Heuristics Matter: The Principle Reason Why Clinical Pathways Fall Short on Capturing Value

Given the pace at which clinical care delivery is changing, providers’ mental bandwidth is being stretched to an extent that limits their ability to critically process information and deliver optimal decisions tailored to their individual patients. In this context, heuristics, or “mental shortcuts”, may play an outsized role in clinical decision-making. This inclination may extend to health care stakeholders as well, whose conceptions of “value” may be based on cognitive biases arising from flawed heuristics. Through an appreciation of heuristics, we can better understand the factors that influence the decisionmaking processes of different stakeholders and adjust our approach to delivering value-based care to our patients. Clinicians are all biased in their delivery of care to patients. Indeed, it is a distinctly human faculty with the potential to be leveraged to improve clinical care outcomes. But, given the breakneck pace at which clinical care delivery is changing with advancing science, technology, and health care reforms, providers’ mental bandwidth is being stretched to an extent that limits their ability to critically process information, deliberate options, and deliver optimal decisions tailored to their individual patients. This is where biases, in the form of heuristics, come to the forefront. At the individual level, heuristics can be considered “mental shortcuts”, or the human equivalent of computer science’s “rule-based system”, in which basic, efficient rules are subconsciously used to form judgements and make decisions. Heuristics are what dictate many intuitive decisions. Importantly, an operative feature of heuristics that lends itself to efficiency is that their use often entails a focus on one facet of a complex problem while ignoring other aspects that contribute to the bigger picture.1,2 In many situations, heuristics provide for acceptable outcomes. However, in the arena of clinical care delivery, to the extent that heuristics are influenced by such factors as clinical experience, practice resources, and organizational priorities and incentives, the pressures of a rapidly evolving health care economy can readily effect providers’ cognitive biases, resulting in systematic departures from rational, knowledge-based decisions that best serve their patients and value-based health care. clinical pathways vs clinical heuristics “The first principle is that you must not fool yourself, and you are the easiest person to fool.”– Richard P. Feynman,  Nobel Laureate in Physics In contrast to electronic health record (EHR) platforms, formalized clinical pathways, whether developed internally within an organization, licensed from a vendor, or imposed by insurance companies, propose the modern promise of enhancing and enabling clinicians’ consistent, evidencebased care delivery. And just like that, an order is brought to the chaos that is health care delivery, “knowledge” again reigns supreme, and the realization of a value-based health care system draws nigh. This sip of the Kool-Aid would usually be quenching if not for the objectionable aftertaste resulting from a conspicuously missing key ingredient, namely patient-centered decision logic. And just like that, health care delivery is actually worse off (for patients) and further away from value attainment than where it began. In my previous column, I introduced the principle need for a system dynamics-based approach to clinical pathways development and implementation, with the reasonable assumption of health care organizational goals of capturing shared value for themselves and the patients they serve. But there are deeper layers to fulfilling this reality that ultimately serve patients’ needs. The layers go deeper beyond additional issues of lacking pathway standards, interface design standards, and organizational knowledge creation and representation infrastructures that function to curtail misaligned organizational strategy to ensure that value-driven patient-centered outcomes are unified with operations and execution tactics. Ultimately, at the core of the human enterprise of health care delivery (extrapolating from Socrates) is the honest understanding that true wisdom lay in knowing that we know nothing at all. One can almost understand why, in this complex, rapidly evolving health care economy, health care delivery affiliations: Dana Farber Cancer Institute; Brigham and Women’s Hospital; Harvard Medical School 51 www.jcponline.com December 2017 • Journal of Clinical Pathways pathways in focus organizations may be inclined to believe the rhetoric of their marketing slogans and mission statements so as to lose their objectivity about fitting the solution to the problem (ie, optimizing patient outcomes). This inclination to accept the illusion of “value”, all the way up from the organizational leadership down to the provider-patient interaction level, is the natural effect of cognitive biases arising from f lawed heuristics. Despite the sincere intentions of existing health care organizations and clinical providers alike, it is the economic pressures of the day that force certain heuristic tendencies that compromise rather than facilitate care delivery optimization initiatives. Specifically, heuristics can compromise any situation when: (1) we are unaware of heuristics; (2) we hold a flawed heuristic; and (3) we rely on heuristics alone instead of using data and testing.3 Through an appreciation of heuristics, we can now understand that the factors that influence the decision-making processes of different stakeholders is important to understanding what decisions they make. In the final analysis, those factors that influence the process ultimately impact the outcomes. leveraging heuristics to develop better clinical pathways In the case of clinical pathway initiatives that propose to do right by patients, strategic and operational misalignment with care providers who also aim to add value to patients’ lives represents a violation of first principles that will ultimately reflect in the objective outcomes of initiatives. Of course, seeing these outcomes requires objectively asking the right questions of your data. It is easy to demonstrate “value” or a return on investment of almost any initiative or acquisition. But I’m not talking about revenue cycles, insurance reimbursements, or clinical trial enrollments. I’m talking about the way any one of you reading these words right now would honestly want your or your family members’ care to be coordinated and managed if in the place of any one of your patients. This statement applies just as much, if not more, to the clinical pathway developers. To engineer a more effective decision-support platform that leverages the clinical mind’s processes, build in decision logic that facilitates development of value-driven heuristics, as opposed to formalizing and propagating static rules that systemically hard-wire fundamentally f lawed cognitive biases. Stated another way, the development and use of heuristics that are purely rational are not sufficient to meet patients’ needs or organizational missions; instead, 52   there must also be an accounting of the psychosocial dimensions that make for optimal care delivery. Through an appreciation of heuristics, we can now understand that the factors that influence the decisionmaking processes of different stakeholders is important to understanding what decisions they make. As health care moves into the digital age, Google provides a great example of how to competitively differentiate yourself by intently creating and capturing shared value better than anyone else can. Like any organizational endeavor, Google’s success is attributable in large part to their culture and leadership that consistently reflects that culture. In contrast to many other internet-based services, Google understands the limitation of long, rigid planning and development cycles (such as those that characterize EHRs). Instead, they learn and evolve rapidly and flexibly in response to the behavior of their users (ie, customers). Google can do this because their culture and leadership is defined by engineering PhDs, not the traditional business tenets of management and finance. Interestingly, the scientific method that drives Google’s approach to serving their customers is the same standard that clinicians insist upon in their acceptance of new drugs and treatment paradigms. I see no reason why this same standard cannot be more effectively extended to the privilege of delivering value-based care to our patients. References 1. 2. 3. Kahneman D. Thinking, Fast and Slow. Farrar, Straus and Giroux; New York, NY; 2011. Finucane ML, Alhakami A, Slovic P, Johnson SM. The affect heuristic in judgment of risks and benefits. J Behav Decision Making. 2000;13(1):1–17. Smith J. Why you need to know heuristics for conversion optimization. Jeremy Said website. https://www.jeremysaid.com/blog/heuristics-for-conversion-optimization/. Accessed November 30, 2017.