Less Can be More in Care Pathways
J Clin Pathways. 2022;8(4):22-23. doi:10.25270/jcp.2022.05.1
Redesign is needed in the US health care system. Despite incredible investment in health care, the US underperforms other developed countries in delivering health to its citizens.1 Among multiple contributing factors, one potential culprit is prevalent approaches to care delivery.
This should come as no surprise to organizational leaders who are trying to use care pathways to improve clinical, quality, and utilization outcomes. Traditionally, care delivery processes have not always been designed to achieve the desired health decisions or outcomes, and pathways represent an important way to combat this issue. But no solutions are immune to unintended consequences. For pathways, one potential risk is that in trying to encompass all relevant aspects of a clinical arc of care, they seek to do too much and inadvertently create high cognitive load.
As an overarching concept, cognitive load describes the mental effort required to understand and act upon a process. The intuition is straightforward: the more mental effort individuals must expend on understanding or processing something, the less capacity they have to use it and make good decisions. Things that increase cognitive load include the presence of too many choices, which can counter-intuitively lead to poorer decisions through choice overload; and ambiguous prompts, which require individuals to expend cognitive energy interpreting or inferring meaning and appropriate next steps.
Cognitive load can affect efforts to redesign care delivery, and pathway and other organizational leaders should be cognizant of these potential dynamics.2 Despite perceptions that they are blanket solutions for addressing unwarranted variation, pathways are not just ‘set it and forget it’ strategies. Instead, they often require clinicians and teams to process information and make decisions over time. For instance, clinicians must determine eligibility (ie, should a patient be on pathway?) and applicability (ie, do all aspects of the pathway apply to a patient?) revisiting these choices based on patient values and clinical course. The inherent ambiguity in these decisions can raise cognitive load.
Pathways also often involve multiple choices over time. For example, hospital surgical pathways often involve numerous elements in the pre-operative (ie,, testing and optimization of surgical candidacy), operative (ie, instruments and approach), and post-operative (ie, reinitiation of diet and physical activity, need for physical therapy or other support services, discharge disposition determinations) periods. The large number of choices can create choice overload and increase cognitive load.
The solution to these risks is not to abandon pathways. A degree of cognitive processing is also required, if not desired, in the process of care delivery. But given the specter of counterproductive levels of cognitive load, organizational leaders can also take several steps to adjust existing pathways and design new ones in ways that better minimize undesired cognitive load.
First, leaders can endeavor to remove unnecessary steps within pathways, and options within each step. Though the idea that “more is more” is understandable—who would not want to provide more data, citations, and information to aid in pathway determinations? —it can also be misguided. If too much mental load can lead to poorer decisions, more information is not always harmless. And asking clinicians to process information and prompts that are not on the critical decision-making path can actively work against them.
Second, to make determinations about what steps and optons are necessary, leaders can leverage the existing emphasis on medical evidence in pathway initiatives, explicitly assessing the clinical evidence behind different pathway elements. While certain components may be backed by clear scientific evidence, others can be based on active areas of debate or expert opinion. Should both types be given equal weight through incorporation in a pathway? Or should steps with less evidence be omitted, both on scientific merits and the desire to reduce cognitive load?
These considerations may seem obvious, and many organizations may already incorporate this into their pathway processes. But the reality is that there can still be significant variability in the strength of evidence behind different pathway elements, and in turn, additional opportunities to thoughtfully prune non-essential ones to minimize cognitive load.
Third, when the evidence is not settled on a particular pathway component, leaders can address the ambiguity by prioritizing testing and evaluation. In particular, if leaders include certain processes despite unclear or weaker evidence, they can plan for and conduct rigorous evaluations to maximize learnings from these decisions. Over time, the bar for inclusion in a pathway may not need to be incontrovertible evidence, but it also cannot be pure clinical intuition. It is difficult to confidently codify what works if we do not measure, evaluate, and validate it.
In all of this, the unifying theme is that despite the desire to encompass more using pathways, less can be more. While leaders should ensure there is enough information in pathways to provide clarity, it is wise to regularly identify and remove unnecessary elements; assess prioritize between those included; and use testing and evaluation to clarify the benefits (or lack thereof) of more equivocal components.
Of course, these steps along cannot address existing limitations in pathways, or broader issues in the US health care system. As noted above, a high level of cognitive load may be appropriate and needed for particular components in some pathways. But leaders can still use awareness about the dangers of cognitive load to design and implement pathways in a way that helps them achieve their potential to improve systems of care.
References
1. Schroeder SA. We can do better–improving the health of the American people
N Engl J Med. 2007;357:1221-1228.
2. Liao JM. Putting the design in health system redesign: minimizing cognitive load
Healthcare (Amst). 2022;10(2):100625.
