Internally Developed Clinical Pathways in an Integrated Health System

J Clin Pathways. 2021;7(6):14-15. doi:10.25270/jcp.2021.0708.3

Tatjana Kolevska, MD, chair, Kaiser Permanente (KP)Northern California Oncology and Hematology, and medical director, KP National Cancer Excellence Program spoke with the Clinical Pathways Forum on April 27, 2021 about KP’s internally developed clinical pathways program.  

KP is an integrated care delivery system with more than 12 million members, 39 hospitals, 23,000 physicians and 300 oncologists across the United States. KP consists of three entities—Permanente Medical Groups, Kaiser Foundation Health Plan, and Kaiser Foundation Hospitals—that service eight regions across the United States: Northern California, Hawaii, Southern California, Northwest, Washington, Colorado, Georgia, and Mid-Atlantic.

KP’s Excellence in Cancer Care (EICC) program takes an enterprise approach to care while considering the unique capabilities and demographics and autonomy of the eight individual regions. Pathways are a key component of the EICC strategy. 

It was critical to clarify the “why” before embarking on KP’s pathways initiative. First, Dr Kolevska engaged with frontline doctors across the eight regions to solicit their opinions about pathways. The main question from many oncologists was, “if we have National Comprehensive Cancer Network (NCCN) guidelines, why do we need pathways?” Dr  Kolevska explained that the guidelines list all treatments that meet a standard of care for given presentation. The primary aim for guidelines is not consistency but rather to ensure that care delivered has been demonstrated to be effective by evidential review. Pathways, however, tailor the treatment for the specific patient circumstances. 

Overspending for low‑value health care in the United States troubles Dr Kolevska. She feels that the main barriers that can be addressed with cancer pathways are failure of care delivery, failure of care coordination, and overtreatment. Specifically, “the status quo of relying upon the individual expertise of any one physician to decide appropriate  care is no longer acceptable in our current age of accountability. Measuring care is an indispensable part of care delivery, and pathways can provide this data.” 

One of KP’s guiding principles is that each of the physicians at the Permanente Medical Group is a leader. Dr Kolevska explained, “it’s everyone’s duty is to ensure we provide value‑centered care, protect our privilege of freedom of practice, avoid preauthorization, and decrease daily practice burden.”  While pressures from external payers were a primary driver for many organizations to implement pathways, KP’s integrated model is focused on overall value of care. KP physicians do not request preauthorization when ordering drugs, including chemotherapy and immunotherapy. She explained, “if I consider that my patient needs any test or any kind of treatment, I can order it. We do not have any preauthorization. That’s why in our medical group, it’s so important for all of us to understand and have the buy‑in in the why.”

In late 2018, KP evaluated several commercial products before ultimately deciding to bring pathway development in-house.

Because there is no external requirement to use pathways for preauthorization, KP recognized that it was critical that frontline physicians found them feasible to use during a busy clinic day. Frontline oncologists were clear that if they were going to use pathways, they needed to be simple. Specifically, there needed to be ≤5 clicks to select and assign treatment. No commercial vendors were able to meet that user requirement.   

Second, the pathways needed to have “clinical pearls”. For example, if an oncologist ordered FOLFIRINOX for a patient, then the pathway should describe, in a nutshell, the outcomes and main adverse events to enable informed consent and shared decision-making with patients. The pathway needed scientific references to define the evidence base for the pathway, and the pathways needed be updatable almost immediately after new changes in standards of practice.

The priority was always physician buy‑in. To get to that, there also needed to be seamless workflow. Instead of the doctors spending valuable clinic time reviewing UpToDate, NCCN, and other guidelines, “we made the right thing to do the easiest thing to do. That was extremely important,” said Dr Kolevska. KP’s pathways are built within EPIC’s Beacon oncology module. The physician can go directly into HealthConnect (KP’s EPIC electronic medical record system) and submit the chemotherapy order and labs directly from within the pathway in ≤5 clicks.

About 40 chiefs within KP oversee the eight regions across the United States. New pathways and results are presented at monthly regional and national meetings. Separate national pathways committees receive continuous feedback and can react quickly to adapt to the needs of frontline users. On a monthly basis, a representative from each of the eight regions reviews over 960 evidence‑based cancer protocols, making sure that all the doses, labs, and supportive care drugs are correct and up‑to‑date. The evidence reviews, quality assurance, and building in EPIC’s Beacon module is done by the national pharmacy team.  

“Whenever I sign a chemotherapy order, I know this was checked by my peers,” said Dr Kolevska, “and I’m confident this is the most up‑to‑date treatment available.”

Audit and feedback to physicians and chiefs is critical to the success of the pathways program. All chiefs receive reports for each physician in their group. Currently, the available pathways analytics include breast cancer, lung cancer, and melanoma, and the analytics are expanding to all pathways. If an oncologist’s pathways use is less than 50%, the chiefs are expected to discuss this with them. If a particular center has a low use rate, then the regional chief reaches out to the local area leader and physicians offering help and support to improve pathways adherence. To fully round out the process for 360-degree feedback, Dr Kolevska also solicits feedback surveys from all physicians.

Drug genomics and survivorship are two examples of new pathways in development at KP. Patient-centered design is being used to develop the patient-facing portions of these pathways for appointments, self-care, and navigation.  

The objective of the genomic pathways is to eliminate low value care in cancer diagnostics. Data in the literature show that up to 58% of the diagnostic workup for stage III lung cancer patients is low value.¹ A genomic diagnostic portion of the lung cancer pathway will be piloted soon in Northern California.

A survivorship pathway also is being piloted in Northern California. All cancer diagnosis from stage I to III will be recognized by HealthConnect through the staging tool. Physicians will have the ability to unenroll patients who are inappropriate for the survivorship pathway. The pathway will include a health maintenance plan that will be built based on algorithms that were designed by KP’s gastroenterology oncology specialists. Patients will get reminders at predefined intervals to book an appointment. There will be an automated ordering of labs, and patient-reported outcomes and a questionnaire will be sent on a regular cadence to determine if an office visit is required.

Avoiding an unnecessary trip to the oncologist is important. According to Dr Kolevska, “about 30% of a survivor’s care is redundant. Patients are seen by surgical oncologists, medical oncologists, gynecologists, primary care, and all for the same reason. We are planning to eliminate that. We’re creating dashboards that will be used as a safety net tool for our case managers and we are making sure that our precision tracking team is overseeing this development as closely as possible.”

The critical success factors for current and future pathways at KP are actionable tracking systems inclusive of virtual navigation, provider decision support tools, patient‑reported outcomes, and ways to engage members in healthy lifestyle behaviors. The pathways must be built based upon useability and acceptability requirements defined by patients and clinicians.

Dr Kolevska described her ultimate long‑term vision for KP pathways: a digital tool that activates when a member joins KP. The pathway then analyzes the electronic medical record, recognizes the patient’s social determinants, family history, and genomics to assess cancer risk.  The ultimate objective is to have the capability to leverage the rich data in in KP’s medical records about a patient’s lifestyles and habits to create a pathway that provides seamless guidance for clinicians and patients for prevention, diagnosis, and treatment.