The Evolving Role of Pharmacists in Custom Pathway Implementation

In this interview, Rebecca Maniago, PharmD, discusses the complexities of implementing custom clinical pathways, emphasizing the need for clear goals, robust resources, and ongoing updates, while highlighting the pivotal role of pharmacists in pathway development, regimen management, and enhancing patient outcomes.

Transcript:

Rebecca Maniago, PharmD: My name is Rebecca Maniago. I'm an oncology pharmacist by background, and I've worked at Flatiron Health for 5 years now, leading the clinical team that's involved in the development of our clinical decision support tool called Flatiron Assist. Our application is built on NCCN guidelines; however we allow for local customization, which means I have had the opportunity to work with several customers that have built custom pathways and ultimately integrated those into our application. I was here to speak on a panel all about how you build a custom pathway program.

Based on your session, what do you feel was the consensus best practices that have emerged for implementing custom pathways?

Maniago: After the panel today, one big theme that kept coming up, no matter who was speaking, was the fact that building a pathways program is no easy task. You really have to be resourced. You have to understand upfront what your goal is and why you are actually doing this—what do you hope to achieve? From there, you have to set up a structure internally to support not only the building of the platform, but the implementation, the ongoing adoption, and then understanding that it doesn't end there, that every month there will be updates. So how are you going to navigate that? Having that full picture understood upfront and willingness to invest in that is critical. I think every single person, no matter if they're a health system or a Management Services Organization (MSO), everybody kept going back to the fact that it ended up being more work than they were potentially aware of before they actually embarked on this journey.

How do these practices enhance outcomes for every stakeholder involved?

Maniago: I think it depends on what outcome we're actually speaking of. Everybody that is brought into the value of pathways programs understands that when you standardize care and you align with these pathways, you are improving patient outcomes. Outside of that, it really starts to become unique to that organization or that health system, and that's where they can really drive those local customization efforts to improve things like cost-effectiveness, overall cost of care, and a lot of those are unique to them. This is a very tailored and custom approach and the outcomes for which they are achieving are going to be unique to them.

When developing custom pathways, how are cost effectiveness considerations balanced with clinical efficacy to ensure optimal patient outcomes?

Maniago: At the beginning, the top tier, when you're thinking about building out your pathway, first and foremost, everybody will agree that it's based on safety and efficacy, and when those things are equal—so clinical equipoise is how we refer to it—that means from there, if there are multiple options that seemingly are equal in safety and efficacy, then you start to consider cost. It is not a very black-and-white consideration because it can be the cost of the drugs, the cost of the patient, the cost of the organization, the cost of care, the toxicity that may come with it. There are a million things that go into really figuring out what is this cost-benefit that we are trying to achieve. Again, it goes back to how, at the local level, being able to control for that is highly beneficial.

Are there opportunities to introduce patient advocacy groups when trying to implement a pathway, or does something like that exist already?

Maniago: I think there are a lot of opportunities. We're starting with a custom pathway from there. Again, depending on what that organization's goals are, they can really take it to where they want. If patient advocacy is part of what is important and something that they are willing to drive internally and really spin up a program and a process for, then the data and just using a tool like this—the standardization—absolutely can lend itself to some type of structure with patient advocacy.

We are starting see pharmacists take larger role in patient treatment. What do you envision as the role of the pharmacist when implementing a custom pathway?

Maniago: The role of the pharmacist can really be multifaceted. I've seen the pharmacist actually lead the disease teams and set up the structure for how that pathway program will be developed. Meaning, they are aggregating the data and the content and presenting that to the specific disease groups and helping them go cohort by cohort as they establish what their preferred pathways will be. Secondarily, the pharmacist is always the one who is the expert in regimen building, regimen migration, and regimen maintenance over time. So getting them involved as well, even if they're not involved necessarily at that disease group organization level, they at some point will absolutely have to be involved in the regimen setup and cleanup that happens over time when these pathway programs are implemented. And then on the backend, they can really be integral in taking the data that they will now have, understanding ordering patterns—they often know a lot of the cost considerations—and so, especially in scenarios where there may be multiple regimens that are equal in safety and efficacy, the pharmacist is the one who can help the organization decide which one they should align on based on whatever contracting is in place, and they often have that information that others will not.

When we think about the ever-evolving role of pharmacists, how crucial is it to get other folks on board with pharmacist integration in pathways, and how can pharmacists be motivated to take on that extra step?

Maniago: It’s a great question, and this really is an opportunity for pharmacists as well. I see, over time, if they take ownership in the update process, basically every time there's a new update, they are the ones who get to disseminate that information to the providers who are part of these disease groups and help them determine which regimen they want to build, and then go on and actually build that regimen. Previously, without tools like this, it was up to them to have to continue to check the guidelines, read the latest data, and nobody has that much time to be able to accomplish that. Putting them in these programs in a role where that information is now fed to them, and they're the owner of making sure that the practice is aware of what's new and what's not, then they can make those considerations and really drive that building and updating and maintaining of the regimen library.