Clinical Pathways

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Man On A Mission: Improving Quality Care With Clinical Pathways

Moffitt’s Pathways Program aims to improve care, reduce health care costs.

If Mark Schippits, M.D., director of the Clinical Informatics Programs at Moffitt Cancer Center, walks and talks like a man on a mission, that’s because he is. His mission for two and a half years has been to collaborate with colleagues and demonstrate to the world at-large how to integrate evidence-based medicine with available technology to standardize, benchmark, measure and improve cancer care through Moffitt’s new Clinical Pathways Program.

The concept of clinical pathways is, first, a model for providing evidence-based, consensus-driven, cost-effective cancer care. Pathways also have taken the form of a complex road map of arrows and diamonds that makes diagrams of the London Underground, or a schematic of your computer’s innards, appear simplistic.

While the London Underground provides solutions on how to get from point A to point B, Dr. Schippits says with a smile, clinical pathways in and of themselves do not provide a solution.

“Clinical pathways offer a systematic tool to help physicians improve patient care,” he says. “Pathways document institution-specific, consensus-driven, standardized best practices that, when shared, provide a rationale for better clinical decision making.” Improvements in standardization and measurement of care mean better outcomes and getting Moffitt “closer to a cure” for even more patients.

By utilizing Web technology, Moffitt’s Clinical Pathways Program is designed to be highly interactive, linking to a variety of additional information, graphics, clinical literature and outcomes data. The program outlines a consistent approach to personalizing patient care, including information to assist Moffitt clinicians and partner practitioners in identifying relevant clinical trials.

Clinical pathways provide a patient management tool not only for physicians but also for the entire health care team. The tool helps standardize and outline a patient’s clinical course of care based on best practices specific to the patient’s situation and personalized treatment needs. Key goals of clinical pathways are to streamline related patient care processes, increase the use of generic drugs for both chemotherapy and supportive care, and assure that patients receive the most appropriate, personalized care to optimize their desired outcomes. Clinical pathways are continually updated to provide a basis for health care providers to evaluate best practices, outcomes information and cost of care, resulting in potential cost savings.

What makes this mission important?

“Moffitt is always looking for ways to improve the quality of patient care and to effectively manage medication and services expenses,” says Jack Kolosky, executive vice president and chief operating officer. “We think Moffitt’s Clinical Pathways will demonstrate value-based outcomes through coordinated quality care and treatment standardization that will be an even more important role in the new health care environment.”

Cost, although an essential element, is not the top priority for Moffitt’s Clinical Pathways. It falls after treatment effectiveness and safety/toxicity as a priority for determining the most appropriate clinical options.

To develop a scholarly and comprehensive portfolio of clinical pathways, Moffitt leadership leveraged a broad, collaborative team of clinicians, administrative leaders and information technology experts. They prioritized common cancers and selected individual physician leaders to “own” and coordinate the development of each tumor-specific pathway. Each pathway owner consulted other specialists in drafting their pathways. Research meetings, department meetings and tumor board discussions were also leveraged to produce a robust clinical result with strong organizational support.

So far, Moffitt has 23 different clinical pathways for diseases that include lung, prostate and breast cancer on its Clinical Pathways Program website, and nearly as many pathways are in various phases of development.

These clinical pathways are made available to physicians outside of Moffitt Cancer Center via the Physician Portal. (Moffitt’s Physician Portal helps referring physicians monitor their patients’ progress while undergoing treatment at the Cancer Center, all from the convenience of their own offices.) Three partner institutions are going live with Web access to Moffitt’s Clinical Pathways in early 2013.

Pathways decision support tools now in development include navigation software that allows a clinician to move from diamond to diamond, each diamond representing a decision made by the clinician. A few examples of such decisions include age, histology, stage, grade, genetic markers, lab values, tumor resectability, functional status and patient choice. Clinicians need only to click on and follow the diamond-shaped stops along the pathways (Dr. Schippits describes them as “bread crumbs”) that make up the decision flow diagrams. Each diamond (or “bread crumb”) in the consensus-based flow diagram represents a decision that will contribute information to a nicely formatted, longitudinal clinical summary for Moffitt physicians. The bread crumbs follow the entire course of care and illustrate the preferred diagnostics, treatments, surgery options and clinical trials for each patient. This information now also forms the basis for Moffitt’s quality benchmarks.

Because of the Clinical Pathways’ broad utility and novelty, Moffitt filed a United States patent application in 2012.

The Clinical Pathways Program seeks not only to optimize treatments based on both evidence (science) and consensus (art), but also to lower costs, for example, by highlighting the likelihood and magnitude of both risks and benefits, including costs, and limiting options to best practices.

“As a percentage of gross domestic product, the cost of medical care in the United States is 50 percent higher than it is in other developed nations,” notes Dr. Schippits. Annual direct costs for cancer care are anticipated to rise from more than $104 billion in 2006 to more than $170 billion in 2020 and beyond, according to an article appearing in the May 26, 2011, issue of the New England Journal of Medicine.

Pathways-related questions about costs are: How can we better control costs? What costs are worth the value? Which therapies are effective, both medically and in terms of costs?

So how does the application of clinical pathways reduce costs?

Dr. Schippits points to a previously published study on Clinical Pathways that shows a 35 percent savings for patients treated via the Clinical Pathways Program for a year, without any perceptible impact on clinical outcomes.

“Cost differences in this study were driven primarily by significantly lower utilization of chemotherapy and other medications, particularly in later metastatic disease,” he says. “Pathways may include these expensive medications, but ideally would include only lines of therapy in which evidence for efficacy is known to be sound. It’s not simply a cost comparison between expensive drugs and cheaper ones.”

Finally, Dr. Schippits emphasized the importance of collaborating physicians, pharmacists and so many staff toward today’s success of this important work, including hopes for future incorporation into health care reform and eventual health care transformation. Several institutions, including other cancer centers, have already indicated a sincere desire to become partners with Moffitt in adopting the use of Moffitt’s Clinical Pathways. “Upon entering 2013, Moffitt is seen as providing progressive thought leadership in the clinical pathways industry,” he says, “and we continue to build a team around developing pathways to help extend the Moffitt name and brand to a brighter and broader future.”

Photos, Clinical Pathways team members.

Top right, L-R: Mark G. Schippits, M.D., Mary C. Pinder-Schenck, M.D., Mary L. Rivera, M.S.N., O.C.N., and Geoffrey T. Gibney, M.D.

Lower left, L-R: Hugo F. Fernandez, M.D., and Mark G. Schippits, M.D.

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