Utilizing Clinical Pathways Tools at Cone Health

In this interview, John A. Ingoglia, PharmD, BCOP, CPP, Clinical Pharmacy Coordinator, Oncology, at Cone Health, provides an overview of how clinical pathways are utilized at Cone Health and shares some of the latest treatment options for breast cancer.

Transcript:

John Ingoglia: My name's John Ingoglia. I am the clinical pharmacy coordinator for the oncology service line at Cone Health. I also run the CPP clinic, which is a clinical pharmacy coordinator clinic at Cone Health, and have been doing that since August of 2022. I trained at Moffitt Cancer Center. I did my PGY one and PGY two there and graduated from there in 2018. And prior to Cone Health, I was working at Atrium Health, Wake Forest Baptist in breast oncology as the clinical pharmacist there.

What sources do you use for designing clinical pathways at Cone Health?

Dr Ingoglia: Yeah, so at Cone Health we use Elsevier, which is ClinicalPath. We've used them since I've started, probably even before I started. They've been using them and it's a great tool. Our medical oncologists, I actually collaborate with four medical oncologists in my breast oncology clinic. They use it extensively. It really helps them guide them on which treatment plan has the best evidence. And they obviously can always go off of pathway if they need to. There's metrics that our leadership looks at if they do go off pathway and when they're on pathway. But it's a great tool from what I've heard. It's evidence based. There's a lot of different committees for the different oncology disease states that meet regularly and review the latest evidence. They're constantly updating the pathways, and so our medical oncologists really like to utilize the tool. And then again, if they need to, they can always manipulate the treatment plan a little bit to meet the needs of the patient. They can always use the clinical pharmacist to assist them with that. But yeah, everything that I've heard, it works really well for our institution.

Are pathways integrated into the electronic health record?

Dr Ingoglia: Yes, they are, which is a really nice thing actually. So we use Epic and we have the oncology platform Beacon that we use. And so when the medical oncologist is designing the treatment plan, they actually can go in and go through ClinicalPath right through the EMR, and so they can punch in the different information about that patient's specific tumor, staging, different things like that. And then ClinicalPath will actually give them a recommendation on which treatment plan to use. And then like I said, if they want to, they can use that treatment plan, which for the most part they do. But if they want to come off pathway, which it's called, and use a different treatment plan or edit that treatment plan in some way, they can also do that as well.

Then the nice thing about with Cone Health is we have a lot of data and analytics that then looks at the usage through ClinicalPath to see which medical oncologists were more on pathway versus off pathway, and if they were off pathway, why? But it gives the medical oncologists a really good tool to navigate through the very complex disease of oncology and which treatment plan to use, what's the latest evidence and ClinicalPath allows them to do that.

Can you talk about any recent updates or developments in the treatment of breast cancer?

Dr Ingoglia: Yes. So I recently went to a breast cancer symposium at Atrium Health Wake Forest Baptist that's given annually. And it was really exciting to see some of the newer oral agents that may be coming out. In my clinic, I see a lot of metastatic breast cancer patients and many of them are on a drug called fulvestrant. Which is a great drug, but as many of you may know, it is given intramuscularly in each buttocks every 28 days after the loading dose. And it's not fun. Patients really do not like to have that done every 28 days. It works really well, but it can be painful and it's not a comfortable experience. And so out of all the oncology agents that I see that probably has the most patient experiences that are negative, the great thing about what's coming on the horizon is there's a lot of agents out there that are being tested that are similar to fulvestrant in the mechanism of action, but they're oral agents, so that would eliminate the patients having to get an IM injection every 28 days.

There is one out currently, elacestrant, you have to have an ESR one mutation in order to qualify to get that drug, but the data that we saw at the Breast Cancer Symposium looked at patients that were ESR one mutated, but also ESR one wild type. So hopefully as these drugs get approved, patients won't necessarily have to have an ESR one mutation in order to get approved for the oral agent, so that's very exciting. Also, I started in breast oncology in October of 2019, and since that time there's been so many new agents that have come out in the triple negative breast cancer space and in the HER two positive breast cancer space.

So the treatment algorithms have changed a lot. There's a lot more information on sequencing. Immunotherapy has come on the horizon, especially in triple-negative breast cancer with the Keynote 522 trial with pembrolizumab, the Keynote 355 trial with pembrolizumab. So a lot of exciting times in breast cancer, hopefully, as these agents get approved. The ultimate thing as pharmacists is for us to try to give these treatment regimens in a safe manner. Keep the patients as safe as possible, and then hopefully as these newer agents come out, patients will be able to live longer, which is obviously the ultimate goal.

What obstacles or barriers do you see for clinicians using pathways in their treatment decision process, and how can these be best addressed to increase utilization among clinicians?

Dr Ingoglia: I wouldn't necessarily say that there's barriers. Like I said, with Elsevier and ClinicalPath, the medical oncologists use that quite a bit and it really helps them guide treatment decisions. Obviously they, I've been blessed to work with a lot of very intelligent medical oncologists, and they're very up to date with the guidelines and the newest treatment regimens and the newest data that's out there. So I wouldn't necessarily say there's barriers. What they can do though is they can look and see what the data is out there. They can always go off a pathway. If ClinicalPath is suggesting a treatment regimen, but the medical oncologist wants to change it, they can definitely go off pathway. And then if there is some sort of reason why there might be a brand new indication for a certain disease state and say it is not an NCCN yet, and it may not be in the clinical pathway yet.

That's where the medical oncologist can definitely submit a treatment plan, build request, and my team and nursing and physicians, we have a multidisciplinary governance team that can look at that request. And then build that treatment plan and validate that treatment plan even prior to ClinicalPath. Designing that pathway, even though even ClinicalPath is on top of things and usually gets the pathways out very quickly. There's always that option for a medical oncologist too, just in case things might be lagging behind a little bit. So there's a lot of different options that we have at Cone Health to try to help the medical oncologist and then ultimately help the patients get the best care possible.

Is there anything else you'd like to add?

Dr Ingoglia: Just working in breast oncology, I'm privileged to work with the patients and the medical oncologists and the different health care professionals that I get to work with every day. The patients inspire me to be on top of my game and to do as much as I can to know the latest research out there and to help them as best as I can, and I just feel it's a privilege to work at Cone Health and to take care of my patients on a daily basis, so I'm very blessed.