Peter G. Ellis, MD
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.
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