Clinical Pathways - Statement of Purpose
Oncologists are rightfully leery of pathways as they have currently been used. Pathways have been set up by insurance companies as a way to control us, deny payments, cost us a lot of money to purchase, and add irritating processes to our workflow.
However, I don’t believe that we should allow insurance companies to deny us a useful tool. Pathways, created by oncologists from the medical literature can assist with decision support, streamlining operational processes in our practice and allow us to demonstrate our quality without turning us into data entry clerks.
As part of the COME HOME CMMI grant, we assembled teams of one physician from each of the 7 COME HOME practices, and one genomics academic expert for each of the 7 tumor types. We started with the NCCN guidelines and used that format, but subtracted the regimens no one uses and added notes as to the appropriate genomic testing and imaging. All the options that were reasonable were kept, and physician discretion continues. We update the pathways quarterly, and upon request of a physician, by a 1 hour phone call.
Decision support: Keeping up with the advances in immune-oncology and targeted therapies is like drinking from a fire hose. Those who specialize in one disease can probably keep up with the alphabet soup of which gene does what when. For the rest of us, having a rapid, point of care memory aid can allow us to order the right test at the right time for the right patient, and also defend our choices from the insurance company’s denial personnel. A pathway becomes the standard of care, and may save us from the litigation heartache of “Doctor, why did you not test for the XYZ gene in my client and spare him harmful chemotherapy and deprive him of a chance for a better longer life?” I also find it useful, for example, when I am looking for a 4th line option for good performance metastatic breast cancer. When I don’t have to look up the doses of a regimen I want to use, it saves me time. Clinical trials and best supportive care only are always on pathway.
Operational Processes: When I started looking at pathways, my practice of 6 medical oncologists had 10 different ways to give AC x 4! We started by agreeing to use the literature based regimens, with the ability to modify doses, and added the mutually agreed upon antiemetic regimen. We discovered that our nurses spent less time standing outside physician exam rooms to confirm orders, patients waited less time, we had fewer administration errors, and we were able to save money on drug purchasing. By adding the every 3 month echo for Herceptin regimens to the pathway and the order, we got the echoes on time, and with less physician work. There are many examples similar to this.
Quality reporting: We all know PQRS is useless. However we also know that the days of just announcing to insurers that we deliver high quality care and having them accept that are gone. The technical quality of oncology practice is knowing the right regimen to use for the right patient with the right stage and intent of therapy and the right performance status. Because as a group of oncologists, we have decided together what the right therapies are, measuring quality can just become measuring compliance with the pathways. We used some of the COME HOME grant money to create a system to measure that compliance. We can pull it from the EMR if doctors enter the diagnosis, stage the patient (including genomics), enter the intent of therapy, the performance status ( part of the PE) and enter the appropriate orders. Since as physicians we are doing that anyway, it eases our workload.
Barbara L. McAneny MD