Engaging Clinicians as Partners in Pathways Utilization

Gordon Kuntz is a health care consultant and strategic advisor with over 30 years’ experience in a multitude of health care settings, working with payers and providers, and in technology and strategy. He began his involvement with oncology care pathways in 2004 as a consultant with US Oncology as they were deploying Level 1 pathways. He subsequently led payer strategy with ION Solutions, a division of AmerisourceBergen, where he gained familiarity with many other pathways vendors, especially in the context of the oncology medical home model. As senior director of strategy for Via Oncology, he deepened his knowledge of the pathway development process, physician adoption, and how both impact cancer center strategies. Mr Kuntz now provides support in strategy and product design as well as assistance in navigating the cancer care ecosystem to established and emerging companies.

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Getting physicians and other clinicians engaged in the use of pathways is not always easy, but it is always essential. Without engaged users of the pathways, the goals of the cancer center in implementing pathways simply cannot be met. The pathways system is a tool—and a tool unused is really of little or no use at all.

In this article, I will use the term “clinician engagement” to refer to anyone using the pathways system to plan or record treatment decisions, including physicians, nurses, and/or midlevel staff. In this context, the term “engagement” specifically means the regular use of the pathways system in the way proscribed by the institution in question. For some, this might mean using pathways as a decision support tool for every patient in advance of making a final treatment decision; for others, it is ensuring that the treatment decisions for patients with a certain condition or type of insurance are recorded monthly. How frequently and for which patients is up to the cancer center and the outcomes they desire from the use of pathways. In some instances, physicians themselves may not interact with the pathways much at all, preferring to have a delegate enter the results of their treatment decisions for them. 

Achieving clinician compliance with the organization’s standards of use requires a number of aligned factors. More than articulating the expected schedule for pathways use and offering training on the mechanics of the software interface, clinician engagement requires buy-in, governance, and organizational alignment. 

Importance of MD Engagement and Barriers

Why is clinician engagement important? Simply put, without clinicians engaging in full and regular use of the pathways system, no change in practice patterns occurs, there is no data, thus the pathways system produces no discernable value. Like a book on the shelf still in its shrink-wrap, a pathways system without clinical engagement is all but useless. Data is not able to be collected that can demonstrate quality. Treatment decisions may or not be based on the latest available clinical evidence. 

Engaging physicians and other clinicians is not easy, however. There are a number of legitimate concerns that need to be addressed along the way, but the end result is worth the effort. When introducing a system such as pathways, clinicians may have several concerns about how it will affect them, their schedule and workflow, and patient care. Often underlying many of their concerns is the fear that pathways represent an attack on autonomous decision-making—that pathways are a way for the clinic administration to check up on them and that pathways will not allow them to exercise their professional judgement. Pathways champions should keep the possibility of this underlying or subconscious fear that physicians may have in mind throughout implementation.

Time

One of the primary concerns clinician express regarding the use of pathways is the amount of time it will take to enter the required data to get a treatment recommendation. Clinicians are, of course, extremely pressed for time and are extremely wary of any process that adds steps or clicks to their workflow. I have heard clinicians refer to the “war on clicks”—the ongoing battle against more data entry for no direct patient care benefit.

Workflow

The workflow in a cancer clinic is like a well-choreographed dance, with handoffs and a series of steps honed to maximize efficiency and optimize patient care. Adding even one step can disrupt the flow. The introduction of pathways can be very disruptive to a clinic’s workflow if not addressed proactively. 

Habit vs Exception

It might seem beneficial to introduce pathways in a phased approach, starting with one type of patient or a handful of diseases. The challenge is that approach creates a series of exceptions to the workflow process. This disruption precludes the formation of new habits, especially if it is infrequent. This approach can result in more erratic use of the system and lower satisfaction.

Unclear Expectations

If the messages being sent to clinicians are not crystal clear as to the importance, priority, and goals of the pathways implementation, resistance is likely to grow. If physician and administrative leaders do not consistently model the expected behavior or are inconsistent in the way they communicate about the use of pathways, staff can get confused about the organization’s intent and feel like their time is being wasted. 

Key Considerations

In trying to address these barriers, it is important to keep a few things in mind:

Maintain patient care as the “North Star” of this initiative. The primary concept to keep top of mind is that pathways represent a better way to care for patients. By following evidence-based recommendations, every clinician can assure every patient that they are receiving the best available care. Maintaining this as a unifying principle helps moderate many other considerations.

Recognize the impacts pathways will have on clinicians. It is important to acknowledge that implementing pathways represents a change but hopefully one that has more positive than negative impacts. The most important part of this is the acknowledgement that the concerns being raised are valid. Secondly, assure everyone affected that you will work with them through any issues.

Understand each clinician’s value proposition. While there are numerous benefits to implementing pathways, there are costs in time, process changes, etc, that need to be considered. The value proposition for a community oncologist who is more likely to use pathways as a decision support tool is very different from an academic physician who has made a career focusing on patients with limited disease types and who may be conducting research on those diseases. In all cases, be sure to emphasize the benefits that accrue to the cancer center (and devolve to individual clinicians) as well as the market expectations addressed by pathways.

Treat clinicians as partners and create trust. Gather ideas, feedback, and concerns, and address them honestly and forthrightly. Engage clinicians in the decision process about pathways, deployment schedule, workflows and standards, reporting, etc. Involve clinicians in the process rather than delivering a solution to them and expecting them to immediately and cheerfully adopt it. 

Listen carefully, respond to issues quickly and thoroughly, and encourage mutual respect. Include clinicians in the rollout planning process to ensure it fits their needs and schedules

Demonstrate competence. Ensure that all clinicians know how the pathways are developed and maintained. Be sure to describe the intellectual rigor and scientific evidence that underlies the pathways. Make sure they understand how often the pathway is updated and, if there is such a mechanism, how their voice can be heard in the pathway maintenance process.

Engage MD intellect. All commercially available pathways systems are based on published literature. Ensure that clinicians know how to find relevant citations in the pathways tool. Ask for their help in designing their department’s workflow that incorporates pathways. If the pathways you are deploying has a physician panel, encourage your clinicians to participate as a way to give them a voice and honor their expertise.

Positioning Pathways to Encourage Higher MD Engagement

In my experience working with cancer centers, engaging clinicians requires a thoughtful, methodical approach. Pathways are a strategic asset of the organization; while they serve many needs, they can influence and support the organization’s business strategies.

Strategy. By connecting the use of pathways to the cancer center’s strategic business objective and long-range planning, it becomes clear that pathways are not “just another thing to do.” There is a purpose and an intentional design to the deployment. In using pathways, clinicians are part of a larger whole and are supporting the organization and their peers.

Governance. Deploying pathways and gaining adherence to their use requires effective leadership at all levels. As acknowledged above, the introduction of pathways is, in and of itself, disruptive. Managing that disruption, maintaining focus, and providing encouragement are functions that an effective governance structure can provide. Pathways governance is both administrative and clinical, and requires dedicated time to communicate with, educate, coach, and encourage those that each person in the governance structure is responsible for.

Communications. As with any initiative, communication is not a one email process, but requires a sustained, well thought-out, and concerted effort. The communications plan should be carefully crafted to reinforce several messages with each communication:

• How does pathways support our strategies?
• How can we address clinician concerns and issues?
• What activities are scheduled in the coming days and weeks?
• Are we on track?

Keeping these guideposts in mind—as well as the form of communication, who the communication is coming from, and how well it fits accepted ways of communicating—are all important considerations. 

Resources. Implementing pathways takes time and energy that had previously been directed elsewhere. This is not another project that people can do in their spare time. The organization needs to communicate its expectations about the behavior and commitment of leadership as well as staff. Those involved in governance and leadership in particular need to have specific time allocated to this effort to ensure its success. Similarly, time should be allocated for ample training and transition time for each clinician based on their workload, especially as they are getting used to the new system. While evaluating a patient’s treatment plan through pathways might take 2 to 3 minutes once the oncologist is used to it, it may take much longer initially when they are unfamiliar with the process. Ensure that enough time is allocated for each patient, so clinicians are able adapt to the process from the beginning. It is much harder to try to fix a poorly implemented solution than it is to get it right from the beginning. 

Taking Action to Address Common Concerns

The key issues many clinicians raise about implementing pathways fall into a few major categories. While all of these can be addressed, remember that these are very real concerns that your staff will likely have.

Time

Doctors, nurses, advanced practice practitioners, and other clinicians are all stressed for time and may already be working 60+ hours a week, with a significant portion of that time devoted not to patient interaction but to administrative paperwork and systems. The very last thing they want to do is enter data in yet another system. The claim may be made that it will take “too much time,” or there may be the implication that entering the data for a patient into the pathway tool will take hours. 

To address the issue of the amount of time pathways will take, consider the following approach:

1. Acknowledge that entering data into the pathways system will absolutely take time and keystrokes. However, once they are proficient, it may not take as much time as they think.
2. Accurately represent the actual number of minutes it takes, on average, to navigate a patient once they are proficient. The vendor should be able to help identify this figure. Depending on the system and the patient, it may take as little as 2 to 3 minutes from start to finish, assuming the necessary data is at hand. Being specific (and citing your sources and assumptions) will help quantify the problem and move it from the realm of “too big to solve” to figuring out how to make it work.
3. Ensure that each clinician understands the benefits from the activity as well. If the clinician would otherwise be developing a treatment plan by using their experience and researching new treatments on a guidelines website or compendia, the pathways system helps put the available options at their fingertips, absolutely saving time.
4. Reinforce that pathways also help reduce the cognitive burden for the clinician. By being prompted for information instead of having to know all the question to ask, by having relevant and available clinical trials presented ahead of standard of care options, and by limiting the considerations to what has been determined to be the best choices available, the clinician can focus on the patient and what would be best for them.

Respect

Some clinicians worry that pathways are simply a tool for the administration to “spy” on them and track productivity and compliance with some arbitrary standard. It is important to address these concerns head-on. While the organization should establish and communicate standards of conduct and timelines for compliance with pathways, maintaining focus on providing the best possible care for patients will help alleviate this issue. 

Ensure that clinicians know that they have the time and resources to get used to the process before any monitoring will be started. Ensure the workflow and system have enough ways to remind a clinician when actions are needed on a specific patient. 

Be sure to connect any monitoring activity to the strategies that pathways are supporting. For example, instead of focusing on an oncologist’s having failed to navigate 10% of her patients, communicate that payers are requiring that we demonstrate our quality, and that one of the ways we do that is by using the data produced from navigating 100% of our patients, which shows how well we adhere to evidence-based standards. We cannot claim adherence to standard treatments if we do not have the data.

Independence

Clinicians are trained to exercise their judgement in a variety of settings. As I briefly mentioned previously, some clinicians will perceive that pathways are usurping their professional judgement and forcing them to follow arbitrary rules. Oftentimes, these clinicians are not aware that pathways are not intended to be followed 100% of the time. While the cancer center may expect that all patients are navigated through the pathway system, in all commercially available pathways, the expectation is that the recommendations will be applicable about 80% of the time, on average. In the remaining 20% of the cases, the clinician will have determined that the recommendation is not applicable to that patient. This expectation should be clearly and consistently iterated to all pathways users.

Ensure that the expectation of the organization is that the physician and all clinicians will apply their professional judgment at all times. The reason for any off-pathway decision should be documented and justified, if necessary, to avoid arbitrary decisions, but those off-pathways choices are fully within the purview of the physician. Off-pathways documentation is not intended for “spying” but to ensure clinicians and leaders have data to demonstrate efficiency. In many cases, if enough physicians have the same reason for going off-pathway, that alerts pathways committees that part of a pathway need updated. 

Timing and Process

The process of engaging clinicians should start well before the decision is made as to the vendor and timing of the rollout. Once the organization is seriously considering deploying pathways, clinicians should be brought into the process. 

Having input from a group of physicians and other clinicians can help ensure that there is adequate buy-in on the vendor selection. They can also provide valuable input and support on rollout planning to ensure that it respects their availability and resource needs. Ensure that they understand that the organization does not expect them to just add the pathways rollout and use to their already heavy time burdens, but that there will be sufficient resources to do the job right.

Telegraph the intent to staff while the vendor selection is under way. There may be those on staff with prior experience with one or more of the vendors. These are potential allies in the process. 

Once a vendor has been selected, communicate the decision to all to help build excitement and allow everyone to prepare. Start to explain the reasons for using pathways in support of organizational strategies and address common concerns proactively, as discussed above. 

Ensure that communications are well thought-out and multidimensional. It takes several mentions to get through to a large group. Consider regular, frequent but brief communications to help reinforce the messages. 

Once the pathways system is live, ensure that there are opportunities for immediate feedback on day-to-day issues. Addressing these before they get out of hand is important. Make sure that all clinical staff understand that the administrative and clinical leadership have an open door for their issues. Address concerns not only to the person raising them but to a broader audience—they may well be shared but unspoken by others. 

Provide an opportunity for feedback after some time has passed and everyone is used to the system as well. This can provide an opportunity to optimize workflow and productivity.

The Special Challenge of Academic Physicians

The ideas shared above are applicable to physicians and other clinicians in all settings—community, hospital-based, and academic. To be fair, though, oncologists working in an academic setting can pose unique challenges.

Unlike their colleagues in community practices or outpatient hospital settings, academic physicians often have dedicated their careers to studying a few very specific cancer subtypes, as noted above. Many participated in the clinical trials referenced in the pathways recommendations or wrote the papers on which recommendations are based. 

The familiarity and specialization of academic physicians is what makes them valuable but is also what makes engaging them in pathways particularly challenging. They do not need the decision support that community oncologists often do. It is important to stress the collective benefits derived from use of pathways and help communicate a value proposition that emphasizes their leadership in the oncology community and the benefit of having them use pathways to show their value to others. Even in academic cancer centers, pathways remain a critical way to demonstrate quality to payers and other stakeholders and to disprove the perception that academic oncologists prefer to only use the “latest and greatest” drugs and technologies. Pathways can be used not only to highlight the availability of clinical trials but also to identify areas where clinical trials are lacking based on patient volumes and patterns of care. Furthermore, pathways are often used as a teaching tool for fellows, providing guidance for them to understand the decision-making process and current standards of care. It is also worth explaining that pathways enable the organization to grow and fund additional resources for research and clinical trials, which are, in turn, available on the pathways. By improving the relationship with payers, academic practices thrive through their stable reimbursement. Additionally, using pathways to identify patient populations that exhibit higher rates of off-pathway treatment selection or increased rates of disease progression can identify research opportunities and help identify additional grant funding opportunities. 

Conclusion

If clinicians are not fully and regularly engaging with the clinical pathways system, cancer centers cannot reach the objectives they set out to achieve when they acquired the system. Clinician engagement requires buy-in, trust, governance, and organizational alignment.