Provider Resistance to Pathways Physician Buy-In & Adoption Michael A. Savin, M.D. Knight Cancer Institute Oregon Health & Science University

Disclosures Michael A. Savin, MD: Breast Cancer Committee Co-chair – Via Oncology

The pathway engagement problem is primarily cultural Physician Autonomy Who develops the pathways What is the purpose of the pathways Are they just another cost-saving tool like prior authorization? How do the pathways fit into oncologists’ work flow What is the burden of the pathways on the physician and practice

Mistrust of Pathway Development and Use Quotes from articles reflecting physician mistrust in oncology clinical pathways: “Transparency lacking in oncology clinical pathways” “Oncologists say Clinical Pathways Are Too Confining”   “The Pathway Problem: Physicians abhor standardization, measurement, efficiency, and transparency”

Mistrust of Pathway Development and Use Concerns contributing to Mistrust of Pathways: Do the developers have conflicts of interest? Are the pathways evidence based? Are the pathways maintained up to date? Do the pathways add value over guidelines? Do the pathways support clinical trials?

Burdens & Obligations with Oncology Clinical Pathways Developers of clinical pathways face two kinds of burdens Administrative Patient Care  

Burdens & Obligations with Oncology Clinical Pathways - 2 Administrative Burdens:   Ensure the pathways are Patient Centric Focused on the Patient, not on the Pathway itself Ensure they cover Comprehensive Care Ensure Transparency - Openness about conflicts of interest of stakeholders Ensure they are analyzed using Meaningful Analytics

Meaningful Analytics Include Measures of Quality Clinical outcomes Costs Integration with the EHR Tools to assist in interacting with payers

Burdens & Obligations with Oncology Clinical Pathways - 3 Patient Care Burdens: Ensuring Comprehensive Care, while: Maintaining physician and patient autonomy Respecting variability among individual patients Ensuring access to Clinical Trials

Elements Necessary for Effective Oncology Care Pathways Foundations of an effective Oncology Care Pathway: Patient outcomes must be optimized Scientifically sound, evidence-based, and kept up to date Designed to maximize value (value-based care) Designed to minimize administrative cost Designed to assist providers in proving value to payers

Perceptive Barriers to Pathways Engagement by Providers: Perception that they are for Somebody Else Perception that they Create an Unnecessary Time Burden Perception that they take away Physician Autonomy

They are for Somebody Else Barriers – 1A They are for Somebody Else From the academic physicians Pathways are designed for community oncologists We develop the treatments, so we don’t need the pathways We know what to do  

They are for Somebody Else Barriers – 1B They are for Somebody Else From the community physicians We see many more patients than the academics We see a much more varied population than the academics We know what to do  

They are for Somebody Else Barriers – 1C They are for Somebody Else From both academic and community oncologists We do not need to be told what to do We do not want to be told what to do Pathways are for them and not us

Additional Barrier to Pathways Engagement: Barriers - 2 Additional Barrier to Pathways Engagement: Perception that pathways create an Unnecessary Time Burden

Too Many Keystrokes!

Barriers – 2A The Problem is primarily with the EHR Multiple keystrokes are required to navigate the EHR Simple order entry on an Epic chart typically takes 12 or more keystrokes

Barriers – 2B The Problem is primarily with the EHR Pathway software typically lives in a separate program from the EHR and is not completely integrated with it, resulting in: Significant increases in number of keystrokes required to navigate the software Adding to the already heavy time burden imposed by the EHR

Example: Via Oncology Pathways and Epic at OHSU

Example: Via Oncology Pathways and Epic at OHSU

Treatment Navigation Menu: Navigate to Knight Pathways (by Via Oncology)

Via Login Screen – Reached by Selecting Knight Pathways

Via Clinic Patient Navigation Screen

Barriers – 3A Physician Autonomy-1 Physicians feel they are in the best position to use clinical judgment and experience to make decisions Physicians are accustomed to relying on knowledge and experience rather than software tools to assist them in making clinical judgments,

Barriers – 3B Physician Autonomy-2 Physician are suspicious of pathways because of concern that they are inflexible and are “one-size-fits-all” Engaging physicians in utilization of OCPs requires an understanding that they are applicable to a majority of patients, but not all patients. The physician retains autonomy to make appropriate decisions when a patient does not fit the pathway as designed.

Leading Physicians is like Herding Cats

How do we improve physician OCP engagement

Tools for improving engagement How to improve provider engagement with OCPs - 1 Preserve provider autonomy pathway selections are designed to be appropriate for most but not all patients pathways are designed to reflect efficacy, toxicity, and cost in that order pathways are not designed to replace provider clinical judgment

Tools for improving engagement How to improve provider engagement with OCPs – 2 Engage providers in the pathway design process most pathways programs and vendors use committee structure encourage participation on pathway design committees by providers emphasize the value of pathways in helping clinical trial accruals by appropriate placement of trials in the pathways

Review of our experience over time at OHSU Clinical Groups at OHSU Knight Cancer Institute Clinics:  CHM - Center for Hematologic Malignancy Clinics CHO - Community Hematology Oncology Clinics HEM - Solid Tumor Clinics

On-Pathway Rate by Clinical Group – August 2016

On-Pathway Rate by Clinical Group – June 2018

OHSU Pathway Performance – Summer 2016

OHSU Pathway Performance – Spring 2018

Off-Pathway Reasons – Spring 2018

On-Pathway Rate by Diagnosis – Spring 2018

Knight Cancer Institute/OHSU experience with provider resistance to OCPs: Integration of Via Oncology Pathways software into Epic Login – within Epic but requires reentry of username and password Need to manually enter clinical data Need to “capture” every visit Problems of maintaining integration of clinical trials  

Knight Cancer Institute/OHSU experience with provider resistance to OCPs: User skepticism: “Not for me” Sometimes expressed by providers who have never opened the program Particularly with hematologic malignancies providers possibly because of complexity of their patients in treatment regimens possibly because of complex subtyping of hematologic malignancies seen by some as only for quote solid tumor docs

Knight Cancer Institute/OHSU experience with provider resistance to OCPs: From 2016-2018: We have seen increased pathways engagement by OHSU physicians Initially in Solid Tumor and Community practices Now increasingly in Hematologic Malignancy practices

Knight Cancer Institute/OHSU experience with provider resistance to OCPs: Providers are being rewarded for increased pathway engagement by: Decreased Time Demands – increased experience and comfort navigating pathways Increased disease committee participation Encouraging participation in pathway development by provide Four disease committee co-chairs at our institution

Knight Cancer Institute/OHSU experience with provider resistance to OCPs: Providers are being rewarded for increased pathway engagement by: Most importantly: by encouraging non-users to navigate the pathways and find that they are useful

Thank you.