Oncology Care Pathways: Perspectives on Strategies and Best Practices

 J Clin Pathways. 2024;10(3]:54-56.

Gordon Kuntz: What are the key clinical considerations and challenges in developing and implementing oncology care pathways? And how do you ensure that these pathways remain dynamic and adaptable to evolving research and treatment protocols?

Jeremy Drainville: Well, we certainly don’t start with small questions, do we? The big challenge, first of all, is really under­standing the scope of work that’s required for a clinical path­ways program. Most organizations significantly underestimate the effort that’s required and really where you fit into the stra­tegic goals within the organization.

First and foremost, as anyone who is implementing path­ways, whether you’re doing it internally, like we do at Moffitt Cancer Center, or you're using a vendor as a partner and looking at it from that perspective, you really need to first define what are those clear goals for the pathways? What’s your main driver? Is it standardization of care? Is it quality? Is it integration or tak­ing advantage of it from a payment and payer cost management perspective? Or is it to support expansion of your facilities?

Figuring out where those priorities rank, among other pri­orities that you may have, is really the first piece where you need to understand that foundation. Because of the scope and magnitude of the effort with pathways, a lot of organizations underestimate that coming in.

Once you’ve got that established, the other part is it has to be fully integrated into the strategy for your organization. That long-term strategy for all of your initiatives, whether it’s your digital initiatives and vision, your data integration or other efforts that you’re doing alongside your data, your payment goals—how do those tie into what you’re going to be doing with pathways, because many of those touch a lot of the pieces that you’re developing with a pathways initiative.

With that, the leadership commitment, and underestimat­ing leadership commitment. Make sure that you really know that this is a long-term commitment in perpetuity. This isn’t a system that you just implement and you forget about. It’s some­thing that’s going to be with you for the rest of your time as long as you're utilizing pathways. And they need to understand that that endeavor requires strong leadership commitment that says, “Yes, this is important for my organization, and we recog­nize how that fits into the workflow for our clinicians because of all the pressures they have on their time.”

And then you also have to realize the amount of time that you have from a resource perspective for all the different piec­es of work. You know, this isn’t just a small team behind the scenes. But really it engages pharmacists to a large degree when you’re dealing with order sets and order set mappings in col­laboration, regardless of if it’s internal resources working with the mappings or if it’s external resources; the physicians them­selves; the leadership; clinical systems teams as you’re main­taining and dealing with things such as integration of, perhaps, clinical trials and some other factors; as well as a lot of ancillary parts from supportive care to personalized medicine and all the other folks that may tie into something you're doing with a pathways initiative.

So, when I talk about the challenges, it’s first really under­standing that broad scope that you have to truly embrace to be able to be successful with pathways. And how do you ensure that these pathways remain dynamic and adaptable? It’s that commitment. It’s that commitment of resources. You really need to develop that capability. And you need that organi­zational support to say that this capability is strategic, and it ties into a lot of the other strategic initiatives throughout the org. And that when it comes for that competition of resources internally—as we all know, everyone has as many health care resources as you need—you’ve got to make sure that you've got the support for that so that you can gain towards those initiatives, whether it’s on the reporting side, supporting pay­er strategies, supporting opening new facilities and ensuring standard of care, and some of those other facets that may be key priorities within your organization.[…]

Larry Shulman, MD: Of course, I would agree with every­thing that Jeremy has said. I would say that a lot of those goals are at the upper levels of leadership, right? I think about those things, and I think about how care is provided through our health system, which I'll come back to in a minute.

But a lot of the work is done by our colleagues in the trenches, the people who go to clinic every day, both at our academic centers and our community centers. At University of Pennsylvania, as I’m sure it is true everywhere, they're work­ing their tails off. They don’t have a lot of spare time. And this could be viewed, as they say, as yet another unfunded mandate. We’re asking them to do something else on top of everything else that they’re doing. And the benefits, that Jeremy very well outlined, are not always going to be obvious to those people who go into clinic every day. You can tell them, but they may not feel it the same way.

On the other hand, I’ve been really pleasantly surprised by the reaction of our faculty to the whole process. What we’ve done at Penn is that we’ve formed disease-based teams, a breast team, a pancreas team, a lung team. And as Jeremy said, each of those teams have physicians, they have nurses, they have pharmacists on them, and each one of them has one of us as the leaders of the pathway development group on it, because we understand a lot of the infrastructure and what’s going on in the background.

We’ve been very careful to include our colleagues at our community sites in these teams. The teams tend to be small— six, eight people. But there’s good representation across our health system, which I think has been very important for buy in and for involvement.

And it’s a lot of work. When we set up the initial breast cancer pathways, they met two hours every Monday for four months. And that’s a big time commitment for those people. But it was a good experience.

But there’s another thing that Jeremy alluded to that is criti­cal, which is that our world is changing all the time—there’s new data coming out and new drugs being approved. This is not a one and done type of process. What you do today is good for today and tomorrow there may need to be modifications, and you need to have systems and commitment to make those modifications.

I will say that at Penn, and I’m sure this is the case elsewhere, we are very anxious to assure that there's the same quality of care on the same treatments being offered across our system. We have 6 hospitals, we have 11 ambulatory sites, and that’s a lot of people in a lot of different places. And this allows us to not only give them direction on what we think are the ide­al ways to practice but also for us to be able to monitor what they’re doing.

And then the last thing I would say is that whatever process or vendor product that you're using, it has to be well integrated into your electronic health record (EHR). We all live in our EHR, I go to clinic, I live in my EHR, and anything that we’re doing really needs to be in that EHR to help guide us. And we've been very careful about that as well.[…]

James Hamrick, MD: Larry, that resonates a ton with things that we’ve seen as we’ve talked to different health systems and individual practices. On the one level, Jeremy, you alluded to, you got to have the executive level buy-in because it’s very re­source intensive, it’s a multiyear effort. People may come and go; you have to have that culture built.

On the second hand, as you said, Larry, you’ve really got to win the hearts and minds of the front line as well. And you do that by respecting their time and how busy they are. So, build it into the EHR, think about it, build a tool that comes from the physician’s workflow and not a tool that dictates the physi­cian’s workflow.

The other piece is, I really like what you said, Larry, about having a system. So, I practiced as a very much general oncol­ogist until very recently, led a little department. What we’ve heard as we’ve spent a lot of time at the elbow of oncologists is it’s really hard to keep up these days. Especially as a general oncologist, where I can’t go to every meeting and read ev­ery journal article. Everywhere, people are trying to scale the knowledge of single-disease experts, scale those out so that we can have a system designed to provide high-quality care to everyone.

We’ve invested heavily in a clinical team with pharmacists and doctors and mid-levels who try to provide updates about, “Hey, here’s the newest stuff that’s coming out from NCCN,” for example, to keep doctors apprised of best evidence. So, we designed our tool, and this is just sort of our approach to the market, as one that would provide the service of helping them keep up and scale knowledge and best practices from the single-disease experts to the people seeing all kinds of different cancers coming through their office.

Kuntz: Great, thank you. And Bryan, I know your perspective is a little bit different, but I think it’s a similar kind of chal­lenge. You know, as you’re thinking about pathways, what are the clinical considerations and how do you make sure that the pathways that you're using, or the doctors who are using them, how do those reflect the most current clinical issues?

Bryan Loy, MD: […] We try to get grounded to how you would want to be treated if you were a patient. And what is the evidence pointing us to in terms of a preference of effec­tiveness, like in a clinical trial. And, secondly, what does the toxicity look like, whether it be a Part B or an oral drug, what is the patient going to have to live with long term? Is there a convenience factor to be considered? And then, and only then, if there’s a tie up—it goes through those filters in that order, by the way—what does the least costly alternative look like? And, in some instances, we find ourselves covering or seeing in our pathways a more preferred agent because of the things that preceded even the cost analysis.

But in the end, it’s our belief that if we can get the right drug to the right patient the first time—and manage to that— we can do whatever we need to, to make sure that the econom­ics get to where everyone can provide that care.[…]

I’d say we kind of brought ourselves to solving for this as a payer over the last decade or so. This standardization and what we could say would make sense in terms of trying to reduce the irrational variation in practice pattern while still allowing for exceptions when there are exceptions needed—whether it be because a patient can’t tolerate a drug for whatever reason, or there's a drug shortage, for example.

So, not setting things up to where someone would expect 100% compliance, but if there is some accountability, and folks that have gone through the exercise would at least have an in­formed opinion on, or an appreciation for why, this payer’s pathways look like they do. And opening ourselves up in the event that someone wants to challenge that or bring new infor­mation to us, that willingness to be able to listen and carefully evaluate what's being said.

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