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.
To an outside observer, a cancer center’s decision to deploy clinical pathways might seem counterintuitive: it can be costly, may negatively impact workflow, and doctors notoriously dislike feeling like they are being told what to do. Yet, regardless of these hurdles, more and more cancer centers are opting to implement clinical pathways for cancer treatment. The decision is sometimes prompted by a payer contract, the need to ensure a single standard of care across multiple sites following a merger or acquisition, or as a response to a competitor who has recently deployed pathways. Some practices will simply stop there and be satisfied with implementing a new pathways tool for the single purpose that initially drives the decision. However, when oncology practices view pathways as a strategic asset, they often realize their significant value instead of just seeing them as an annoyance or only as a cost.
Based on 15 years of working with community oncology, hospital-based practices, National Cancer Institute (NCI) cancer center practices, and various pathways systems in a number of settings, I have found that there are distinct characteristics of (and benefits within) practices with a clear vision of the objectives of their pathways program vs those that tolerate pathways grudgingly.
Those thinking of employing a pathways program or who are currently implementing one should understand why they are using pathways. This article outlines the most common strategic initiatives that practices aim to achieve with pathways. Cancer center leadership should establish and articulate to staff why they are choosing to deploy pathways and how the pathways are enabling them to accomplish their strategic initiatives. Making sure physicians, clinicians, and others on the care team understand the “why” underpinning new pathways activities will improve acceptance, use, and success of a pathways program.
Back to Basics: What Defines a Pathways Program?
My first article in this column series expanded greatly upon what the term “clinical pathways” means and what a pathways program entails1; to support the aims of the present article, a summary of that discussion is below.
Pathways systems may be developed by providers, payers, or third-party vendors. Pathways programs in the United States tend to use the same framework to recommend a treatment plan for a particular disease presentation (programs developed in other health care systems outside the United States may have different priorities and criteria). Options are evaluated based on 3 criteria: efficacy, then toxicity (or safety), and then cost. Pathways are typically designed to offer recommendations that are appropriate for 80% of patients; oncologists are always able to make off-pathway choices and are encouraged to exercise their professional judgement in selecting the actual treatment plan for a particular patient.1-4
Most pathways systems support clinical decision-making, providing guidance to oncologists in selecting the most appropriate treatment. While pathways can provide a valuable resource to oncologists in complex cancers or disease presentations they treat infrequently, they may be considered a hinderance by more experienced oncologists who routinely see a limited number of cancer types or do research in a specialized area.
Regardless of the type of pathways and the type of oncologist using them, a successful pathways implementation is a result of 2 forces: evidence-based, unbiased, and credible content; and clinician buy-in (Figure 1). Pathways must be created and viewed by users as based on verifiable evidence from credible sources, not conjecture or anecdotes, and be unbiased. In addition, physicians and other clinical and administrative staff should understand the context and reason or reasons why the practice is deploying pathways. Together, these 2 forces encourage the culture change needed within an organization for successful implementation of pathways; without these 2 key components, any efforts by the vendor or practice will be frustrated at every turn.