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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.
Pathway Compliance

There are no financial incentives or penalties for compliance with pathway treatments (“on-pathway rates”). It is our philosophy that the pathway is likely to be appropriate for roughly 80% of patient presentations but cannot account for 100% of patient presentations and, therefore, physicians are free to choose “off-pathway” therapies as they deem appropriate. The software requires that the practitioner record the reason for the “off-pathway” decision from a drop-down list and document the actual treatment administered. The system is set up to facilitate the work flow so that “off-pathway” decisions are not more burdensome to document than “on-pathway” decisions.
 
UPMC does employ financial incentives for all practitioners to use (“chart”) the Via Portal. This results in over 94% of all patient Evaluation and Management (E&M) visits across all sites being reported in the pathway system. In instances where the Via Portal detects a visit in the practice management system that was not charted in the pathway system, a reminder e-mail is sent daily to the practitioner to complete the pathway charting.
 
Across all diseases and all presentations, the network average “on-pathway” rate is 79.6% (based on all new treatment starts). Reports are presented to all physicians outlining their “on” and “off-pathway” rates each month and lists their performance in relation to their peers.
 
Obtaining Buy-In from Physicians

The success of a pathways program ultimately depends on physician acceptance of the content and the delivery tool (the Portal). When polled, very few physicians ask for limitations on their autonomy or to integrate another piece of software into their work flow. As such, obtaining physician buy-in to the value proposition for pathways is paramount. Leadership and transparency around the goals of pathways—to reduce unwarranted variation, drive standardization around evidence-based care, measure performance, and drive clinical trial accrual—are essential. Most physicians today are cognizant of the need for cost containment in oncology care and understand that “if we do not take the lead, someone else will for us, and we will not like the outcome.”
 
The open and democratic pathway development process, the fact that clinical pathways are physician-rather than payer-driven, and the ability for each user to contribute to pathway content enhance acceptance of the product. Keeping software design simple and as useful as possible to facilitate clinical care is important, so that practitioners are not burdened. Finally, it is important to always point out to reluctant practitioners that the alternative to a physician-led solution to the cost crisis is a payer- or government-led decision and that status quo is not an option!
 
Pathways, a Decade Later

Throughout the 10 years following the initiation of clinical pathways at UPMC, our “on-pathway” rates have been in the 70%-to-80% range (based on treatment start) and we have consistently captured more than 90% of patient visits to ensure completeness. For the 12 months ended December 31, 2015, we captured over 94% of all E&M visits (n = 241,520) within the pathways database and achieved an on-pathway rate of 81.4% for all treatment decisions (n = 16,484).
 
Several factors contribute to the high compliance rates. First, physicians are provided a monthly performance feedback compared with UPMC overall and the Via Network overall. Second, the Via disease committees review the pathway compliance reports each quarter to identify poor performing branches and determine a course of action. This action could be:
  • A re-review of the data
  • An e-mail to all physician users to clarify the rationale for the pathway recommendation
  • Delineation of a new alternate patient presentation to address a commonly occurring comorbidity or other factor driving off-pathway use.
With an expansion of Via Oncology’s customer base throughout the United States, we have also diversified representation on the disease committees to reflect the views of Via Oncology’s many customers. By allowing all Via Network physicians to participate in every meeting and having co-chairs representing the various customers, we have not only created a vehicle for strong physician buy-in, but also improved the quality of our pathway programs.
 
We have also worked with Via Oncology to expand the concept of pathways beyond drugs. Our clinical care pathways also cover radiation oncology, surgical oncology, and the continuum of care from work-up to symptom management, survivorship, and advanced care planning. Finally, we have the resources and datasets to begin publishing the results of our efforts and are demonstrating the impact of pathways on quality and cost of care by presenting our data at national/international meetings and in manuscripts. We are also supporting our research efforts through prospective trial promotion within the Via Portal as well as retrospective analysis of accrual opportunities by physician, site, and disease. EBO
 



Author information:

Peter G. Ellis, MD, is medical oncologist, UPMC CancerCenter and medical director, Via Oncology.
 
Address for correspondence:

Peter G. Ellis, MD
5150 Centre Avenue
Suite 506
Pittsburgh, PA 15232

E-mail: ellipg@UPMC.EDU
PDF
 
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