Table 2.

Traditional paper-based pathways vs. digital pathways.

(16)	Traditional paper-based pathway	Digital pathway
Access to pathway contents	• Paper-based: This may complicate information exchange between stakeholders, which in turn may limit stakeholder integration (56). • Pathways tend to only refer to a specific episode of care (18), only involving stakeholders of one and the same organization, which may also limit stakeholder involvement. • The number of stakeholders which can use the pathway or be involved in pathway definition is limited by the use of paper. • Physical access required (56): Pathway information needs to be copied or physically transferred for information exchange. At least in the first place, i.e., at the place of recording.	• Digital format: Information can digitally be transferred and exchanged between stakeholders. • Supports digital processing of data which enables the automation of some tasks which previously required human labor. • Allows for the digital and even semi-automatic or fully automatic integration of information. • Democratization (57): The group of pathway stakeholders can be extended more easily, e.g., active involvement of patients since electronic devices such as smartphones are mass-market consumer goods by now and internet access is widely available (58).
Evidenced-based care	• Scientific insights need to be manually integrated into the pathway by responsible team members. • This requires self-initiative from team members/their organizations to check appropriate source for updates of professional guidelines, new scientific insights on a regular basis.	• Potential sources of new scientific insights (e.g., public scientific databases, official regulations and professional guidelines that are being published electronically) can be linked to the pathway. • Responsible team members can be automatically alerted to relevant information retrieved from these sources. • Even the automatic integration of relevant information (as far as sensible and reliably doable with available technology), i.e., automatic update of pathways becomes possible.
Chronology of events	• Pathways are fixed, i.e., pathways do not automatically adjust when a patient differs from the pathway that is in use. Potential changes that may become necessary due to such deviations are not foreseen by definition, i.e., not defined on paper. • Prone to human recording mistakes (e.g., forgetting to indicate the time/date of a patient visit due to stress). • Multiple paper forms (e.g., orders for medication sets and tests, laboratory reports etc.) containing information belonging to a patient’s pathway (33) or even single pieces of information from those must be matched and sorted by hand if a chronology of all events is required. • Risk of incomplete information due to missing relevant information: blank in chronology of events.	• Time and date and other additional meta-information considered to be essential (e.g., name of the person in charge) can be added automatically. • Chronological order of events may be determined automatically. • Integration of pathway information from different sources provides a more complete picture of events. • Through the implementation of interoperability standards and corresponding interfaces, pathway information from multiple different sources (e.g., recorded by different stakeholders) can even be integrated automatically. • Ideally, a more complete picture of events can be obtained this way: complete chronology of events.
Inventory of actions	• Once a pathway has been defined, there is no flexibility to quickly add additional interventions not foreseen at the time of pathway definition by the responsible team. • In general, the inventory of actions that can be used for the definition of a pathway is limited due to the limited amount of space on paper.	• Through the use of AI, an updated version of the prospective pathway for a specific patient could be provided automatically based on advanced analysis of variance and patient population data. • The size of the inventory of actions is basically unlimited as relevant activities could be displayed or discarded on screen as needed, plus scrolling and browsing is an additional option on screen to fit in more activities.
Management of patient care	• Information exchange and thereby the coordination of activities heavily relies on the exchange of papers or paper copies and scans (paper-based patient files). This is highly labor-intensive and time-consuming. • Keeping track of information and gathering potentially relevant information from outside stakeholders is complicated. Pathways therefore tend to only refer to intra-organizational settings or one episode of care (20, 25), i.e., the coverage of the patient’s journey is limited. • Risk of redundancy: Although this risk is already reduced by the use of pathways in general, there is still a risk that activities carried out multiple times for a lack of knowledge or due to lacking standardization and interoperability.	• Exchange of information is facilitated by means of electronic communication. • Albeit the use of interoperability standards and corresponding interfaces is highly recommended (59). A lack of such poses a barrier. Implementing such standards/interfaces also requires the investment of time and financial resources. The return of investment on the other hand (in terms of money but also in terms of informational gains) highly depends on the initiative of the stakeholders involved. The more stakeholders decide to make the effort, the higher the return on investment for all actors involved. • Presuming interoperability, the risk of redundancy can be reduced through the electronic recording, storing and exchange of information.
Variance analysis	• The detection of deviations from the pathway and finding possible explanations is mostly left to the HCPs using the pathway (20). This makes it prone to human errors. • Relevant information can easily be missed or also go missing when everything/much information is recorded on paper. This can lead to mistakes in the analysis of variances. • The quality of analysis and interpretation of results very much depend on the expertise and experience of the person in charge.	• Semi-automatic or automatic recording and detection of deviations becomes possible. • AI can support HCPs in identifying possible reasons for deviations. • Any program is only as good as the algorithm behind it: Errors in programming can lead to false analytical results. • The same goes for the use of machine learning or AI: Computers do not “think” like humans, they only calculate. • Human expert knowledge can be translated into algorithms. This may benefit, e.g., less experienced HCPs. This especially poses an advantage when there is a shortage of experts (e.g., fewer specialized physicians in rural areas).
Education of patients and care providers	• Prior to digitilization, pathways were mainly drafted for and used by clinic staff. • Limited reach: Reaching of potentially relevant stakeholders has also been complicated as analogue education materials (e.g., handouts, CDs, DVDs) cannot as easily be spread. • Interactive education requires physical presence (e.g., doctor-patient workshops on site).	• Comparably more stakeholders can be reached as physical access is not required anymore. • Currently, especially the number of older people who do not know or do not want to use electronic devices (e.g., smartphones or tablets) might still be relatively high. On the other hand, older people are more likely to be sick and therefore would also be among those who would primarily benefit from the use of pathways in healthcare. In this regard, the digitilization of pathways could also pose a barrier in communication that would have to be overcome. However, chances are that this issue will resolve over time as younger generations who have been raised in a digital world grow older. • Education becomes independent of time and location (25). • Interactive elements (25) can also be included in digital formats (e.g., using quizzes, virtual reality, touch screen functions) which might further increase patients’ adherence.
Communication	• Improves communication between stakeholders as it supports the exchange of information, e.g., use of standardized paper forms. • Reduces loss of information by guiding HCPs in their routines. • Translates professional guidelines, scientific recommendation, and official regulations into practice by adopting them to local structures. • Promotes team work by easing communication through the support of information exchange, e.g., change of hospital staff between shifts (20).	• Electronic devices offer more opportunities for communication (58). This facilitates the sharing of pathway information and opens additional channels of communication, e.g., direct information exchange between caregivers becomes possible, no need for the patient to carry papers back and forth. • Can facilitate patient-caregiver/doctor communication. Everyone having access to the pathway is kept in the information loop. Hence, everyone is up to date what has happened and knows what needs to happen next.
Data collection and storage	• Purely or mostly paper-based: time- and space-consuming, labor-intensive. • Lacking standardization and harmonization due to human errors complicates data exchange and reduces comparability. • Lack of data interoperability: information can only be matched and merged by hand. • Interpretation of data strongly depends on the expertise and experience of the person in charge. • Analogue media such as printed images or radiological scans, text may be compromised through storage (e.g., damaged by sunlight or water or in the process of transport or copying). • Risk of data loss in the process of information exchange/transfer between stakeholders.	• Provides a structure for digital data collection and thereby supports the standardization of documentation. • It may allow for the automatic check of entries which also benefits the standardization of documentation and thereby promotes interoperability and supports information exchange. • Computers/servers consume less space than paper files. • Can be more time-efficient dependent on the usability and design of software applications in use. • More energy-intensive in terms of electrical power needed for the use of electronic devices. In particular, the training and use of AI requires a lot of computing capacity and therefore a lot of energy. • Easier to backup. Backups can be created automatically. Therefore, the loss of data can be avoided more easily. • Risk of hacker attacks. • Facilitates the integration of multimodal data. Thereby more data becomes available for the purpose of variance analysis.

Source: Self-prepared, loosely based on (54, 55).