Journal of Clinical Pathways spoke with Michael Hassett, MD, MPH, Dana-Farber Cancer Institute (DFCI), at the Oncology Clinical Pathways Congress (October 11-13, 2019; Boston, MA) regarding some of the challenges of integrating the clinical pathways program at DFCI within the standard workflow as well as the role of technical innovation in pathway development.
Integrating a pathways program into the workflow at Dana-Farber Cancer Institute...
Dr Hassett: To do pathways correctly you really need to have the workflow and the pathway program fit together. Otherwise, it just seems like added work. Anything that's added work is really a hard bridge to cross when you are talking about 400 or 500 busy clinicians.
From the outset, a major focus of our effort has been to integrate the pathways program within the standard workflow. That's been done in both big ways and little ways. On the big side, we try to integrate our pathways program with our EHR. It's very easy for the clinician who is seeing a patient can jump right into the pathways program. In little ways, we try to provide added benefits. One example of that is the pathways solution that we use not only makes a suggestion about a treatment recommendation, but it provides a full consent form with side effects around that treatment recommendation. That's work that the clinician doesn't have to go off and do outside of the pathways program.
The need for further research to understand the full cost implications of a pathways program...
Dr Hassett: There's a lot that we know about pathways about what they can do. Pathways really stem out of this concept of disease management and decision support. Pathways are what I would think of as a next‑generation version of that. We know with pathways programs that we can standardize care and push physicians to use one drug over another drug.
There are broader questions that research can really help us with. Many pathways programs have a bigger impact than just saying, "We're going to use the same treatment in the same situation." Cost is a good example of that. How does a pathways program influence the cost of care? Really specifically, not just the cost of the chemotherapy medicines that we prescribe, but the costs of all the care that we provide. Making a better decision about chemotherapy will certainly change the cost of chemotherapy, but it might change hospitalization rates or side effects.
Being able to do research to understand the full impact of a pathways program is really critical for understanding return on investment, if you will, of that program.
Multiple current studies examining the cost benefit of pathways...
Dr Hassett: There's much more that is needed in the near future. The studies have shown some value to the program by reducing drug costs specifically. There are other costs that those studies haven't included. There are other benefits that those studies haven't evaluated. For example, what is the impact of a pathways program on a patient's quality of life? How do we study that?
We haven't even started to scratch the surface with that. In the end, as a doctor who treats cancer patients, I want to try to improve my patients' quality of life as much as possible. Really being able to expand the analysis of the impact of the program is going to be really helpful.
The technical innovation needed for EHR interoperability and data analysis...
Dr Hassett: The technical innovation is a really critical part of pathways development. It's still a relatively new technology. To make it work well, it's going to evolve over time. That's true for any software tool. It's not a static thing. It's an evolutionary thing. Specifically with pathways, these programs require a lot of data.
Getting the data right is really important. That means being able to pull information from the medical record and send information back to the medical record so that data transfer in interoperability is really critical.
Creating an efficient user experience is really also important. When a person sits down in front of a computer and they're going to try to enter a pathway, what's the fastest, most efficient way to do that? Many studies suggest that clinicians spend about half of their time in front of a computer and maybe a quarter to a third of their time with patients. Most clinicians would like to flip that ratio; they would like to be spending more time with patients and less time in front of the computer.
Anything that we can do on the technical innovation to speed the amount of time that it takes to enter the information that we need for pathways programs and free up time for time with patients would be a big one.