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 decision-making 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, evidence-based 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.

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