Category Archives: Cancer Care

What Happened in Washington This Week

By Brittney Fairman, MPS, MA, ACCC Policy Analyst

U.S. CapitolIt’s been quite a week in Washington, D.C.  Let’s recap.

On Wednesday, July 12, the Centers for Medicare & Medicaid Services (CMS) held the latest in a series of webinars explaining the agency’s proposed rule for CY 2018 updates to MACRA’s Quality Payment Program. If you missed ACCC’s webinar on the implications of this proposed rule, members can access the webinar, presentation slides, and a summary [login required].

On Thursday morning, July 13, U.S. Senate Republicans unveiled their revised draft of the Better Care Reconciliation Act of 2017 (BCRA). The updated bill is the latest effort to repeal and replace the Affordable Care Act (ACA), and we continue to have concerns about the erosion of protections for cancer patients in the exchange marketplaces. ACCC is continuing to monitor the effort on the Capitol Hill and measure the evolving legislation against ACCC’s health reform principles.

Then later that same day, the Centers for Medicare & Medicaid Services (CMS) released the proposed CY 2018 Hospital Outpatient Prospective Payment System rule and CY 2018 Physician Fee Schedule rule. ACCC is currently analyzing both rules and will provide in-depth information to members on the impact on oncology. At first glance, the proposed, significant cuts to hospitals in the 340B Program and to new outpatient facilities cause concern, particularly for small, rural cancer programs and programs in vulnerable communities without other sources of healthcare. Stay tuned for information on the date and time of an upcoming ACCC members-only webinar on these proposed rules.

Also Happening on Capitol Hill
So this week, while much of the nation’s attention has been focused on Congressional action on ACA repeal and replace, and many healthcare providers awaited CMS’s release of the proposed 2018 Medicare rules, it’s important to note that another significant piece of legislation moved forward on Capitol Hill. On July 12, the U.S. House of Representatives passed the FDA Reauthorization Act (HR 2430). This legislation includes important bills for cancer care, including the Research to Accelerate Cures and Equity (RACE) Act and reauthorization of the Prescription Drug User Fee Act (PDUFA), which allows the FDA to collect fees from drug manufacturers to fund the new drug approval process. The User Fee Program plays an important role in the timely review of new drug applications and patients’ ability to access novel therapies.

The “RACE” Act is a bill which has important implications for the fight against childhood cancer. The legislation specifically updates the 2003 Pediatric Research Equity Act (PREA), which requires studies of adult drugs in adolescents during a drug’s development process.

PREA has experienced success in providing important information on a drug’s use in children in hundreds of cases; but, it has not yet been applied to pediatric cancer drugs. It is well known within the oncology community that many pediatric cancer patients are typically treated with “off-label” adult drugs. Under the RACE act, the FDA will be given authority to require a pediatric investigation into adult drugs if those drugs use molecular targeting and that same target is “substantively relevant” to the continuance of a pediatric cancer. If passed in the U.S. Senate, this act will permit clinicians to know the dosage, safety and efficacy in pediatrics and grant accurate labeling for use on children. Additionally, the RACE act will mandate that molecular targeting drugs be given an orphan designation to go through a pediatric investigation.

As summer in Washington continues to heat up, ACCC is closely monitoring legislation on Capitol Hill and performing an in-depth analysis of CMS’s proposed rules for 2018. Stay tuned for updates.

 

Creating a Navigation Intake Assessment Tool

By Tricia Strusowski, MS, RN

Compass pointing at answers-SMALL      “I want to be aware of the navigator and support services as soon as possible.”

This is a frequent response from patients when asked about the optimum point in the cancer care journey to learn about navigation and support services.

And yet, during a first visit (or intake interview) with a patient, navigators may question how much to review. Where is the balance between too much information and not enough?  Based on my experience in care coordination and patient navigation, here’s my perspective on creating and using an intake assessment tool.

Number 1 Rule:  Assess if the patient is ready for this discussion. First, provide support. Let the patient and his or her family take lead in the conversation. Listen. Then, based on your assessment, ask the patient and family if they are ready to review the support services and their specific needs. Once you receive their permission, you can then initiate the intake assessment process.

Each cancer program should have a consistent process for assessing and educating patients and families about the cancer program and support services.  A well-crafted intake assessment tool can be used for all cancer disease sites and should include the following:

  • Role of the navigator and the support staff at your cancer center
  • Mini assessment of immediate support service needs
  • Preferred learning style for education
  • Questions that prompt a conversation on what the patient knows about his or her cancer
  • Questions to elicit from the patient specific concerns, goals, and family concerns
  • Family, medical, and surgical history
  • Mini symptom and behavior risk assessment
  • A listing of national and community resources (usually included in patient’s treatment journal).

Gathering this essential information at the time of your initial visit with the patient will establish a strong foundation for the multidisciplinary team. The navigator’s assessment process is an opportunity to begin the discussion about goals of care and/or goals of their treatment—a pillar for providing patient and family-centered care. Further, identifying patients’ preferred learning style and using it across the continuum sets them up to succeed in understanding their cancer and treatment plan. This information can be shared at tumor conferences, multidisciplinary meetings, huddles, or via email if a secure environment is established.  It is also vital to support the navigator role in educating the patient and family consistently, as well as providing an important resource tool for navigators who may be called on to cover for a colleague. An assessment tool is a key component for a consistent foundation to navigation, but health literacy training and patient education teach-back methods can enhance the process and support staff success in educating patients and their families.

Assessing the immediate needs of the patient and family, while providing education and support, establishes a patient-centered approach and lays the groundwork for a strong bond between the patient, family, the navigator, and the support services.

View a sample navigation intake assessment tool. You are welcome to revise this tool as needed for your cancer program.


ACCC member Tricia Strusowski, MS, RN, is a consultant with Oncology Solutions, LLC.

The upcoming 34th ACCC National Oncology Conference, Oct. 18-20 in Nashville, Tenn., features multiple sessions focused on optimizing patient navigation services to improve the patient experience, and more. View the conference agenda.

Turning on the Light Switch

June is Cancer Immunotherapy Month, shining a spotlight on advancements in immuno-oncology. 2017 ACCC Institute for Clinical Immuno-Oncology Innovator Award winner Oncology Specialists S.C. at Advocate Lutheran General Hospital has been delivering immunotherapy for cancer for more than six years. For highlights on how they’ve developed their program and how “Turning on the Light Switch” helps their providers and patients talk about managing immune-related toxicities, read on.

by Ann McGreal, RHanging BulbsN

For more than 30 years the world of oncology nursing and the patients we care for has been bound by the expectations of the known effects of chemotherapy on the human body. While these toxicities can be difficult and, at times, even life threatening, for the most part they are predictable. As experienced oncology nurses, we know that after a certain number of days the patient blood counts will likely drop. Our patients being treated with chemotherapy anticipate that they may experience nausea, diarrhea, bone pain, and other side effects. For the most part, with chemotherapy we can expect a logical start, progression, and end to toxicities.

Immuno-Oncology Brings a Paradigm Shift
However, the new dawn of immuno-oncology and the rapidly increasing use of immunotherapy for cancer have upended not only our approach to supporting oncology patients, but also how we approach the toxicities of treatment.

Our practice, Oncology Specialists at Lutheran Advocate General Hospital, in Park Ridge, Illinois, has been on the cutting edge of using immunotherapy for melanoma treatments from the beginning. We were among the highest accrual sites for the original ipilimumab clinical trials. Then, in 2011, immunotherapy took its first big step into the limelight with the FDA approval of ipilimumab for the treatment of Stage IV melanoma. The demand on our clinic for ipilimumab increased greatly.

Initially, our practice was able to deal with the need to think about symptom management in a different way because we were caring for a small population of patients—all in the melanoma space. However, in 2014, with the dawn of PD-L1 checkpoint inhibitors that all began to change. Today, the potential for this class of drug seems unlimited, with more than 500 current studies underway in the U.S., and new indications and approvals occurring on what seems like a daily basis.

Educate. Educate. Educate.
As we implemented immunotherapy in our practice, our nursing team took on the challenge of how best to educate both staff and our patients on the mechanism of action for these new therapies, as well as their potential toxicities.

We quickly learned that peer-to-peer education was the most effective way to help our medical staff develop a better understanding of immunotherapy. We also found that the real challenge lay in accepting that immunotherapy for cancer requires a different way of looking at the total treatment picture. To implement this new treatment paradigm, we needed to better educate our patients so that they had a clear understanding of how immunotherapy differed from traditional chemotherapy and why early reporting of toxicities is so important. This meant we had break through long-held beliefs such as, “everyone gets sick during cancer treatment” and “I should just ‘tough it out’ or they will stop my therapy.” We needed our patients to understand that with immunotherapy just “tough it out” can be a deadly mindset. Patients on immunotherapy need to partner with their providers and report any toxicities early so that their healthcare team can work quickly to resolve the issue.

Flipping the Switch
With this need in mind, we created a set of education tools built around the analogy of the patient’s immune system functioning like a light switch. The immunotherapy treatment turns the switch on. If the treatment starts causing toxicities, the patient’s body cannot turn the switch off by itself. Unless the toxicities are reported, the affected system (the light) will burn out. Today, these education tools and discharge instructions are the backbone of our immunotherapy program.

Next Step: Incorporating into Our EMR
With our staff education and training on managing immune-related toxicities and patient education in place, we looked at processes to ensure cohesive documentation in our EMR so that an on-call physician or covering nurse could easily pick up the treatment thread and assist patients. This not only led to the development of templates but also a standardized treatment plan for immune-related toxicities, including the use of corticosteroids.

At the ACCC 34th National Oncology Conference in October, we’ll be presenting a more in-depth look at how we have developed and grown an immunotherapy program at our practice.  We hope you’ll join us in Nashville.
________________________________________________________________
Ann McGreal, RN, is an Oncology Nurse Clinician at Advocate Lutheran General Hospital in Park Ridge, Illinois.

Read more about upcoming ACCC 34th National Oncology Conference here.

ACA Repeal & Replace Update: Senate Republicans Put Their Cards on the Table

By Brittney Fairman, MA, MPS, Policy Analyst, ACCC

U.S. CapitolLast Thursday, June 22, Senate Republicans publicly unveiled their discussion draft legislation titled, the Better Care Reconciliation Act—their version of the House’s recently passed American Health Care Act (AHCA) (H.R. 1628). Neither bill was drafted under regular order, as Republicans try to maintain steam in pushing forward with the repeal and replacement of the Affordable Care Act (ACA). Unfortunately, for multiple stakeholders, including many of those within the cancer care community, it is questionable how much the Republican Caucus sought patient and provider feedback to incorporate into their bills.

Although there was much speculation that the Senate version of the AHCA would undergo an entire re-write, the legislation released last week represents more of a fine-tuning of the House AHCA bill. Much of the Senate draft’s language reflects that found within the AHCA. The Senate bill contains various tax cuts for mostly high-income Americans; maintains the elimination of the individual and employer mandates; proposes less generous premium subsidies for those with lower household incomes; holds onto the AHCA’s similarly deep cuts to the Medicaid program—phasing out the expansion over three years and transitioning to a capped financing structure which essentially re-shapes the program’s funding; changes state adjustment-of-age bands by allowing insurers to increase the ACA’s ratio from allowing insurers to charge up to three times more for older individuals to permitting insurers to charge up to five time more; and still allows states to apply for waivers to overhaul their insurance markets (including the option of ending the essential health benefit requirement and potentially reinstating annual and lifetime coverage gaps).

There are, however, several notable changes within the “draft” Better Care Reconciliation Act signaling some improvement from the House bill. This Senate version would require insurers to cover people with pre-existing conditions and ban them from charging higher premiums because of their health history. But there is a caveat—there would not be an essential health benefit (EHB) requirement. This means that insurers would be able to offer less comprehensive policies that may or may not cover a patient’s treatment for pre-existing condition(s). Additionally, for individuals with household incomes between 100 percent and 200 percent of the federal poverty (FPL), authorized funding for cost-sharing reductions (CSR) payments would continue until 2020.

On Monday, June 26, the nonpartisan Congressional Budget Office (CBO) released a CBO score for the Senate legislation that finds the bill would result in 22 million more uninsured Americans by 2026, relative to the number under current law. This is slightly fewer than the increase in the number of uninsured estimated for the House-passed AHCA legislation.  According to the CBO score under the Better Care Reconciliation Act, by 2026 an estimated 49 million people will be uninsured, compared to the 28 million who will be uninsured that year under the current law.

A vote on the Senate bill is expected this week, leaving Senators with a relatively short window for reviewing the bill and also leaving stakeholders limited time to weigh in on the bill’s negative consequences for healthcare.

In a statement, the Association of Community Cancer Centers (ACCC) has expressed deep disappointment in the Senate’s draft legislation both in terms of policy and process, noting that the bill violates ACCC’s health reform principles.  ACCC believes this bill would be devastating for cancer patients and their families, and urges lawmakers to vote against the Better Care Reconciliation Act of 2017.  ACCC members can contact their Senators here.


Editor’s note: This post was updated on 6/26/17 to reflect release of the CBO score for the Better Care Reconciliation Act of 2017.

Navigation Caseload Quandary?

Learn about 2017 ACCC Innovator Award winner USA Mitchell Cancer Institute’s homegrown Oncology Navigation Acuity Tool.

By Rev. Diane Baldwin, RN, OCN, CBCN, and Meredith Jones, MS, BSN, RN

FinalSealUnfortunately, nurse navigation services are typically non-revenue generating, necessitating a cost/benefit evaluation of these services for many programs. To justify nurse navigation in this new era of value-based care, we must define appropriate caseload volumes through risk stratification, and determine how best to allocate nurse navigation time and resources among those caseloads.

How Best to Measure & Define Acuity?
Acuity tools have been used in healthcare for decades and have proven successful as a means of determining staffing needs, improving patient care, and controlling costs.  Most acuity tools score patients on a scale of specific attributes. For nurse navigation programs, an acuity tool can be used to determine caseloads and aid in more efficient nurse navigator caseload management.

At USA Mitchell Cancer Institute, our nurse navigators, known as Clinical Care Coordinators, maintain a caseload of approximately 175 patients. However, as we identified more patients needing navigation services, we recognized the need for an acuity tool specifically for caseload management.

As we researched acuity tools, we found limited options related to oncology nurse navigation. Each of the tools we identified was specific to a facility, and was either used to determine overall staffing or focused specifically on the amount of time spent with patients.  We believed that a more generalized tool, including more patient factors, was needed to accurately determine patient acuity. Therefore, the USA Mitchell Cancer Institute began developing an Oncology Navigation Acuity Tool, universally designed to benefit our practice, while also allowing for use and adaptation by other cancer programs.

More Than Just a Number
USA Mitchell Cancer Institute’s goal was to develop a tool that measures a patient’s acuity through a holistic lens. As cancer care providers know, each patient’s navigation needs depend on a variety of factors. Our Oncology Navigation Acuity Tool considers 11 factors that we identified as directly correlating with patient resource utilization and, therefore, acuity level.  Each factor is reviewed individually to determine the acuity score, placing less emphasis on cancer type and stage, and more emphasis on overall patient context. For example, two patients with the same type and stage of cancer, receiving the same treatment, may present with different comorbidities and levels of family support, resulting in two very different acuity scores.

An inherit weakness in most acuity tools is that the “score” assigned to the patient determines overall acuity. However, we know that our patients are more than just a number.  Standardized tools often fail to identify important elements needed to address individual patient needs. Therefore, our Oncology Navigation Acuity Tool includes a 12th factor in determining a patient’s acuity: The clinical assessment of the nurse navigator.  This factor is essential to assessing the “whole patient” and our aim of providing holistic care.  Our nurse navigators use the 11 factors of Oncology Navigation Acuity Tool as a guide to assess the acuity of the patient and combine this with their overall clinical assessment, for a final acuity score.  Ultimately, our nurse navigators, may elect to change the acuity level based on their assessment of the individual patient.

Putting the Tool to Work
The Oncology Navigation Acuity Tool allows us to easily assess the needs of each navigated patient prior to caseload allocation and to quickly determine the level of navigation the patient will need. The tool has also guided managerial decisions to adjust caseloads based on acuity rather than patient count alone.  Further, we’ve utilized this tool for both quality and process improvement to study the varied needs of patients among the acuity levels, and to determine the effect of accurately navigated patients on system utilization and cost.

In our presentation at the ACCC 34th National Oncology Conference, October 18-20, in Nashville, TN, we’ll share more on how using this low-cost, simple to implement tool has resulted not only in a cost-effective, efficient means of refining navigation utilization, but also in the delivery of more personalized, comprehensive, improved quality of care for our navigated patients.

We look forward to seeing you in Nashville!


Rev. Diane Baldwin, RN, OCN, CBCN, is Manager, Quality Assurance, and Meredith Jones, MS, BSN, RN, is Director, Quality Management, at the USA Mitchell Cancer Institute.  

From ASCO to ICLIO to Your Program—Immunotherapy Moves into the Community

By Amanda Patton, ACCC Communications

Once again immuno-oncology (I-O) was center stage at this year’s American Society of Clinical Oncology (ASCO) Annual Meeting (June 2-6, 2017) where more than 250 presentations featured checkpoint inhibitors. Currently, six immune checkpoint inhibitors have received FDA approval for more than nine cancers, with more than 1,000 studies in progress.

On June 2 at ASCO, two pre-eminent immunotherapy investigators provided perspective on the rapidly evolving immuno-oncology landscape with a look back and a look to the future.  During their presentation, “On the Shoulders of Giants: Historical Approaches to Immunotherapy in Solid Tumors,” James P. Allison, PhD, of The University of Texas MD Anderson Cancer Center, and Suzanne L. Topalian, MD, of the Bloomberg-Kimmel Institute for Cancer Immunotherapy, touched on some of the critical challenges the oncology community faces with these new and emerging therapies, including:

  • How to deal with the flood of information from clinical studies
  • The need to better understand the biologic processes underpinning of side effects of these new therapies
  • The imperative to identify biomarkers.

Read highlights from their presentation in this ASCO Daily News article.

ICLIO’s Evolving Role—Supporting Integration of I-O into Practice
Just as insights from ASCO 2017 will continue to ripple throughout the broader cancer community for weeks and months to come; the wave of new approvals and indications in immuno-oncology will continue to spread from academic settings into community programs and practices, where it is estimated that 85% of the nation’s cancer care is delivered.

Since its inception more than two years ago, the ongoing mission of ACCC’s Institute for Clinical Immuno-Oncology (ICLIO) is to create education, resources, and tools that provide practical, real-world support for multidisciplinary team members engaged in bringing immunotherapy to patients in their communities. Hear about ICLIO’s growth and latest initiatives in this ASCO Post interview with ICLIO Advisory Committee Chair Lee Schwartzberg, MD, FACP, Chief, Division of Hematology Oncology; Professor of Medicine, The University of Tennessee; The West Clinic, PC.

ICLIO In the Community
In 2017, ICLIO launched two exciting new programs—ICLIO Visiting Experts and Case Studies in Immuno-Oncology—that bring clinicians with immunotherapy expertise out to providers in the community.

“It’s an area that ICLIO is spearheading,” said ICLIO Visiting Expert Jarushka Naidoo, MBBCh, Assistant Professor of Oncology at Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University and Bloomberg-Kimmel Institute for Cancer Immunotherapy.  With the ICLIO Visiting Experts program, “Investigators such as myself who are particularly interested in immunotherapy can actually go to community providers and give our hands-on experience of how we give these agents, what are the common side effects that we see, and what are some of the ways we’ve gotten around some of those particular considerations. We’re able to interact with the workshop participants one-on-one and talk about specific cases they’ve managed, some challenges they’ve had, and how we might have dealt with that from an academic perspective.”

Learn more in this Hem/Onc Today interview with Dr. Naidoo:

For the just-launched Case Studies in Immuno-Oncology, an ICLIO faculty member will travel to an ACCC-member program for a 60-minute case-based tumor board discussion on immunotherapy treatment decision-making and the management of associated immune-related adverse events. Learn more and apply.

Immuno-Oncology Advances from ASCO 2017
Access top-level takeaways on advances in immunotherapy for cancer from the ASCO 2017 Annual Meeting in this  ICLIO webinar presented by Lee Schwartzberg, MD, FACP.  View webinar.

View all ICLIO has to offer by visiting accc-iclio.org.


Editor’s note: This post was updated on 6/28/17.

Desperately Seeking Oncology Nurses?

Stressed by nurse staffing shortages? Learn how 2017 ACCC Innovator Award winner Loma Linda University Cancer Center tackled this challenge.

By Lexine Thall, MN, RN-BC, AOCN, and Kristina Chase, BSN, RN, OCN

FinalSeal

One of the most challenging issues in healthcare is the ongoing balancing act of staffing and retention. For specialty areas, such as oncology, staffing presents an even more difficult challenge. Finding those perfectly qualified individuals with all the right experience to fill open positions can be a taxing, time-consuming task. As a result, cancer programs may find themselves dealing with lengthy vacancies, which can cause some real strains on a growing clinic and may led to an unhappy environment for nurses and patients. When our cancer program encountered this understaffing dilemma, chemotherapy skilled and oncology experienced (CS-OE) RNs in our cancer center began facing increased workloads, which put them at risk for potential burn out, being vulnerable to making errors, and causing longer wait times for patients.

Our cancer program leadership team had to think outside of the box and create a road map to alleviate some of these staffing strains. An analysis of appointment types and RN skill level needed for each visit type revealed that 40 percent of our supportive care therapies (e.g., hydration, blood transfusions) did not require a CS-OE RN. Given this information, we decided to pilot a program that would fill RN vacancies with experienced non-oncology nurses and create a pathway for these RNs to attain the ONS Chemotherapy/ONCC Chemotherapy Biotherapy Certificate. Our aim was to provide a mentorship program in conjunction with vetted education tools to develop these RNs professionally and alleviate our staffing crisis. The pilot program launched in 2014, and to date, 17 nurses have been accepted into the mentoring program. All RNs who opted to pursue the ONS/ONCC Chemotherapy Biotherapy Certificate (7 of 7) have attained their goal and 86 percent (6 of 7) of the RNs who attained this certification have remained with our organization.

Our mentorship program has drastically decreased the length of time we have unfilled RN positions posted—from an average of 113 days down to 29 days. It has also given many nurses an opportunity to gain focused experience in a specialty area for which many employers may not be willing to bear the educational costs. In addition to the benefit for the non-oncology nurse, the program has provided professional satisfaction and role expansion for the CS-OE RN mentors. A win-win for all parties involved.

At the ACCC 34th National Oncology Conference, October 18-20, 2017, in Nashville, TN, we’ll be sharing the details of our mentorship journey, “how to’s” for developing a program like ours, and some lessons we’ve learned along the way.  I hope you can join us in Nashville!

Hear more from all the 2017 ACCC Innovator Award winners at the ACCC 34th National Oncology Conference, Oct. 18-20, 2017, in Nashville, TN. Learn more.


Lexine Thall, MN, RN-BC, AOCN, is Director, Patient Care, Loma Linda University Cancer Center; Medical Oncology/Hematology; Women’s Cancer/Surgical Oncology; and Kristina Chase, BSN, RN, OCN, is Patient Care Supervisor.

The Journey to EHR Optimization

Second in a two-part series from ACCC’s Optimizing Electronic Health Records project. Read part one.

By Joseph Kim, MD, MPH, MBA

While the vast majority of oncology clinicians use an Electronic Health Record (EHR) today, many continue to struggle with poor usability and increased workloads. Recognizing the needs in the community, the ACCC Optimizing Electronic Health Records (EHRs) education initiative aims to identify practical solutions and effective practices to help cancer programs navigate their ongoing journey with EHRs.

ACCC convened two focus groups for this project bringing together a diverse group of stakeholders to talk frankly about how their cancer programs are overcoming some of the common EHR challenges that hinder provider efficacy.  Four key themes emerged during these conversations, read on.

Coordination of EHRs Across Multiple Locations
Given that some cancer programs span multiple locations that offer different services, it remains critical for all the sites to share patient information effectively. However, even when the sites are all using the same EHR, flawless interoperability is not guaranteed since some hospitals may be running different versions of the same system.  As a result, clinicians who work at multiple locations may need to get accustomed to different screen layouts when they log in, or they may have access to different functionalities based on the customizations that exist at each local site. Moreover, the use of certain add-on modules (e.g., Epic Beacon module for medical oncology) may not be consistent across the health system. Ample opportunities remain to standardize the digital workflow across health systems so that clinicians can work more efficiently.

Another common barrier in the community is the lack of interoperability across the systems used by medical oncology, radiation oncology, pathology, radiology, and the hospital. While some health systems are consolidating to a single EHR system across all those departments and services, many still run into challenges with read-only access versus the need to log in to different computers to access patient records. While establishing local interoperability within the same health system remains an ongoing journey, some regions are also actively leveraging solutions offered by the Carequality Interoperability Framework or the CommonWell Health Alliance to achieve interoperability more rapidly.

Data and Reporting
When clinicians switch to a new EHR system, data migration is one of the biggest time-consuming tasks because of the complexity of mapping all the structured data fields from one system to the next. Cancer programs with access to a dedicated informatics specialist can make customizations and run reports with greater ease. Since oncology is changing at a faster pace than any other medical specialty, cancer programs with access to the necessary IT resources are having an easier time offering new therapies and monitoring patients effectively.

While the cancer registry is usually its own separate system, registrars may provide valuable feedback about data fields and automated reports. Cancer programs participating in programs like the ASCO Quality Oncology Practice Initiative (QOPI) or the CMS Oncology Care Model (OCM) have made considerable investments to generate ongoing reports from their EHRs, so other cancer programs may learn from those experiences and adopt similar approaches within their own institutions.

Building Order Sets
By now, most cancer programs have an established process for creating new electronic order sets and treatment plans for new drugs and therapies. They may have a core multidisciplinary team that meets to create and test new treatment protocols. An oncology pharmacist is an essential member of that team, providing guidance around drug dosing and safety alert parameters. Nurses can also provide important input regarding clinical documentation around safety monitoring. Since order sets for oral oncolytic agents need to be linked between the medical oncology EHR and the pharmacy systems, it remains critical to map how orders are transmitted to different specialty pharmacies that dispense those medications. In some cases where those systems are not integrated, redundant workarounds may be required for the e-prescribing of oral agents.

Superusers
Superusers may either be formally designated or informally recognized as tech-savvy clinicians who are willing to play a greater role to help their colleagues and peers use EHRs more effectively. In some cases, superusers may carry over from a recent implementation of a new system. It’s important for cancer programs to maintain and foster a group of superusers who can lead the development of new order sets, help to train new users, and provide input on new releases or customizations to the system. Some cancer programs invest in their superusers by sending them to annual corporate training events so that they can also learn how other health systems are tackling common problems and issues. Be sure to give recognition to the superusers because some may take on more formal roles such as Director of Informatics or Medical information Officer.

Look for more insights from the ACCC Optimizing Electronic Health Records initiative in the coming months.


Guest blogger Joseph Kim, MD, MPH, MBA, is serving as a consultant for the ACCC Optimizing Electronic Health Records (EHRs) initiative.  Dr. Kim is President of Xaf Solutions.

Challenges to EHR Optimization for Cancer Programs—Workload, Cost, and Interoperability

By Joseph Kim, MD, MPH, MBA

While electronic health records (EHRs) remain a necessary component of care delivery, in a recent survey of ACCC Cancer Program members, 62% of respondents report that EHRs have increased the workload of their staff and 51% indicate that their EHR system has increased their total operating costs. Only 34% of respondents said that both medical and radiation oncology practices can interface with the hospital system. And about one-quarter (27%) report that neither medical nor radiation oncology practices can interface with the hospital system.

The survey was conducted for the ACCC Optimizing Electronic Health Records (EHRs) education initiative, which aims to help cancer programs identify ways to optimize their EHRs to meet the growing demands for accurate, integrated, comprehensive data capture and analysis.

ACCC conducted the survey (n=98) in early 2017 to assess members’ experience with their EHRs; 70% of respondents represented community cancer programs, 17% were from academic programs or NCI-designated cancer centers, and 11% were from outpatient oncology practices.

Among survey respondents the most common EHR systems in use were Epic and Cerner.

  • 47% have been using their current EHR system for more than 5 years.
  • 26% are actively switching to a different EHR system (either to Epic or Cerner).
  • The most common reasons for switching:
    ♦ To standardize EHR use across the entire health system
    ♦ To Increase data extraction and reporting capabilities.

While some EHR systems come with optional packages and add-on modules, others require their users to install third-party software.  According to survey responses, the most common add-on software packages are currently being used for:

  • Billing and coding
  • Survivorship care plans
  • Patient engagement and communication via patient portals.

In the current landscape, interoperability even within the same system remains a significant challenge. Specifically:

  • Only 34% of respondents indicate that both medical and radiation oncology practices can interface with the hospital system.
    ♦ 22% indicate that only medical oncology interfaces with the hospital system.
    ♦ 9% indicate that only radiation oncology interfaces with the hospital system.
  • 27% report that neither medical nor radiation oncology practices can interface with the hospital system.

The survey also asked respondents to rate different usability factors. Those receiving the highest ratings (i.e., most usable) were:

  • Entering patient information
  • Searching for medical information about a patient
  • Interfacing with the patient portal

The usability factors with the lowest ratings (i.e., least usable) were:

  • Ability to incorporate third party add-on modules
  • Customer service provided by EHR vendor
  • Making customizations within the EHR

Cancer programs rely heavily on their designated superusers, who often train new users, to provide recommendations or test new releases. Responses in several survey areas indicate that the increased use of scribes (also called clinical documentation specialists) may be a growing trend, especially for certain providers who may benefit substantially in their ability to see more patients.

Through this project, ACCC will be identifying real-world examples of how community cancer programs are optimizing their use of EHRs. Stay tuned for more project updates here.

Coming next, see what a focus group of ACCC members reveals about real-world challenges to EHR optimization.


Guest blogger Joseph Kim, MD, MPH, MBA, is serving as a consultant for the ACCC Optimizing Electronic Health Records (EHRs) initiative.  Dr. Kim is President of Xaf Solutions.

Creating a Caregiver Toolkit: 24 Tips for Caregivers

This is the final post in a two-part series on creating a toolkit for caregivers.

By Tricia Strusowski, MS, RN

Hands offering supportA recent symposium on Palliative Care in Oncology also called attention to the importance of ensuring that the needs of cancer patients’ caregivers are recognized. “Despite providing essential home and healthcare services, cancer caregivers are underserved and undervalued while facing a multitude of unmet needs,” said J. Nicholas Dionne-Odom, PhD, RN, ACHPN, of the University of Alabama at Birmingham School of Nursing. “There are 2.8 million cancer caregivers performing a variety of invaluable and time-consuming tasks that can take a marked toll on their physical and mental health.”1  Caregivers are tasked with daily activities in the home and at work, potentially child/elder care, appointments, transportation, medication administration, meals, and medical procedures needed by the patient just to name a few.  We need to ensure that we are discussing the needs of the caregiver, as well as those of the patient, on a routine basis.

As navigators, we can provide education information for caregivers, support groups, or educational programs.  Make the caregiver a high priority in your navigation program.

Here are 24 practical tips that patient navigators can share with caregivers to help them through the process.

  1.  Give yourself and your loved one time to adjust to the diagnosis.
  2.  A positive attitude is beneficial for you and your loved one.
  3.  Giving care to a loved one with cancer requires patience, flexibility, courage and a good  sense of humor.
  4.  Good communication is essential to learning how to best work with your loved one.
  5.  Plan special times together away from the routine of treatment, such as a special evening  out for dinner, a movie or play, etc.
  6.  Talk about the future.  Hope is very important.
  7.  Being a caregiver can reveal hidden strengths and enrich your family life.
  8.  As a caregiver, you can choose to take the primary caregiver role or, depending on the level  of support from family and friends, divide it between two or more persons.
  9.  Being a caregiver can affect you emotionally, physically, and financially. For guidance, speak  with your cancer program’s social worker.
  10.  To better understand your loved one’s diagnosis, treatment and progress, be an active  participant during clinic visits.
  11.  Stay organized (e.g., use a journal or notebook during your loved one’s appointments).
  12.  Encourage your loved one to engage as much as possible in normal daily activities.
  13.  Give yourself permission to feel emotions about your loved one’s situation, and confide in a  friend or counselor who can provide insight and support.
  14.  Set up a list of activities that your family or friends can sign up to do weekly or monthly.
  15.  To help reduce your stress, make time for regular exercise, meditation, or some other form  of relaxation.
  16.  If care is long-term, arrange for extended periods of relief (e.g., take a vacation).
  17.  Attempt to maintain as much of your routine as possible, but recognize that you may need  to alter some of your daily activities if you are the primary caregiver.
  18.  Take advantage of caregiver support groups and credible websites for resources and  support.
  19.  Taking care of YOU is important too. Get adequate rest and nutrition, and take time for  personal care.
  20.  Select funny movies to watch together. Good humor is healthy for the body and soul.
  21.  Allow yourself private time to do nothing, or something important to you.
  22.  Spiritual support through prayer or the guidance of a spiritual leader can be good  medicine.
  23.  Designate a family member or friend who can help field phone calls regarding your loved  one’s progress.
  24.  If you have children in the home, assign them age-appropriate tasks to accommodate the  necessary changes in the household routines.

Source:  http://cancer.ucsd.edu/coping/resources-education/Pages/patient-tips.aspx
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1 Doyle C. Palliative care for caregivers: Implementing caregiver support programs. Oncol Pharm. November 2016;(9)6. Available online at http://theoncologypharmacist.com/ton-issue-archive/2016-issues/november-vol-9-no-6/16928-palliative-care-for-caregivers-implementing-

Other Caregiver Resources are available from:
American Cancer Society
National Cancer Institute

ACCC member Tricia Strusowski, MS, RN, is a consultant with Oncology Solutions, LLC.