospital, from nurses and nutritionists to doctors and systems engineers. Just walking around this hospital (on a tour by a very capable young woman from the TQM department who was instrumental in achieving the JCI award), one can sense the pride of the employees in their work and the sense that they know they are a part of something unique and important.
Dr. Soejima summarized at the end of the overview of Clinical Pathways by stating that he believes in ‘clean big data’, which can only be produced if there are standardized templates for collection of the information. Expanding this to other hospitals, he is now challenged with harmonizing terminologies and metrics for a number of the outcome measures with other hospitals that will begin to use this Electronic Clinical Pathways system. Having spent over 20 years of my life building consensus around data standards, I could certainly relate to the challenges this important task entails. However, this is what it will take to be able to provide clinicians (and patients) with a ‘consumer reports’ type of report such that they can make educated and informed healthcare decisions and to continue to learn based on data.
After learning how the Electronic Clinical Pathways work at Saiseikai Kumamoto Hospital, with a demo from Dr. Soejima himself, I was invited to attend the 122nd Clinical Path Meeting, which took place 17:30-19:00 on 5 December. There were several hundred attendees not only from Kumamoto but from other areas of Japan, including Hokkaido and Sendai. These meetings occur every 2 months, which means that they have taken place for 20 years now.
At each meeting one department of the hospital leads the presentation of analyses of Clinical Pathways data to the attendees and makes specific proposals to be discussed. The 122nd meeting was somewhat different from others in that the presenting department was the Operating Room, which serves a number of other departments. Presentations were given by an anesthesiologist, a nurse, an administrator and a systems engineer. Based upon outcome measures and related variances from the Clinical Pathways system for 148 patients who went through laparoscopic cholecystectomy (LC), they presented observations related to the type of anesthesia and related this to the timing and value of inserting urinary catheters in these patients. The data are based on an ultimate outcome of discharging the patient with improved outcome units such as ‘stable respiration’ and ‘pain management’. Based on the data they presented, proposed changes in the current Clinical Pathway were discussed. The systems engineer commented on how the data are presented, how to customize the masters for data collection, connecting data such as cost data and care data and how to present the data by individual role. The administrator tied the information to optimizing the time for scheduling the surgeries, including comments such as how the anticipated time of the surgery must be adjusted depending on the patient’s BMI.
The rewards from the Clinical Pathways initiative have been significant in terms of improving the quality of patient care and reducing costs. The data can also be analyzed for other purposes such as studying the management of warfarin dosing across a large number of patients, which is a study that is now being done in partnership with Japan’s Translational Research Innovation Center. Others would do well to understand and adopt the Clinical Pathways principle as a means to realize a true learning health system.
As a reminder, anyone interested in the details on how this remarkable initiative has taken hold and improved continuously at this award-winning hospital and how they are extending it to other hospitals can hear Dr. Soejima speak at the Bridging Clinical Research and Health Care Collaborative on 4-5 March at the National Academy of Sciences in Washington, DC. www.bridgingclinical.com.