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.
Over the last 5 years, many oncology practices have adopted clinical pathways, often with mixed results.1 The same product may be implemented in different practices and see much lower adoption and utilization rates, or low adherence to the recommended treatments. For instance, through my experiences, I have even heard of clinicians using pathways to record the on-pathways recommendation, then ordering what they believe to be the “right” treatment despite it not being the recommended standard of care, so as not to incur the “off-pathway” mark on their record.
Effectively implementing a pathways program can be more challenging than one might initially believe. If a practice goes into the project simply thinking it is an IT implementation, they will be disappointed. Implementing a pathways system and making it an effective part of the practice’s daily efforts for success are two very different approaches. Although the pathways implementation has numerous technical components, the clinical and operational components are among the most important.
There are often several simultaneous goals for a practice in deploying a pathways system. This may often include a single, pressing reason—for example, that a payer program requires the use of pathways. However, concurrent with that imperative is the realization that there are several strategies that pathways can support. As described in a recent article in this series, these may include marketing, standardization of care among a network of remote sites, or readiness for advanced payment programs.2
The central foundation necessary to accomplish any and all of these various goals through pathways is the culture change that must occur within the practice among the physicians and staff. In order to encourage the correct shift in organizational culture, practices should demonstrate their full commitment to the ideologies underlying clinical pathways across the organization focusing on several key areas of pathway implementation that will be expanded upon below.
“An organization’s culture comprises an interlocking set of goals, roles, processes, values, communications practices, attitudes and assumptions.”3 Many of the roles, attitudes, and assumptions in cancer centers are built on the primacy of independent physician decision-making and actions. Similarly, I have heard from many colleagues that their cancer center only treats the sickest patients and that there is some sort of “secret sauce” in how they provide care. This creates a shared belief within the cancer center that it is somehow “special,” that is, they are only successful through extreme measures of independent brilliance and effort—not from a predictable set of processes and models of care.
The success of a pathways program, however, relies on the willingness of oncologists and the broader staff to accept that pathway recommendations are valid and meaningful for about 80% of patients. Without this belief, the notion that one could create a repeatable process for delivering the most appropriate treatment for a specific disease presentation seems unimaginable.
Creating this shift in the organization’s culture requires a myriad of tools and approaches that require high levels of organizational leadership and commitment, and an understanding of the reach and impact of pathways implementation.
Pathways impact many departments in the organization, not just the oncologists seeing patients. For example, pathway recommendations can help optimize inventory management for costly drugs, which may in turn impact the finance department and the group purchasing organization programs in which the practice is involved. The clinical trials team will be required to manage the placement of clinical trials on pathways but may also be able to use the data collected along the pathway to identify areas where additional trials should be considered. The pharmacy department, often responsible with IT for managing orders within the electronic medical record (EMR) and order entry system, will need to manage the library of orders more closely and ensure its ongoing alignment with pathways recommendations. Finally, nursing and advance practice providers may be impacted due to changes in workflow, and on and on.
A practice’s organizational culture must evolve and mature to affect a true culture change among physicians and staff so that each team and process noted above are working in harmony toward the same goal. The attitude toward the new initiative is as important as all of the operational changes taking place for pathways implementation. In many cancer centers, prior to the introduction of pathways and the clear establishment of a limited standard of care, oncologists were allowed to select and order the therapies they felt were best. While it is likely that most oncologists chose among therapies that were included in broad guidelines, there may have been significant variance and use of “favorites” in the ordering system. Effectively using pathways means accepting that strong evidence dictates that there is a “best way” to treat a specific disease presentation and trusting that pathways can provide that recommendation about 80% of the time.
The culture shift required for the organization is profound and often overlooked. While doctors absolutely retain their independence of professional judgement and can order off-pathway treatments as appropriate, they must trust that the pathway recommendation should be the first option considered and that any off-pathways choice should be justified from patient-specific considerations. Difficult as it is, clinicians also need to accept the inherent monitoring that comes along with use of a pathways tool. The challenge is that, without being able to track pathway compliance—both the use of the pathway tool and the on-pathway compliance rate—cancer centers cannot demonstrate quality and will not achieve the goals of implementing the pathways in the first place.
This tension between using the pathways software—including the tracking and standardization that comes with it—and achieving the larger goals of the organization is what drives the need for culture change in deploying pathways. However, administrators should recognize that gaining support and participation from clinicians early and throughout the process of selecting and deploying pathways will help ensure that their needs are met.
Because of the complexity of the culture change needed in deploying a pathways program, there are a number of critical success factors for cancer centers to consider.
Determining Key Objectives
Prior to selecting a pathways system, cancer centers are well served by understanding the specific strategies they hope to support with pathways. How a practice decides to deploy pathways can impact their ability to reach certain strategic goals. If a practice decides to document their own pathways, they may find that the results do not carry the same weight with payers as a nationally-recognized pathway would. Similarly, using flowcharts or written guides of pathways can be helpful in achieving standardized care but do not allow for easy data collection.
Knowing the goals to be achieved also allows the cancer center to feel comfortable applying appropriate resources and enforcement to the pathway’s deployment. For example, if one strategic goal of the practice is to demonstrate use of a common standard of care across all physicians in all sites, it would be best to set the expectation from the outset that the pathways tool will be used for all patients without exception, even if it is just to indicate that a patient is a consult-only or is a nonmalignant hematology patient. If the utilization is hit or miss, it is hard to represent that there is one standard of care.
For a cancer center, clearly articulating the objectives it is pursuing and how pathways are an essential element of achieving those objectives creates trust and understanding with clinicians, which provides a strong imperative for clinicians to use the pathways tool in support of the organization’s goals.