Cirrhosis Care Path

Care Paths are an advanced form of clinical decision support available in the Connect Care clinical information system. They promote evidence-informed and goal-directed workflows by providing clinicians with simple and intuitive recommendations delivered via Best Practice Advisories (BPAs). These consider patients' results, medications and health status to help align care with evidence-informed practice guidelines. Care Paths also include a wide range of documentation and ordering supports. These help clinicians track patients' progress and provide individualized care at key milestones in a chronic disease journey.

Care Path Components

The Cirrhosis Care Path promotes multidisciplinary coordination of a patient’s health care, with the objective of improving care across the continuum from acute, community and primary care. An initial focus relates to patients admitted with cirrhosis as a primary (principal) problem or as an active hospital problem. The Care Path toolkit includes components in three categories:

Documentation Supports

Decision Supports

Inquiry Supports

At this time, the cirrhosis documentation supports are available to all clinicians. Other Care Path tools are released throughout 2024.

Problem Overview

Problem overviews provide a high-level summary of key attributes of health conditions that any clinician might need to be aware of. They are stored at a patient level, and so are available in all care contexts (e.g., inpatient, emergency, outpatient, community, etc., care). Only one overview is associated with a health problem, and so overviews are jointly maintained by all prescribers.

Connect Care offers a growing number of provincially curated overviews for common chronic illnesses, including cirrhosis. This uses a consistent structure, is rendered to easy-to-read prose, and has interactive text for managing the core data relevant to cirrhosis care. The core data includes elements essential for cirrhosis care path decision supports.

As soon as a cirrhosis-related problem is added or activated in a patient's problem list, a link appears just below the overview edit box ("Problem Overview Data - ..."). This can be used to access the standardized data set for cirrhosis care. An interactive text-block can be added to the overview text box (or any other documentation) by using the ".OVERVIEWCIRRHOSIS" SmartLink. The resulting text is "interactive" in that anything in dark blue font can be selected in order to, again, bring up the structured data editing form. A refresh of the overview text will update with the new information. 

The same link can be used in any other documentation, such as a discharge summary. Cirrhosis overviews appear in the cirrhosis sidebar and all cirrhosis documentation templates. 

Sidebar Summary

A "Sidebar" is available as the right-most screen section when patient charts are opened in most clinical contexts (inpatient, emergency, critical care, outpatient, etc.). It can be collapsed or expanded. When open, it facilitates quick access to information that can help with clinical documentation and decision-making.

Access

A cirrhosis sidebar is enabled for patients with cirrhosis-related medical histories or problems and is available for inpatient and outpatient encounters. It can be accesed by using the "Notes" index item at the top index of the chart sidebar. It can also be accessed by using the "Views" index item and then selecting the "Diseases" sub-menu. 

Interaction

The cirrhosis sidebar adopts Connect Care's "interactive documentation" norm. Any heading, subheading or text coloured dark blue can be selected to "interact" with the displayed text. In this way, additional clinical details can be reviewed (click to activate a popup report) and structured data can be updated in place (selecting a text item and enter or edit the relevant data). 

A "refresh" icon at the top of the sidebar will update sidebar contents with the most recent clinical information.

Content

The cirrhosis sidebar includes a number of text blocks containing information relevant to cirrhosis care. SmartLink (dot phrase) mnemonics are offered for most sections, helping users to pull one or more block into personalized documentation tools. The text blocks also appear in standardized progress and summative (e.g., consult, discharge summary) document templates. Sidebar sections, from top to bottom, include:

Support

Trackers

Symptom Tracker

The Cirrhosis Symptom Tracker facilitates simplified capture of patients' experiences with fatigue, pruritis, appetite, nausea, bloating and dyspnea. A symptom summary can be activated from within progress and summative documentation (consults, history & physical, discharge summary, disease summary). The pulled-in text block resembles what appears in the cirrhosis sidebar and is interactive, allowing updates to be made by clicking on dark blue text.

Sign Tracker

The Cirrhosis Sign Tracker facilitates simplified capture of clinician observations about bowel movement frequency, gastrointestinal bleeding, edema, ascites, asterixis, delirium, weight change and encephalopathy staging. This can be activated from within progress and summative documentation (consults, history & physical, discharge summary, disease summary). The pulled-in text block resembles what appears in the cirrhosis sidebar and is interactive, allowing updates to be made by clicking on dark blue text.

Investigations Trackers

Interactive listings of etiologic and tracking laboratory test results can be pulled into progress and summative documentation.

Etiologic labs relate to the possible causes of cirrhosis and are subgrouped into metabolic, genetic, immunologic or infectious causes. Tracking labs are used to follow the progression of cirrhosis and its renal, hematologic and liver function complications.

Medications Trackers

Lists of cirrhosis relevant (therapeutic and risk) medications can be pulled into documentation with these interactive tools.

Procedures Trackers

Lists of cirrhosis relevant interventions (e.g., endoscopy, banding, paracentesis) can be pulled into documentation with these interactive tools.

Cirrhosis Scores and Calculators

Interactive support is provided for just-in-time calculation and use of Child-Pugh, Hepatic Encephalopathy Stage, MELD, FIB-4 and Fibroscan scores in planning cirrhosis care.

Cirrhosis Timeline (Synopsis)

A "Timeline" (Synopsis) allows different types of cirrhosis information to be viewed together, with changes trended across configurable time ranges. Using this tool, for example, the start and stop of different medications can be correlated with changes in symptoms, signs, laboratory tests and procedure results. 

The Cirrhosis Timeline can be accessed via a link at the top of the Cirrhosis Sidebar. By favouriting various rows, different combinations of symptoms, signs and other findings can be tracked alongside interventions.

Cirrhosis Patient Education

Patient education resources are available within Connect Care and from the CirrhosisCare.ca website. Links to the associated libraries are provided at the top of the cirrhosis sidebar. Digests of some resources are automatically brought into cirrhosis consult and discharge summary templates.

Document Templates

Standardized note templates are provided for cirrhosis clinical summaries, discharge summaries and progress notes for inpatient care. In the outpatient setting, templates are provided for initial consults, repeat consults and for a chronic disease summary.

The templates can be accessed from links at the top of the cirrhosis sidebar. They also appear as options within the "notes" sidebar section when patients have cirrhosis-related conditions in their problem list.

Order Sets and Panels

Multiple related orders can be combined and organized through the use of condition-specific order sets (inpatient) and order panels (outpatient). Order sets are among the building blocks for care paths. Accordingly, a number of order sets have been developed and implemented for cirrhosis care, including ones related to ascites, encephalopathy, hepatitis, hepatorenal syndrome, peritonitis and variceal bleeding. These are found by using the keyword "cirrhosis" when searching for orders. 

Best Practice Advisories

Best Practice Advisories are clinical decision supports that recognize patterns in a patient's clinical information that match evidence-informed clinical guidance. Providers can then be alerted to possible needs for additional information or interventions. A number of BPAs are developed to serve the needs of the cirrhosis care path.

Hepatic Encephalopathy

Hepatic Encephalopathy (HE) is associated with a high morbidity and mortality burden for patients with cirrhosis. It is also the most common reason for cirrhosis-related hospital admissions. Readmission risk can be reduced through adherence to evidence-informed clinical guidelines.

Connect Care prescribers are alerted for patients whose problems, history or other clinical data are suggestive of HE. Care recommendations are dynamic, reflecting each patient's unique circumstances, and address needs for tracking, medications, nutrition and infection prevention. The BPA is linked to other documentation and decision supports for cirrhosis care.

Care Path Summary

Once a patient is added to a Care Path, key information and actions are summarized in a report that can be viewed within the "Summary" activity of an opened inpatient chart. The summary can be found by searching for it from among the summary views available to prescribers within the activity. It can also be opened directly by using links provided via the chart sidebar (use "Notes" or "Views>>Diseases" links from the sidebar index.

The Care Path summary provides a digest of cirrhosis-care clinical observations together with links to relevant:

Patients move along a Care Path automatically based on specific criteria being met (e.g., clinical condition or length-of-stay data), or may be moved manually based on prescriber discretion and clinical judgement. The hepatic encephalopathy part of the cirrhosis care path summary is illustrative:

Care Path Use

Care Paths have been shown to reduce unhelpful practice variation, prescribing errors, length of stay, readmission rates, patient mortality, and healthcare costs. They also improve patient follow-up with primary care providers, specialists, and specialty clinics. 

Care Path feedback metrics are designed to help clinicians recognize missed opportunities for leveraging the potential positive impact of these tools.

Available metrics are found in Meaningful Use Dashboards: 

Education Modules

Self-directed learning materials are available via MyLearningLink (MLL), accessed by searching with "Care Paths" as a search term. 

Resources