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.
Getting physicians and other clinicians engaged in the use of pathways is not always easy, but it is always essential. Without engaged users of the pathways, the goals of the cancer center in implementing pathways simply cannot be met. The pathways system is a tool—and a tool unused is really of little or no use at all.
In this article, I will use the term “clinician engagement” to refer to anyone using the pathways system to plan or record treatment decisions, including physicians, nurses, and/or midlevel staff. In this context, the term “engagement” specifically means the regular use of the pathways system in the way proscribed by the institution in question. For some, this might mean using pathways as a decision support tool for every patient in advance of making a final treatment decision; for others, it is ensuring that the treatment decisions for patients with a certain condition or type of insurance are recorded monthly. How frequently and for which patients is up to the cancer center and the outcomes they desire from the use of pathways. In some instances, physicians themselves may not interact with the pathways much at all, preferring to have a delegate enter the results of their treatment decisions for them.
Achieving clinician compliance with the organization’s standards of use requires a number of aligned factors. More than articulating the expected schedule for pathways use and offering training on the mechanics of the software interface, clinician engagement requires buy-in, governance, and organizational alignment.
Importance of MD Engagement and Barriers
Why is clinician engagement important? Simply put, without clinicians engaging in full and regular use of the pathways system, no change in practice patterns occurs, there is no data, thus the pathways system produces no discernable value. Like a book on the shelf still in its shrink-wrap, a pathways system without clinical engagement is all but useless. Data is not able to be collected that can demonstrate quality. Treatment decisions may or not be based on the latest available clinical evidence.
Engaging physicians and other clinicians is not easy, however. There are a number of legitimate concerns that need to be addressed along the way, but the end result is worth the effort. When introducing a system such as pathways, clinicians may have several concerns about how it will affect them, their schedule and workflow, and patient care. Often underlying many of their concerns is the fear that pathways represent an attack on autonomous decision-making—that pathways are a way for the clinic administration to check up on them and that pathways will not allow them to exercise their professional judgement. Pathways champions should keep the possibility of this underlying or subconscious fear that physicians may have in mind throughout implementation.
One of the primary concerns clinician express regarding the use of pathways is the amount of time it will take to enter the required data to get a treatment recommendation. Clinicians are, of course, extremely pressed for time and are extremely wary of any process that adds steps or clicks to their workflow. I have heard clinicians refer to the “war on clicks”—the ongoing battle against more data entry for no direct patient care benefit.
The workflow in a cancer clinic is like a well-choreographed dance, with handoffs and a series of steps honed to maximize efficiency and optimize patient care. Adding even one step can disrupt the flow. The introduction of pathways can be very disruptive to a clinic’s workflow if not addressed proactively.
Habit vs Exception
It might seem beneficial to introduce pathways in a phased approach, starting with one type of patient or a handful of diseases. The challenge is that approach creates a series of exceptions to the workflow process. This disruption precludes the formation of new habits, especially if it is infrequent. This approach can result in more erratic use of the system and lower satisfaction.
If the messages being sent to clinicians are not crystal clear as to the importance, priority, and goals of the pathways implementation, resistance is likely to grow. If physician and administrative leaders do not consistently model the expected behavior or are inconsistent in the way they communicate about the use of pathways, staff can get confused about the organization’s intent and feel like their time is being wasted.
In trying to address these barriers, it is important to keep a few things in mind:
Maintain patient care as the “North Star” of this initiative. The primary concept to keep top of mind is that pathways represent a better way to care for patients. By following evidence-based recommendations, every clinician can assure every patient that they are receiving the best available care. Maintaining this as a unifying principle helps moderate many other considerations.
Recognize the impacts pathways will have on clinicians. It is important to acknowledge that implementing pathways represents a change but hopefully one that has more positive than negative impacts. The most important part of this is the acknowledgement that the concerns being raised are valid. Secondly, assure everyone affected that you will work with them through any issues.
Understand each clinician’s value proposition. While there are numerous benefits to implementing pathways, there are costs in time, process changes, etc, that need to be considered. The value proposition for a community oncologist who is more likely to use pathways as a decision support tool is very different from an academic physician who has made a career focusing on patients with limited disease types and who may be conducting research on those diseases. In all cases, be sure to emphasize the benefits that accrue to the cancer center (and devolve to individual clinicians) as well as the market expectations addressed by pathways.
Treat clinicians as partners and create trust. Gather ideas, feedback, and concerns, and address them honestly and forthrightly. Engage clinicians in the decision process about pathways, deployment schedule, workflows and standards, reporting, etc. Involve clinicians in the process rather than delivering a solution to them and expecting them to immediately and cheerfully adopt it.
Listen carefully, respond to issues quickly and thoroughly, and encourage mutual respect. Include clinicians in the rollout planning process to ensure it fits their needs and schedules
Demonstrate competence. Ensure that all clinicians know how the pathways are developed and maintained. Be sure to describe the intellectual rigor and scientific evidence that underlies the pathways. Make sure they understand how often the pathway is updated and, if there is such a mechanism, how their voice can be heard in the pathway maintenance process.
Engage MD intellect. All commercially available pathways systems are based on published literature. Ensure that clinicians know how to find relevant citations in the pathways tool. Ask for their help in designing their department’s workflow that incorporates pathways. If the pathways you are deploying has a physician panel, encourage your clinicians to participate as a way to give them a voice and honor their expertise.