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Evidence-Based Oncology April 2016
ASCO Policy Statement on Clinical Pathways in Oncology: Why Now?
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Developing an Oncology Clinical Pathways Program - the UPMC Case Study
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Developing an Oncology Clinical Pathways Program - the UPMC Case Study

Peter G. Ellis, MD
An overview of the oncology clinical pathways development program at the UPMC CancerCenter and how it led to the creation of Via Oncology, a clinical pathways vendor.
Background of UPMC

UPMC CancerCenter (UPMC) experienced significant expansion between 2000 and 2004, growing to a network of 25 medical oncology sites of service that cover a geographic area extending more than 250 miles in Western Pennsylvania. During this time, an extensive management team was developed to drive operational standards of care consistent with the expectations of a major National Cancer Institute–designated Comprehensive Cancer Center.
 
The Need for Standardization

Surveys of clinical care patterns completed by practicing physicians at those 25 sites of service during 2004 revealed substantial variation in clinical decision making. Although this variation is to be expected in a geographically diverse network that includes physicians who received training at academic institutions throughout the country, this was not deemed to be in the best interest of the patients served by UPMC. We felt strongly that our entire network should, where possible, standardize care around best evidence for all the patients of UPMC, regardless of location, and that care should be measured and reported. This decision led to the creation of what eventually became Via Pathways.
 
Developing a Pathway

In late 2004, UPMC physician staff included academic domain experts and community clinician experts in the various medical oncology subspecialties, such as breast cancer, lung cancer, etc. Using this expertise, we created a methodology to establish a UPMC-wide standard for the best evidence-based care of patients. Disease-specific committees were organized with academic and community co-chairs and membership made up of willing UPMC oncologists. These committees were charged with defining 2 things:
  • The various patient clinical presentations of disease
  • The best evidence-based care for those presentations
The committees were to reach consensus on a “single best” therapy for each defined presentation. They were also encouraged to outline common comorbidities existing in these patients and to define sub-pathways for patients with those comorbidities as well. When determining the “single best” therapy, committees were asked to consider efficacy first, followed by toxicity; if all else was equal, they were asked to include cost in their deliberations.
 
Developing clinical pathways was a daunting task, but more vital was the need to keep them current in a rapidly changing oncology environment. This demanded the development of a system where committees were subsequently convened quarterly to review new literature and make appropriate alterations to the content of the pathway. That quarterly committee process continues to be an ongoing standard for Via Pathways today. Conflicts of interest are minimized through disclosure at each meeting along with public disclosures on the Via Oncology (the parent company) website. Pharmaceutical companies are not allowed to participate in the pathways process except to submit published data. Administrative and pharmacy support are provided to each committee to help it complete its task. The decisions of the committee are then converted into a decision support algorithm by a content management team at Via Oncology and sent back to the committees for verification and approval. Currently there are 18 medical oncology disease committees, 12 radiation oncology disease committees, and 6 surgical oncology disease committees (covering well over 90% of all cancers). The chairs of these committees rotate on roughly a 2-year cycle.
 
Implementing Pathways into Workflow

Once we had developed pathways for the various disease entities, we turned our focus to their integration into physician work flow (knowing that otherwise, they would gather dust on the shelf). In the early years, a manual process was implemented to identify patients and subsequently append a paper copy of the appropriate pathway to the chart. During the course of a patient visit, the physician was asked to mark his or her therapeutic decision on the paper pathway, based upon a decision support algorithm. As the number of pathways expanded, however, this manual process quickly became overwhelming and the need for a Web-based portal to deliver the pathways at the point-of-care became self-evident.
 
Through many years of multiple iterations and much trial and error within the UPMC network, a simple user interface that integrates with the practice management system was eventually developed to present the appropriate pathway to the physician within his/her daily workflow. This interface (called the Via Portal) pulls patient schedules and demographics from the management system and presents a complete daily schedule to the physician. From that schedule, the physician charts the outcome of that day’s interaction with the patient, choosing from options such as:
  • Continue plan of care
  • Change to a different treatment
  • Take off treatment
Under appropriate circumstances, the portal presents the decision support algorithm in real time, for whichever action is taken, to allow the practitioner to initiate the desired therapy. The results of that decision are then communicated back to the practice’s electronic health record, if one is in use. All the information about the patient’s disease status and treatment are databased into discrete fields within the Via Portal for subsequent reporting and analysis.
 
Additionally, multiple resources are imbedded into the pathway navigation to facilitate quality care for the patient, including links to full text articles that inform pathway decisions; concise summaries of pathway committee deliberations around appropriate care; 1-page overviews of regimens outlining effectiveness, toxicities, and appropriate dose reductions; patient educational materials; and chemotherapy consents. The system also simplifies the generation of treatment summaries and survivorship plans.
 
Supporting the Research Mission

It is standard practice to place locally available clinical trials first in the decision algorithm and at the appropriate point in the pathway to facilitate accrual. If the practitioner does not enroll a patient in the trial, he or she must choose, from a drop down menu, the reason for nonaccrual before the standard of care option is presented to the physician. The data around the number of patients seen by the practice who may be eligible for a given clinical trial, and reasons for nonaccrual, are regularly provided to the research team for analysis. Our research colleagues have found this a useful tool to drive clinical trial accrual.
 


 
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