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

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

4. 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

5. 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”

6. 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?

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

8. 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

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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

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

17. Too Many Keystrokes!

18. 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

19. 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

20. Example: Via Oncology Pathways and Epic at OHSU

21. Example: Via Oncology Pathways and Epic at OHSU

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

23. Via Login Screen – Reached by Selecting Knight Pathways

24. Via Clinic Patient Navigation Screen

25. 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,

26. 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.

27. Leading Physicians is like Herding Cats

28. How do we improve physician OCP engagement

29. 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

30. 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

31. 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

32. On-Pathway Rate by Clinical Group – August 2016

33. On-Pathway Rate by Clinical Group – June 2018

34. OHSU Pathway Performance – Summer 2016

35. OHSU Pathway Performance – Spring 2018

36. Off-Pathway Reasons – Spring 2018

37. On-Pathway Rate by Diagnosis – Spring 2018

38. 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

39. 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

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

41. 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

42. 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

43. Thank you.