This document proposes a system to make medical oncology clinical pathways work for patients, providers, and payers. It involves three parts: 1) Standardizing pathway names across different systems so payers see equivalent pathways, 2) Validating pathways are clinically equivalent through an independent committee, and 3) Establishing a Patient Safety Organization to analyze pooled outcome data from multiple providers while protecting patient privacy. The goal is to improve care quality, reduce costs by controlling variability, and empower providers with comparative data, while ensuring patient interests are prioritized.

1. Making Medical Oncology Pathways Work for Patients, Providers and Payers
Using the PSO Structure to Benefit all Parties
Finding the Unicorn – Making Order from Chaos
Wes Chapman & Aaron Lyss
December 6, 2014
In our September blog regarding medical oncology pathways, we examined what payers are
trying to get out of the current system, and why they have been disappointed. While they look for
best practice conformance and cost control from disparate and proprietary clinical pathway
systems, they are instead finding provider resistance and growing confusion. The variation in
process that their proprietary pathways impose on practices result in decreased quality and
increased cost, and have done little to reduce payer dependence on clumsy, expensive and
ineffective prior authorization methods.
In this follow up blog, we address,” how existing systems can be made to conform to existing and
prospective payer requirements. It will require substantial changes to the existing prior
authorization systems (including a dramatic upgrade in clinical capabilities)”; points we raised
at the end of our last blog on the subject.

2. Making Order from Chaos
A Problem Solved in Three Parts
First, the easiest problem to address is technical: How to convert pathways selected in any one of
6-7 commercially available pathway systems into a single equivalent pathway system selected by
an individual payer. Remember that all of the pathway systems are “NCCN compliant”, and
85%-90% of all pathways used by large medical oncology practices are clinically equivalent –
differing in minor ways which typically do not change clinical utility, toxicity or cost. From a
technical basis, this is pretty trivial, and the diagram below shows a very straightforward solution
to this part of the problem.
Pathway System A
CHOP-R Pathway
Name ABC123
Pathway System B
CHOP-R Pathway
Name XYZ@#$
Pathway System C
CHOP-R Pathway
Name MNB)(*
Interpretive Database
All Signals
recognized as
CHOP-R
Signals of different
Names but precisely
the same Pathway
ABC123
XYZ@#$
MNB)(*
Signals sent
to payer as
CHOP-R

3. Database Recognizes and Interprets disparate nomenclature
The second part of the problem however, is clinical, and a lot more problematic to fix: who
determines when differences stop being trivial, and start being meaningful. This is a bigger
problem than you might first imagine, because the individual pathways can differ in small but
important ways between practices; as an example, dosages may differ by small amounts, and
supportive drugs may be quite different, or entirely unspecified by some practices. Someone, or
some group, must be trusted to provide the adjudication fairly, and according to the criteria
agreed to by the individual practices and payers. Furthermore, pathways are continuously
updated – typically quarterly – to keep up with current literature about best practices.
There are currently parties capable of delivering the required clinical oversight needed to make
the database work: 1) The design and/or validation of NCCN compliant pathways for payer
selected systems, and 2) The validation of individual practice pathways as compliant with
specific payer requirements. This is a fair amount of work, and requires a large compliment of
unbiased and well informed clinical experts. It is pretty clear that a vendor like Via Oncology has
a committee based system that meets most of the requirements associated with this problem, and
may be able to gear up to offer the clinical validation needed.

4. Practice
Layer
• Practice selects pathway system
• Practice selects treatment pathway for individual patient
Database
Layer
• Database operator validates pathway system
• Database operator valides individual practice pathways
• Database receives individual patient pathway, validates and
forwards on to payer in appropriate system code.
Payer Layer
• Payer selects individual pathway system
• Payer contracts with Database operator
• Database provides validated patients and related pathway to payer
• Payer approves prior authorization for pathway of care and payment
Database facilitates interoperability, pathway validation, payer notification & approval
The third part of the problem is how to take advantage of the data that is generated by the
system. A Patient Safety Organization (PSO) offers a number of very important advantages that
would be beneficial in this structure. PSOs are designed to gather data in confidence and under
pre-determined protocol, exclusively for the benefit of patient care and safety. The structure was
created by the Patient Safety Act of 2005, is administered by AHRQ and attaches privilege and
confidentiality to “patient safety work product” for data in the PSO.
From a practical perspective, this allows the use of pooled clinical data from multiple provider
groups to be analyzed and interpreted for the benefit of patient care. PSOs are normally chartered
with the involvement of one or more medical societies, to ensure effective collaboration. What
makes the use of a PSO so compelling in this structure, is that multiple pathways are being
mapped to common definitions, and the collection of safety and outcome data associated with the
standard pathways would provide compelling outcome data. Because the physicians providing
care are also interpreting the data, relevant cohorts can be developed – reflecting the full range of
selection criteria.
While it is not permitted to sell data out of the PSO, participating members can decide to pool
their data for commercial use outside of the PSO – providing truly meaningful data for
pharmaceutical and device companies to evaluate and improve their products.

5. What is most important from our perspective is that the patients interests come first, and patients
benefit before anyone else. We feel that it is absolutely critical that the focus of the system be
patient care – commercial interests must take a back seat. Second, we recognize the primacy of
the patient /physician relationship, and want to do everything possible to empower providers
with relevant data to improve patient care and safety. Finally, we recognize, however, that strong
and viable research is greatly aided by the use of good data, and that payers need to be able to
control costs and escape from the overly costly and intrusive prior authorization systems
available today.
Clinical pathways offer the ability to dramatically improve medical oncology care as well as
reduce variability in care delivery. Like all innovations, clinical pathway systems in oncology
require new application methods to achieve their full value – and we think that this system goes a
long way to achieving that potential.