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Elsevier’s ClinicalPath: Supporting Value-Based Care and the Path Forward

July 07, 2020

In January 2018, Elsevier—an information analytics business specializing in science and health—acquired Via Oncology – a leading decision-support and clinical pathways vendor. Since that time, Elsevier has rebranded Via Oncology as ClinicalPath and integrated this solution into the company’s Clinical Solutions portfolio. ClinicalPath delivers evidence-based oncology pathways that are embedded in the provider’s clinical workflow.

Journal of Clinical Pathways sat down with members of the ClinicalPath team for an update on their current activities and vision for pathways. The resulting article addresses how pathways support institutions in reducing unwarranted variation; supporting the clinical workflow and care coordination; managing practice trends; and adapting to changing practice drivers.

Sonali Fonseca, PhD, Vice President of Oncology Pathways and Programs; Tate Erlinger, MD, MPH, Vice President of Clinical Analytics; and Zach Lorinc, Vice President of Pathways Content, provided insight on these topics.

How do your pathways support care standardization?

ClinicalPath supports care standardization through evidence-based medical and radiation oncology pathways that cover more than 95% of cancer diagnoses. Our pathways support oncologists in their treatment decisions by surfacing the optimal therapies identified for a given patient presentation. Through these well-defined treatment plans, our pathways enable practices to standardize care across their sites.

     Sonali Fonseca, PhD

How do you develop your pathway content?

Our pathways are developed by disease committees who meet to review the latest published evidence. During our committee meetings, physicians evaluate the latest published literature to determine the most optimal treatment based on the hierarchy of efficacy, toxicity, and cost. Each disease committee is tasked with making the pathway as specific as needed to reach a “single best” recommendation for each state and stage of disease. 

In addition to providing a primary recommendation, the committees are also tasked with identifying alternate recommendations for “other patient scenarios” in which a commonly encountered comorbidity (eg, performance status) would preclude the use of the primary recommendation. Between the primary recommendation and these alternate scenarios, our goal is to develop pathway recommendations that cover 80%+ of the patient presentations seen in clinical practice.

What diseases are covered in the pathways? Do you have any pathways in development?

Our pathways cover more than 95% of cancer presentations, including solid tumor and hematologic malignancies. The body systems we cover include breast, gastrointestinal, gynecological, genitourinary, head and neck, respiratory and thoracic, CNS, hematologic disorders, and skin and soft tissue. Our pathways include decision support for both medical and radiation oncology, including hand-off points where multidisciplinary care is required. 

We continue to expand our pathway coverage based on feedback from our customer network. We recently launched medical oncology pathways for sarcoma and neuroendocrine tumors. In the future, we are planning on developing a radiation oncology pathway for liver.

Can you speak to the comprehensiveness of your pathways?

Our pathways encompass the patient journey from workup after a cancer diagnosis to treatment selection, symptom management, and end-of-life considerations. 

While the primary focus of any clinical pathway is treatment, we have built in decision support materials across the continuum of care. Where appropriate, our pathways include decision support for staging, imaging, laboratory testing, molecular diagnostics, symptom management, post-adjuvant surveillance recommendations, oral drug monitoring guidance, and biomarker testing where clinical utility has been proven. 

We also provide supplementary materials including patient education, radiation contouring guides, cost modeling tools, oral therapy monitoring guidelines, symptom management decision support, and care coordination support through action-driven messages.

      Zach Lorinc

How do your pathways support care coordination?

We believe multidisciplinary care coordination is a critical component of improving patient outcomes. ClinicalPath has key features built into the solution to support this coordination of care across multiple care teams.

ClinicalPath can be configured to send a secure message to the teams that support prior authorization efforts when a new treatment has been selected for a patient. This message contains all the necessary information on the patient’s presentation with supporting evidence on why this treatment decision is appropriate. This reduces the need for the prior authorization team to follow up with the oncologist for missing information and decreases the time for a patient to begin treatment.

We also provide secure messaging to clinical research teams. Clinical trials are embedded in our pathways to support oncologists in identifying optimal trials for their patients. When an oncologist selects a patient to be screened for a clinical trial, a secure message is automatically sent from ClinicalPath to the research team. This supports the patient in accessing the best care option available to them while enabling the institution to achieve their clinical research goals.

Within our pathway branches for late-stage disease, we include a prognostic question which has been shown to be an accurate predictor of increased one-year mortality risk. During pathway navigation, oncologists are presented with this question and identify patients at increased risk who likely would benefit from additional support, including advanced care planning and palliative care. When the oncologist selects this option, ClinicalPath automatically sends a secure message to the palliative care team to coordinate services for the patient.

How do your pathways support clinical research?

ClinicalPath supports practices in their research goals by presenting relevant clinical trials ahead of standard-of-care treatment recommendations on the pathways. Clinical trials are mapped to pathway branches based on inclusion and exclusion criteria so that only the most relevant trials are presented. This allows physicians to become aware of and consider trials for their patients, without the added step of consulting a local study directory.

When the physician selects a patient to be screened for a trial, a secure message is sent to their clinical research team. When a patient is not a candidate for accrual to a trial, the physician selects a reason why, providing data and insights to clinical research administrators.

Furthermore, data on clinical trials are captured at a granular level, allowing oncology leadership teams to understand where clinical trial portfolios have optimization opportunity, where trials are not available for particular patient presentations, or where provider engagement with the research program may be reinforced.

Why is integrating ClinicalPath into the physician’s workflow so important?

With oncology therapies evolving so rapidly, a decision support solution to guide physicians in their treatment decisions is valuable. It is important that this decision support tool be easily accessible and integrated into the current workflow. The provided guidance needs to be specific to patient presentations to protect against decision fatigue.

We understand that a poorly designed decision support tool contributes to provider burden and increases unwarranted care variation. ClinicalPath solves these issues by making decision support a natural part of the clinical workflow. Our pathways are integrated so they can be launched from within the electronic health record at the decision point. Physicians get guidance toward what current evidence shows to be the optimal treatment for each patient; and each pathway branch includes the supporting evidence as the rationale for the recommendation and the associated research links.

What analytics and insights do you currently provide to users?

Since data captured during a pathway navigation are structured and complete, we can provide clinical, operational, and research insights to users.

     Tate Erlinger, MD, MPH

Our reports include capture rates, on-pathway rates, disease-specific biomarker reports, disease-specific pathway adherence reports, trial screening, and decisions without trials reports. These reports can be filtered based on physical location, department (service area), or by individual physician.

Our reports are sent monthly and our Customer Success team discusses any questions with our customers quarterly. This allows users to identify trends and benchmark their performance against other practices in their network. They also use these discussions to identify areas of unwarranted variation and adjust their quality improvement efforts accordingly.

We also provide a weekly Decision Extract with every captured decision from pathway navigations. This extract can be imported into a local clinical data repository or matched with other data to obtain additional clinical and operational insights. For institutions that participate in registries or perform similar reporting activities, these data can also be used to support those efforts as the information is captured in a structured, consistent, and complete manner.

Has there been data published on the impact of your pathways?

There are several published reports highlighting the impact of our pathways on standardizing care, managing costs, driving appropriate use of precision oncology, clinical trial accrual, and reducing ED visits.

From a care standardization perspective, our users have shown that our pathways are an effective tool to drive rapid changes in prescribing patterns – across both academic and community sites.

Our users have also published reports that show cost savings from the use of pathways, such as when a lower cost regimen is found to have comparable efficacy and toxicity. This trend has also been highlighted in radiation oncology where adoption of appropriate hypofractionation results in cost savings.

Use of ClinicalPath has further shown an increase in biomarker testing and appropriate use of targeted therapies compared to practices not using pathways. Many of our users adopt pathways to support their clinical research program and have shown an increase in clinical trial accruals as a result of patients being identified for screening during pathway navigation.

Finally, with many quality metrics focused on reducing ED visits, our users have shown a reduction in ED visits for patients treated on pathway due to fewer toxicity-related adverse events. This trend has been demonstrated in breast cancer and non-small cell lung cancer patients.

How do institutions get started with pathways? 

The oncology pathways evaluator is a tool we have developed to support oncology practice leaders as they evaluate pathway programs. It helps them identify the best vendor partner for their needs. This tool builds on our learnings from supporting oncology practices for over 10 years in developing impactful pathway programs.

It consists of 15 questions that cancer centers should be asking their pathway vendors, including who is developing their pathways, what is the scope of their pathways, how often are the pathways updated, and what kind of analytics are available from the pathways. Additionally, practices can assess their ratings on a 1-to-4 rating scale for each of these 15 topic areas. This allows for a head-to-head comparison of different pathway vendors.

The oncology pathways evaluator tool is publicly available and free to all practices who are interested in learning more.

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