Founded in 2016, the Clinical Pathways Forum is a community of pathways professionals—now totaling 15 institutions from across the United States—who are utilizing clinical pathways in their practices and institutions to improve cancer care. Forum leader Mishellene McKinney, MHA, RN, OCN, organizes quarterly conference calls with Forum members to facilitate discussion of shared experiences and lessons learned regarding pathway use as clinical pathways become more prevalent and evolve to meet the needs of value-based health care systems and reimbursement models.
The September 2020 Clinical Pathways Forum session focused on Moffitt Cancer Center’s approach to clinical pathways, which they create and maintain independently. Clinical Pathways Informaticist Kelly McKee, MSN, RN-BC, presented an overview of the program and how it has evolved, then performed a demonstration of how the pathways are integrated into Moffitt’s electronic medical record (EMR) created by CernerTM.
Brief History of the Moffitt Pathways Program
Located in Tampa, FL, Moffitt Cancer Center is the only National Cancer Institute (NCI)-designated Comprehensive Cancer Center in the state. Moffitt was also one of the first NCI Cancer Centers to develop a clinical pathways program, starting in 2009. Since then, they have grown the program to include 56 web-based pathways that cover more than 90% of cancer types treated at Moffitt. Unlike most commercial products that focus on medical oncology, Moffitt pathways are multidisciplinary and include diagnostics, surgery, radiation, medical oncology, active clinical trials, surveillance, and supportive care. Pathways creation, updating, and integration is overseen by Karen K Fields, MD, medical director of Clinical Pathways and Value-Based Cancer Care.
Moving Toward EMR Integration
In 2014, Moffitt partnered with Cerner to launch the pathways within the EMR with the objective of adding value to the physician workflow and increasing analytic capabilities. So far, 23 of their 56 pathways are fully integrated into their Cerner EMR, covering greater than 75% of cancer incidence seen at Moffitt.
To create and maintain the pathways themselves, the department employs a staff of 14 that includes clinical, technical, and operational oversight roles. Three clinical pathways specialists (CPSs) work with physician teams to define pathway content and translate it into an algorithim using Visio™ software. Once the pathways initial design is captured, the pathways are submitted through a multi-step approval and consensus process. Upon pathways content and design signoff, a systems analyst then finalizes the pathway for translation into an interactive web content display. The pathways are published on the intranet using an internally developed methodology that ensures consistency, safety, and usability.
The web-based algorithms include links to periodicals, guidelines, clinical trials, and drug information. In addition to the Visio diagrams, there are detailed design tables built into Excel™ that outline the overall build and testing; version control; orders libraries; initial workup order sets; treatment recommendations for medical, surgical, and radiation oncology; clinical trials; and surveillance.
The physician teams meet regularly with CPSs to keep the pathway content up to date with current guidelines and evidence. Dr Fields explained that annually there is one “overhaul” of the pathways. This is led by the pathway physician author and includes all coauthors and a clinical pharmacist. Then consensus is achieved by the department through a formal presentation. Pathway content is reviewed at least three times annually, and ad hoc updates can be quite frequent in disease states like non-small cell lung cancer.
More on the pathway development process, department staffing, and the missions and objectives of the department are well-described in the 2019 article that can be found here: bit.ly/MoffittPathwaysInDepth.
Translating a Pathway Into EMR Workflow
Once a pathway algorithm is final in its web content version (Image 1), clinical pathways informaticists (CPIs) translate the visual workflow and supporting evidence and documentation to the user interface in the EMR. CPIs partner with physician champions to optimize interaction and workflow in the EMR. A pathway algorithm with 12 pages in web form may only be six display screens within the EMR. Dr Fields explained: “A significant portion of the work is to make what looks nice on a piece of paper work efficiently when that translates into clicks for the end-user.”
The 23 pathways now in the EMR are available both as an interactive decision-support tool within the EMR and also in their web-based interactive form. All information from the web-based versions are also available in the EMR. The CPIs use the web-based algorithms with their links to periodicals, guidelines, clinical trials, drug information, and tables to design the logic that will dictate the build in the EMR.
Using Pathways in the EMR: A Dedicated Focus on the Clinician User
Clinicians begin at the Clinical Pathways “MPage” which is a Cerner summary page (Image 2), where users can do a complete chart review. The page includes labs, diagnostics, pathology, documents, staging, and other relevant patient information. This page was created to reduce the time providers spend searching through the chart to enter pathways information.
The ICD-10 code triggers a pathway. This prompts a list of suggested pathways from which the physician can select. Once the pathway has been selected and key information has been entered, order sets that are associated with the pathway, such as workup and diagnostics, are available for quick selection. The most commonly used orders for a particular pathway are pre-selected with order details completed to align with pathways recommendations.
A critical success factor for the EMR-integrated pathways is to have prefilled orders as much as possible to minimize provider burden. For example, radiology orders for Appropriate Use Criteria are prefilled with the standard reasons for the exam as a time-saver to help streamline the ordering process. The pathway automatically populates discrete data, such as staging, age, sex, and performance status, as the provider navigates these questions. Clinical trials relevant to the clinical situation and open at Moffitt will display on each page. The pathway displays the trial names, status, contact information, inclusion and exclusion criteria, and clinical trials information. The provider can indicate if a patient is a potential candidate and if the patient was screened, referred, or enrolled in the trial so that this data can be tracked from the pathway.
The conceptual design is for the provider to be able to perform a complete chart review right from the Pathways page. Labs, diagnostics, pathology, clinical trials, and surveillance are all accessible from the page. Once inside a pathway, the basic structure of every pathway in the EMR is the same. The left-hand side of the screen is dedicated to questions and answers, such as criteria and actionable target mutations, and the right-hand side displays treatment options, including orders for treatment, molecular testing, and supportive consults such as social work and distress screening.
For medical oncology care plans, the preferred drug regimen is displayed first, along with other options based upon patient characteristics. Drug regimen and follow-up order sets accompany all pathway recommended treatments. The pathway is saved at the last point that the provider entered data, so that they can return to the regimen selection page to continue on current therapy or to change to a different treatment, if needed. Users can view pathway history and jump between treatment lines to navigate to any part of the chart.
To support clinicians using surgical pathways, consent forms, and preoperative prep forms are also available for quick access. Procedure-specific “Power Plans” have been built into the surgical pathways to help standardize the most common procedures and to make sure that physicians are all practicing according to the same standard of care. All services can document simultaneously on a patient at the same time. To document off-pathway treatments, users can select from a drop-down list of reasons, including additional underlying disease factors, medical contraindication, and patient choice. There is also an option to type in a free-text reason. It will prominently display in red on the landing page that the patient is “off-pathway.”
Ms McKee noted, “Surveillance is one of our physicians’ favorite part of the Pathways. The interface allows users to select a time frame for follow-up, then will display recommended orders, including prefilled follow-up appointments with the medical oncologist and supportive services.” The follow-up order sets include appointment request types (virtual or in-person), labs, and diagnostic tests.
Other time-saving features include hyperlinks to reference documents and periodicals, carried over from their original web-based versions. Summaries of the staging guidelines are also available for quick reference as support for staging. As the example shows in Image 3, the Prostate Cancer Life Expectancy Calculator and staging guidelines are easily accessible as the clinician navigates the criteria for a prostate cancer pathway.
Multidisciplinary Tumor Board Support
The pathway prompts providers to request that a patient be presented at a multidisciplinary tumor board review at critical points within the pathway. This helps to make the process more efficient by abstracting pathway data to be presented for the tumor board review. The Pathway data is used to prepare for tumor board review, and most teams have pathways open as a reference during tumor board. While physicians are very familiar with the pathway content and do not necessarily need to refer to it for answers, they will use it to compare the clinical recommendation with the pathway.
Dr Fields commented that being able to use artificial intelligence for analytics will be a future focus. The team is always exploring ways to increase physician utilization. “It takes a lot of creativity on the part of the CPI and systems analysts,” she said. “For example, we have found that they can reduce administrative burden by incorporating Appropriate Use Criteria so that, rather than having to interact with the Appropriate Use tool, it can be completely bypassed because there is a direct match to the appropriate values.”
Through ongoing efforts to streamline workflows and bundle orders within the EMR, the team was able to reduce clicks when compared to early iterations of the pathways and/or the standard workflow in the EMR. These significant improvements in workflow demonstrate the user-centricity of the Moffitt pathways system, making it an exemplar in the field.