First Things First: Deciding Why Your Practice Is Implementing Pathways

Gordon Kuntz is a health care consultant and strategic advisor with over 30 years’ experience in a multitude of health care settings, working with payers and providers, and in technology and strategy. He began his involvement with oncology care pathways in 2004 as a consultant with US Oncology as they were deploying Level 1 pathways. He subsequently led payer strategy with ION Solutions, a division of AmerisourceBergen, where he gained familiarity with many other pathways vendors, especially in the context of the oncology medical home model. As senior director of strategy for Via Oncology, he deepened his knowledge of the pathway development process, physician adoption, and how both impact cancer center strategies. Mr Kuntz now provides support in strategy and product design as well as assistance in navigating the cancer care ecosystem to established and emerging companies.

To an outside observer, a cancer center’s decision to deploy clinical pathways might seem counterintuitive: it can be costly, may negatively impact workflow, and doctors notoriously dislike feeling like they are being told what to do. Yet, regardless of these hurdles, more and more cancer centers are opting to implement clinical pathways for cancer treatment. The decision is sometimes prompted by a payer contract, the need to ensure a single standard of care across multiple sites following a merger or acquisition, or as a response to a competitor who has recently deployed pathways. Some practices will simply stop there and be satisfied with implementing a new pathways tool for the single purpose that initially drives the decision. However, when oncology practices view pathways as a strategic asset, they often realize their significant value instead of just seeing them as an annoyance or only as a cost.

Based on 15 years of working with community oncology, hospital-based practices, National Cancer Institute (NCI) cancer center practices, and various pathways systems in a number of settings, I have found that there are distinct characteristics of (and benefits within) practices with a clear vision of the objectives of their pathways program vs those that tolerate pathways grudgingly. 

Those thinking of employing a pathways program or who are currently implementing one should understand why they are using pathways. This article outlines the most common strategic initiatives that practices aim to achieve with pathways. Cancer center leadership should establish and articulate to staff why they are choosing to deploy pathways and how the pathways are enabling them to accomplish their strategic initiatives. Making sure physicians, clinicians, and others on the care team understand the “why” underpinning new pathways activities will improve acceptance, use, and success of a pathways program. 

Back to Basics: What Defines a Pathways Program?

My first article in this column series expanded greatly upon what the term “clinical pathways” means and what a pathways program entails¹; to support the aims of the present article, a summary of that discussion is below.

Pathways systems may be developed by providers, payers, or third-party vendors. Pathways programs in the United States tend to use the same framework to recommend a treatment plan for a particular disease presentation (programs developed in other health care systems outside the United States may have different priorities and criteria). Options are evaluated based on 3 criteria: efficacy, then toxicity (or safety), and then cost. Pathways are typically designed to offer recommendations that are appropriate for 80% of patients; oncologists are always able to make off-pathway choices and are encouraged to exercise their professional judgement in selecting the actual treatment plan for a particular patient.^1-4

Most pathways systems support clinical decision-making, providing guidance to oncologists in selecting the most appropriate treatment. While pathways can provide a valuable resource to oncologists in complex cancers or disease presentations they treat infrequently, they may be considered a hinderance by more experienced oncologists who routinely see a limited number of cancer types or do research in a specialized area.

Regardless of the type of pathways and the type of oncologist using them, a successful pathways implementation is a result of 2 forces: evidence-based, unbiased, and credible content; and clinician buy-in (Figure 1). Pathways must be created and viewed by users as based on verifiable evidence from credible sources, not conjecture or anecdotes, and be unbiased. In addition, physicians and other clinical and administrative staff should understand the context and reason or reasons why the practice is deploying pathways. Together, these 2 forces encourage the culture change needed within an organization for successful implementation of pathways; without these 2 key components, any efforts by the vendor or practice will be frustrated at every turn.

It Helps to Understand the “Why”

In my previous and current roles, I have encountered cancer centers that only purchased pathways due to some external requirement, and their leaders and staff lacked a full appreciation of any overarching, strategic reason for implementing pathways. Those for whom pathways are a box to be checked and who cannot articulate the strategic drivers behind acquiring pathways are much more likely to have difficult or failed pathways implementations. The system may exist, but if it is not used consistently and uniformly throughout the organization, even the modest expected benefits will not be realized. 

Connecting pathways to the cancer center’s strategic plan can alleviate the concerns physicians, other clinicians, and staff have and can facilitate the systemic changes necessary to effectively integrate pathways into the culture of the organization. Without strategic underpinnings, it is difficult to justify to physicians why they have to use the tool, why consistent treatment selection is important in clinically similar cases, and why it is important for them to take the time to use another tool and enter data when they “already know what to do.”

Physicians have numerous systems to support them as they care for patients. Electronic medical records offer a retrospective view but typically do little to help guide complex and critical decisions. Computerized physician order entry systems (CPOEs) help translate the care decision to the rest of the organization and ensure accurate delivery of the desired therapies but do not help with complex case management or decision support. 

By describing the standard of care and the care model for every cancer patient, pathways can become the heart of the cancer center. Few clinical systems operate as pathways do, at the point of decision-making for cancer patients. Pathway systems use clinical data and the best available evidence to recommend the most appropriate treatment plan for each individual patient. Pathways also provide a longitudinal record of a patient’s care to ensure that the treatment decisions remain relevant over time. The data collected along a pathway can provide a broader view of the practices’ patients, allowing practices to demonstrate quality through consistent application of the most effective, safest, and most cost-efficient care.

The ability to capture point-of-care decisions, to aggregate data across physicians and sites of care, and to ensure quality through consistent application of broad standards of care mean that pathways systems are uniquely positioned to support multiple cancer center strategies, which most physicians should be willing to support. Even if physicians already know the best care prescribed within a pathway, using the pathway to capture treatment choices for later analysis is invaluable from a data analytics perspective and potentially for payer contracting. 

Indeed, there are as many as 12 strategies (in no particular order of importance or popularity) that pathways can support at a cancer center. Most cancer centers implement pathways to support 4 to 6 of these strategic initiatives:

1. Marketing – Cancer centers seek to gain a competitive advantage by enhancing the public’s perceptions of their quality. Direct-to-patient advertising can help increase patient preference, and focused outreach publicizing a cancer center’s quality can help increase referrals. Using a pathway program is one way to demonstrate quality, since pathways imply that the institution is focused on providing patients with the most effective and safest care.
2. Payer Relations – Cancer centers that can demonstrate quality to payers can help enhance relations and encourage deeper cooperation, potentially minimizing administrative burdens and maximizing revenue.
3. Innovative Payment Arrangements – As practices move from fee-for-service to value-based and risk arrangements, the ability to predict and control costs becomes ever more important. The standardization of care and the resulting predictability that pathways allow increases a cancer center’s chances of being successful under these arrangements.
4. Program Requirements – Programs such as Medicare’s Oncology Care Model as well as some payer programs require use of a standards-based pathway and the ability to report results.⁵
5. Provider Alignment – Pathways help standardize treatment selection between providers, care teams, and sites, promoting quality, consistency and strengthening team dynamics.
6. Network Development – Health systems and larger cancer centers with affiliated provider networks can use pathways to ensure quality and consistency among geographically dispersed practices. 
7. Quality Improvement – The design of pathways programs encourages oncologists to provide the best available care for every patient every time. As mentioned above, most US-based pathway programs target on-pathway rates of 80%, on average. In other words, the oncologist considering a specific patient will find the recommendation provided by the system to be appropriate 80% of the time. At every step, oncologists continue to apply their medical judgment and expertise to ensure the best treatment is provided for each and every patient. 
8. Minimize Unnecessary Patient Referrals – One of the most basic uses of pathways is to support clinicians in determining the most appropriate treatment to use for a given disease presentation. Oncologists can more confidently treat patients with cancers that they do not routinely encounter, resulting in fewer outbound referrals of patients to other institutions.
9. Promote Clinical Research – Many pathways systems offer clinical trials as an “on-pathway” option, and some even identify specific trials that may be beneficial. Thanks to the presentation of clinical trials data at the time of decision-making, pathways help ensure exposure to the most appropriate clinical trials and increase accruals to trials.
10. Cost Management – Clinics with high Medicaid populations and those with risk-based contracts must manage a budget for chemotherapy and other high-cost services. Pathways help ensure appropriate utilization of these high-cost services to better manage scarce resources.
11. Operational Efficiency – Deploying pathways across a care team can help oncologists feel confident that their clinical support staff are consistently providing high-quality care to patients, reducing the need for the physician to monitor supportive care regimens.
12. Reducing Cognitive Burden – Pathways provide an opportunity to reduce the cognitive burden on clinicians by reflecting the latest operational changes, such as changes to order sets or the availability of clinical trials, and by presenting a single best recommendation or set of appropriate choices, including clinical trials, at the time of treatment determination. With the proliferation of targeted therapies and the pace of cancer care literature availability, it is unreasonable to expect each oncologist to be the absolute best source for all possible information about every treatment, clinical trial, side effect, etc for every type of cancer and combination of disease, comorbidities, patient characteristics, etc. Because they are not designed to apply to every patient, pathways allow oncologists to apply their clinical decision-making skills based on curated information.

How Pathways Contribute to Costs of Care

You may note that “cost savings” is not one of the above-listed strategies. While pathways can help ensure that expensive drugs are only used on patients that need them, this is primarily a clinically-driven, not a financial, decision. Since all pathways programs consider a therapy’s efficacy, toxicity, and cost—in that order of importance—the recommendations made are primarily clinically-driven, or at least clinically equivalent. If the recommended standard of care happens to cost less than an off-pathways regimen, it is by chance rather than by design. Nevertheless, pathways can assist with overall cost management in alternative ways. For example, pathways help reduce ineffective, and therefore wasted, treatments. By focusing on the best available evidence balanced with the oncologist’s judgment, every patient has the best chance of the optimal outcome in their circumstance. Treatments that would have otherwise failed can be avoided, which may have resulted in disease progression, more costly and toxic therapies, and higher overall health care costs. Secondly, because pathways actively consider toxicity or safety as the second characteristic, less toxic drugs tend to be used, potentially reducing side effects and the resulting resources needed to manage those side effects, though pathways do not explicitly consider the cost of managing side effects or hospitalization.  

Conclusion

When cancer center leadership understands and can articulate why they are choosing to deploy pathways and are able to identify which strategic initiatives their pathways support, communication to staff becomes much easier. Allowing oncologists, nurses, and other staff to understand the strategic and tactical value puts the resources requirement in perspective, improving acceptance.

References

1. Kuntz G. What do we mean when we talk about “clinical pathways”? J Clin Pathways. 2019;5(1):36-39. doi:10.25270/jcp.2019.02.00060

2. Lawal AK, Rotter T, Kinsman L, et al. What is a clinical pathways? Refinement of an operational definition to identify clinical pathway studies for a Cochrane systematic review. BMC Med. 2016;14:35. doi:10.1186/s12916-016-0580-z

3. Ellis PG. Development and implementation of oncology care pathways in an integrated care network: the Via Oncology pathways experience. J Oncol Pract. 2013;9(3):171-173. doi:10.1200/JOP.2013.001020

4. Butcher L. Clinical pathways in practice: a report from the front lines. Oncol Times. 2007;29(5):18-19. doi:10.1097/01.COT.0000267751.25033.3b

5. Centers for Medicare & Medicaid Services (CMS). Oncology care model. CMS website. https://innovation.cms.gov/initiatives/oncology-care/. Updated February 25, 2019. Accessed March 1, 2019.