Enhancing primary care through integrated care pathways: a convergence of theory and practice

TheoreScal framework and pracScal applicaSons of ICPs ICPs form the foundation of care that is systematic, evidence-based, and multidisciplinary. The ideal goal of an ICP is the management of healthcare provision to standardised levels while ensuring that care remains personalised to meet the peculiar needs of each individual patient. This model assists in fostering a systematic approach to health conditions; this becomes quite easy, especially in primary health settings where the needs of patients can be highly variable. By outlining specific steps in the care process, ICPs provide healthcare professionals with a consistent framework that guides the entire patient journey-from initial diagnosis to treatment and long-term follow-up-ultimately reducing variations in care and enhancing patient safety 3,4 , (Table 1).This structured approach has a special application in the management of chronic conditions, which by nature require frequent monitoring and change in treatment. ICPs guarantee uniformity in guidelines, as all health professionals involved in the care of a patient work on the same evidence-based protocol; this leads to a reduction in the chances of error or omission in the provided care. It involves combined efforts, for example, in diabetes; general physicians, endocrinologists, dieticians, and pharmacists are involved. This will lead to good coordination and enhanced control of the blood glucose levels as it helps the patient in longterm outcomes. 5 The structured communication by ICPs also allows early identification of potential complications, thereby enabling timely intervention and preventing hospitalisation. 6 ICPs not only optimise clinical outcomes but also enhance efficiencies in health systems by taking into consideration resource utilisation. Applied in particular clinical pathways, say, elective surgeries or chronic disease management, ICPs manage to support health providers in arriving at informed decisions on the most appropriate use of resources such as staff time, medication, and utilisation of beds within hospitals. Oosterholt et al. 1 , showed how ICP pathways can manage care effectively by reducing lengths of stay in hospitals and making sure every intervention is necessary and not delayed. This is very important in surgical care since exact coordination between the pre-operational, intra-operational and postoperational care groups can prevent unnecessary delay and allow for optimizing the times of recovery. This represents how ICPs not only help raise care quality but also contribute to economy, and thus health administrators who are concerned with efficiency will consider ICPs to be a very welcome solution.Despite these advantages, there are still challenges that ICPs face in their integration into practice. One of the major criticisms by health professionals is the perceived rigidity of ICPs, which may inhibit their judgment in practice. 7 The resistance to ICPs partly stems from concerns that standardised care protocols cannot always be flexible enough to meet the needs related to the preference of individual patients or complex medical conditions. While ICPs are meant to be flexible, the balance between standardisation and customisation remains a thorny issue. ICPs can only hope to deliver their promise in the primary care brass section if active involvement of health care providers from development through refinement is present, including a balanced approach between evidence-based care and individualised treatment. 8 Professional resistance to ICPs Professional resistance is one of the most important impediments to the successful implementation of ICPs in a primary care setting. ICPs make health providers, especially physicians, feel that this damages their clinical autonomy. The rigid protocols invaded by these pathways in current clinical practice lessened professionals' latitude for individual decisions according to the needs of the patients. 9 This tendency for a perceived loss of autonomy can lead to frustration, which is, in turn, precipitated when the clinician perceives he/she is being coerced into a "one-size-fits-all" model that fails to take account of the subtleties of clinical reality as it is experienced in everyday practice. Many clinicians indeed believe that while ICPs standardise care, they reduce the latitude needed in the management of patients with complex, multivariate diseases-a multitude of whose examples are seen in primary cares. 10,11 This perceived rigidness results in professional dissatisfaction on the grounds that health professionals feel their expertise and judgment are being belittled for process standardisation.Another layer of resistance in this regard is related to the fact that some administrative workload, which is commonly imposed by ICPs, may be burdensome. Added documentation, compliance requirements, and communications among multidisciplinary teams have a tendency to increase non-clinical tasks that many healthcare providers feel detract from patient care. According to Rathod et al. 4 , clinicians involved in psychosis care also found the ICP protocols too rigid and thus dampening their ability to make fine-tuned, patient-specific decisions, while administrative tasks associated with the ICP added to their frustration. In the same line of thinking, Lalani et al. 2 also comment on how many clinicians consider ICPs as meant to further bureaucratise practice, which will only result in more administrative burdens without necessarily impacting the delivery of quality in patient care. This feeling is certainly common within busy primary care settings where providers are already at their limits and may more likely view an ICP as added layers of complexity rather than a practice tool to facilitate ease in the delivering of care. 12 Overcoming professional resistance to pathways requires a collaborative strategy, which involves healthcare providers in the design and operation of ICPs. Early involvement in an ICP tends to promote views among clinicians that these pathways are supportive tools that enhance rather than limit clinical practice. A number of studies have reported that ownership of care pathways can be increased and resistance to adoption decreased by involving clinicians in developing the pathways themselves. 13,14 In addition, efforts to highlight how ICPs would allow practitioners to reduce cognitive load, make decisions more quickly and effectively, and manage patients more efficiently can ease some concerns about the perceived administrative burdens. 15 Assuring providers that ICPs serve as dynamic frameworks to support individualised care, rather than inflexible protocols, may increase provider willingness to adopt these pathways for the benefit of their practice and for patients everywhere.-ICT-system interoperability challenges One of the greatest barriers to the implementation of ICP is the lack of interoperability between the various information and communications technology (ICT) systems. 16 The ICPs require that information related to the patient be prepared to thread their way through and be seamlessly followed by different care teams for timely, coordinated interventions. 17 Most probably, in most primary cares, this flow is disparaged with different ICT systems, thus creating fragmented cares and thereby missing the chance for timely intervention. Lalani et al. 2 note that integrated information and communication technology systems are vital in experiences to ensure that ICPs realise their full potential in respect of enhancing the coordination of care. Without appropriate data sharing, the providers of healthcare services get obliged to operate within silo systems, which tend to lower efficiency in care provision. Parry et al. 5 observe that poor interoperability associated with the ICT system in this Tower Hamlets was associated with higher active elective inpatients admission rates. Therefore, it suggests poor coordination of care despite the application of ICPs.Interoperability of ICT-systems necessitates investments into interoperable EHR systems that will enable both sharing and exchange of paSent informaSon in a secure way with all care providers involved in an ICP. 18,19 Besides, integraSon of decision-support funcSonality within such systems can maximise the impact of ICPs by enabling real-Sme data-driven decisions for clinicians. 20,21 Among recent innovaSve technologies, there are blockchain soluSons, promising to tackle current limitaSons of ICT interoperability for secure data sharing. 19 -A new concept: ICPs and predicSve analyScs for proacSve care While much of the discussion around ICPs has focused on standardisation and coordination, one area that has been highly unexplored is the integration of predictive analytics into ICP frameworks. That approach could shift the paradigm of ICPs from a reactive care-only approach-where the intervention in care is based solely upon symptoms or conditions as they present themselves to a patient-to proactive care: guided, decision-based interventions based upon predictive models created directly from the patient data. Predictive analytics can analyse big volumes of health data to find out patterns and trends indicating future health risks. Thus, integrating such tools into ICPs might enable healthcare providers to predict possible complications far in advance and to intervene much earlier. For example, wearable devices could monitor a patient with COPD, while predictive algorithms automatically alert the care team about subtle changes in respiratory function that presage an impending exacerbation. 16 Embedding predictive analytics in an ICP thus marks new territory to get healthcare personalized and data-driven. Such a novelty, disclosed herein, corresponds with the ICPs' goals of improved patient outcomes, reduced admissions, and efficient resource utilisation. Accommodating other criticisms levelled by practitioners for the rigidity of ICPs, predictive analytics will also permit dynamic and personalised care plans that change in near real time in response to changing data inputs. 22,23 IncorporaSng predicSve analyScs into ICPs might therefore also offer a soluSon for some of the challenges related to interoperability of the ICT systems. Advanced algorithms could run within exisSng EHR systems, providing real-Sme alerts and decision support without requiring far-reaching changes in the underlying infrastructure, thus integraSng predicSve tools as a cost-effecSve and scalable soluSon to improve the quality of ICPs in primary care. 24,25 -Novel concept: paSent co-design of ICPs While much attention has focused on healthcare professional involvement in the design of ICPs, there is a growing awareness of the benefit of engaging patients themselves as codesigners of care pathways. This perspective involves direct patient participation to be an active partner in shaping the ICPs in a novel approach toward improving satisfaction and care outcomes for the patients.Patient co-design is more than a matter of feedback; the patients get actively involved in decision-making about their pathways of care. A model like that might increase treatment adherence and patient outcomes because the care pathways would then be tailored to the needs, preferences, and values of the individual. 26 Simply consider that when the patient is empowered to contribute to developing their pathway of care, they will be more engaged in the process of care; thereby their health outcomes should be improved. 27 Recent studies have shown the prowess of patient co-design in chronic disease management, as patients are usually aware of the daily usefulness or deficiencies in current modalities of therapy in the management of their ailments. 28 Thus, incorporation of the patient's perspective into ICPs has the potential to give healthcare systems pathways that are more flexible and responsive to the particular challenges presented by a patient. This precept aligns with personalized medicine policies where treatments are made to meet the needs of each patient. 29 It also serves to help reduce some of the resistance from health professionals in addition to patient-centred outcomes. Involving patients as co-designers in pathways allows providers to make them more flexible and patient-centred, hence reducing concerns about the rigidity of ICPs. 30 This professionalism fosters an integrated relationship between the patients and the providers for improvement in the quality of the care in general. 31 Balancing the potenSal gains with challenges While ICPs hold immense promise for improving healthcare, practical implementation has to be a balancing act between the overall potential benefits and the professional resistive capabilities and limitations issued from the ICT systems. Among the important hidden balances is whether the total benefits of ICP-improved coordination of care and reduced medical errors that are associated with better patient outcomes-constitute higher value than burdens imposed on healthcare professionals and the healthcare system itself. 32,33 The adoption of ICPs usually requires a practice to undergo operational and also cultural change. Such changes are met with resistance more often than not, exclusively when the perceived benefits of the ICPs would be abstract or long-term, while challenges that would be brought forth in the forms of administrative burden and workflow changes are real and will be felt immediately. All these changes may be overwhelming for every healthcare provider, especially in primary care, and often result in resistance to adopting the ICPs, no matter how much they could help in caring for the patients.Moreover, the infrastructural requirements, specifically interoperability concerns related to ICT systems for the implementation of ICPs, may offer formidable barriers. Very many health systems have digital platforms that are antiquated or cannot work in concert with other such systems; thus, the easy flow of patient data across multidisciplinary teams is not possible. In the absence of proper ICT infrastructure, the efficiency gains that ICPs promise, such as realtime data sharing and integrated decision-making, become unreachable. This means that special attention has to be given not only to the design issues of the ICPs as such but also to the preparedness of technological systems that these ICPs depend on. While analysing the balance between potential benefits and operational challenges in the process of ICP implementation, the costs related to upgrading ICT systems, training of health professionals, and system maintenance have to be accounted for.Carlile's work on overcoming knowledge boundaries sheds light on this balancing act. To quote Carlile, "building collaboration in complex systems such as ICP is possible". 6 His study thus infers that successful implementation requires the bridging of gaps among professional groups and shared responsibility among all the involved stakeholders-from the clinicians to the ICT specialists-so a sense of being invested is established across the board. 34 Such a culture can reduce some of the barriers to ICPs, enabling them to move from perceived threats to professional autonomy to collaborative tools that enhance the quality of care. This cultural shift becomes necessary not only for overcoming any professional resistance but also for developing and using the ICT systems in such a way that successful integration of ICPs into everyday practice is possible.While the ICPs do hold great promise for major enhancement in healthcare provision, especially at the primary care level, these are to be aaained aber overcoming many systemic stumbling blocks. Each of the stakeholders has a different orientaSon; thus, clinicians in both primary and secondary care, paSents, integrated care boards (ICBs), and the NaSonal Health Service (NHS) itself have to be orientaSonally different from each other. The concerns of each stakeholder group have to be addressed to create an environment in which ICPs can be at their best in providing coordinated, efficient, and paSent-centred care (Table 2). For primary care clinicians, who commonly are the point of entry for paSents and oben responsible for a wide range of health condiSons, this rigidity from ICPs may threaten their ability to provide appropriate management for their individual paSent needs. Resistance among professionals usually is viewed as stemming from standardizaSon, perceived to reduce the clinician's areas of autonomy. 9 These issues can be addressed only by designing the ICPs to allow a certain degree of flexibility in their adoption so that the primary care clinicians can deviate from the protocol where necessary. The challenge here is a balance between structured, evidence-based care and individualised decision-making, which is at the heart of primary care. By engaging clinicians as co-designers of ICPs, they thus can make a contribution to pathways that are standard yet stable and, therefore, feel empowered rather than by the system constrained. 13 Such engagement can also be giving them an opportunity to look upon the ICPs not as backward protocols, but rather, frameworks come through in facilitating quality care by reduction of errors and ensuring consistency.For secondary care clinicians, especially those in hospitals or specialist settings, ICPs provide the opportunity to better coordinate care with primary care. One of the major irritants in health care generally is the fragmentation between levels of service, which can result in duplicated tests, delayed diagnoses, and suboptimal patient outcomes. 18 ICPs are the bridge that would ensure a smooth transition of care from the primary to the secondary level of care and that all providers work with the same standardised care plan. The problem still remains for the communication of the care has to in information about and treatment from primary care. 17 This that the ICT systems between the should allow for interoperability between them so as to ensure ease of information That is, secondary care clinicians are involved in their development so that the of care are into ICPs are for the benefit of the their is often not the pathways of care. patients in the co-design of ICPs may lead to an improved and satisfaction of the care 26 is that patients who in their of care are more likely to to treatments and better outcomes on their a patient's the challenge is to services in settings from providers, the nature of the or complications in one has ICPs informed by their through co-design can thereby be tailored to individual and needs, with the active participation of patients in their care. These will help in the healthcare process and make it much on the of the patients to their current and future care and take responsibility for their 28 of the digital engagement tools through ICPs are patient which to provide current and facilitate in communication between the patient and provider in 31 are involved in the and monitoring of ICPs. major is to that the various levels of care, such as and are toward common is by in across various healthcare providers and in ensuring that each stakeholder to the pathways for this the has to in ICT systems providing for the necessary communication and sharing of data across the care This would ensure that the care is coordinated with no or in the care Besides, needs to ensure that monitoring and of ICPs so that in the system may be with on 19 it will clinicians and patients in developing and these pathways so that ICPs are and a healthcare the has the added responsibility of ensuring that the ICPs are scalable and across and health of the major challenges the to in ICT interoperable systems that patient data across all care settings are the full potential of ICPs will be The also has to deliver a cultural change in the way health care is To care has been provided by of and care providers that often work in from one ICPs are to the needs to a more integrated approach where care is as a with all providers to the same overall care plan. and that promote collaboration and across care settings will be in this 34 the should be concerned about the long-term ICP While the investments in both investments in technology and training are the benefits that will be from paSent by reduced admission and more of care, would thus create a balance with those and of evidence-based ICPs will guarantee in and in a changing health environment because of in the complex implementation of ICPs requires in to concerns and by all concerned clinicians should be empowered in using ICPs as flexible tools that personalized care. The secondary providers should be integrated into the of care through interoperable ICT systems timely engagement in the of care pathways is necessary to make them active in their health The guarantee coordination and across care settings, and the should lead the way to promote a culture of collaboration and they many of these challenges in many ICPs can be tools toward improvement in the delivery of ICP should be to provide patients with coordinated, efficient, care through engagement and integration within the patients directly in co-design for more personalised pathways, by digital engagement patients as of their healthcare patients contribute their experiences to ICP they of become active improving adherence and blood integrated into patient that allow patients to the realtime of their health decisions, ownership and engagement with their professionals collaboration and cultural change for ICP on the long-term benefits of ICPs, and provide for ICPs as for a within a sense of shared responsibility that every stakeholder value in the creating a more healthcare delivery a where healthcare teams are for successful ICP with boards and collaborative goals that and cultural change toward