Integrating Academic and Community Cancer Care and Research through Multidisciplinary Oncology Pathways for Value-Based Care: A Review and the City of Hope Experience

Abstract

As the US transitions from volume- to value-based cancer care, many cancer centers and community groups have joined to share resources to deliver measurable, high-quality cancer care and clinical research with the associated high patient satisfaction, provider satisfaction, and practice health at optimal costs that are the hallmarks of value-based care. Multidisciplinary oncology care pathways are essential components of value-based care and their payment metrics. Oncology pathways are evidence-based, standardized but personalizable care plans to guide cancer care. Pathways have been developed and studied for the major medical, surgical, radiation, and supportive oncology disciplines to support decision-making, streamline care, and optimize outcomes. Implementing multidisciplinary oncology pathways can facilitate comprehensive care plans for each cancer patient throughout their cancer journey and across large multisite delivery systems. Outcomes from the delivered pathway-based care can then be evaluated against individual and population benchmarks. The complexity of adoption, implementation, and assessment of multidisciplinary oncology pathways, however, presents many challenges. We review the development and components of value-based cancer care and detail City of Hope's (COH) academic and community-team-based approaches for implementing multidisciplinary pathways. We also describe supportive components with available results towards enterprise-wide value-based care delivery.

Keywords: Early Recovery After Surgery (ERAS); cancer care plans; integrated cancer care; oncology medical home; oncology pathways; supportive care pathways; surgical pathways; team-based care; value-based cancer care; value-based care.

Figure 1

Value-based care framework projects for City of Hope Enterprise: Green represents the three pillars of value-based care: evidence-based care, care management, and care after cancer. The boxes represent categories of projects to facilitate measurable delivery of value-based care. Purple indicates clinician-led projects. Blue indicates patient-focused projects. Orange indicates projects after active therapy or curative therapy, whether in survivorship or end of life. Within the category of complete discrete patient diagnosis are the projects that will help to accomplish this. Omics refers to genomics, proteomics, metabolomics, and microbiome information that impacts a patient’s treatment episode choices and potential outcomes. SDH refers to social determinants of health. Med Onc—medical oncology, Hem—hematology, Rad Onc—radiation oncology. ClinPath is the pathway system by Elsevier (formerly called VIA Pathways). EPIC refers to the EHR. IM—intramuscular, IV—intravenous. EHR—electronic health record. ERAS—early recovery after surgery pathways. SOP—standard operating procedures. Televisits—telephone and televideo visits. The purple arrow indicates that goals of care pathways are incorporated during active therapy as well during in advanced end of life care.

Figure 2

ASCO’s criteria for high-quality oncology pathway programs under pathway development, implementation and use, and analytics as described by Zon et al., J Oncol Prac 13:207–210, 2017 [63].

Figure 3

Clinical trial accrual at Duarte and community sites 2017 through September 2020. Light blue bars are the number of patients accrued to treatment trials at community sites where some trials were available. Dark blue bars are number of patients accrued to treatment trial at the Duarte academic campus.

Figure 4

Percentage of new EPIC Beacon starts that were navigated in ClinPath by medical oncologists for solid tumors since go live for enterprise overall then by Duarte campus site and all community sites. Note Q3 data were incomplete at time of manuscript data collection in May 2020, so the final% of patients in Q3 who were navigated in ClinPath is likely higher, as is seen in other recent quarters.

Figure 5

Pathway compliance percentage over time for medical oncology patients navigated in pathway tool (ClinPath) for enterprise, Duarte academic campus, and community sites for new therapy regimens ordered in the EPIC-BEACON EHR from January 2019 through June of 2020. Green bars are on-pathway choices (including clinical trials) and yellow bars are off-pathway choices. Note that the scale of the x-axis representing the numbers of patients is different for each group to show the comparison percentages in one graph. The combined number of patients navigated in Duarte and community sites is reflected in the number totals described on the enterprise graph.

Figure 6

Individual patients seen by radiation oncologists by the enterprise per quarter since ClinPath pathways were initiated for radiation therapy in Q1 of 2019. The numbers represent the number of individuals with a decision made each quarter who are: on therapy with a non-pathway diagnosis, shown as “other trial” (purple), were on a pathway but went off treatment (yellow) that quarter, on a pathway treatment (green), are off treatment (light blue), are on an off-pathway treatment, (red) or on a clinical trial (dark blue) for an on-pathway disease.

Figure 7

Ten-step supportive care patient and family meeting program pathway with expanded details about step 9 in second section of diagram to improve end of life care at COH.

Figure 8

Pain plan of care compliance for those reporting moderate to severe pain. Blue represents results from the 3 QOPI reporting quarters (Fall 2016, Spring and Fall 2017) from the previous EHRs (Allscripts on campus and TouchWorks in community sites) prior to the EPIC implementation. Orange represents results from the 4 QOPI reporting quarters (Spring and Fall 2018 and Spring and Fall 2019) after the December 2017 EPIC transition for both the campus and community sites.

Figure 9

COH enterprise QOPI final certification scores. Blue represents the 3 reporting quarters (Fall 2016, Spring 2017 and Fall 2017) before the -EPIC implementation. Orange represents the 4 QOPI reporting quarters (Spring and Fall 2018 and Spring and Fall 2019) after the EPIC go live December 2017.

Figure 10

City of Hope’s overriding digital framework to empower value-based care and real-world insights.