Tag Archives: care coordination

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.

Patient Navigation: Creating a Toolkit for Caregivers

The first post in a two-part blog series focused on support for caregivers.

by Tricia Strusowski, MS, RN

Two hands offering support

Several years ago, I facilitated a Patient and Family Advisory Council at our cancer center.  Our patients and families provided us with great insight on our program and helped us create our yearly goals.  On one occasion, one of our family members said, “Hey, what about us? The patients get these great journals, but we need resources too.”  This became our next project.  Two important takeaways from our experience:

  • Don’t Reinvent the Wheel: In creating a toolkit for caregivers, first keep in mind that there are excellent caregiver resources available through national organizations, so there is no reason to reinvent the wheel.
  • Be Concise: Keep your information short, educational, and practical. Our advisory council and countless focus group participants at many cancer programs have said, “Don’t give us so much information! If I get too much, I don’t read anything.”

For navigators interested in putting together a caregiver toolkit, read on for some basic but very good information to share with caregivers.

Remind caregivers that “the care you give yourself is the care you give to your loved one.” The stress of caregiving can take an emotional and physical toll. Caring for someone you love with cancer is undoubtedly difficult. The stress of caregiving can often manifest itself both emotionally and physically.  While caregiving is a rewarding experience that can strengthen the bond between you and your loved one, 60 percent of caregivers report symptoms of depression and other painful signs of strain.

Physical effects of caregiving can include:

  • Sleep disturbances
  • Weight fluctuation
  • Fatigue
  • Stomach/digestive problems (cramping, constipation, gas, heartburn, etc.)
  • Headache
  • Weakened immune system
  • Skin changes

Emotional effects of caregiving can include:

  • Depression
  • Anxiety
  • Feeling of isolation
  • Withdrawal
  • Substance abuse
  • Mood swings/irritability
  • Lack of concentration/memory

While your main concern is surely that of your loved one, it’s vital to care for yourself as well during this difficult time. If you experience any of the symptoms listed above, contact your physician and ask what your healthcare provider suggests. Fatigue is usually the first and most common complaint of caregivers, so ask your doctor about effective ways to manage your fatigue.

Encourage caregivers to ask for help. Provide some practical tips, such as the following:

  • You may have had offers of help with everyday tasks such as running errands, getting groceries, making a meal, taking your loved one somewhere, etc.  At first, most people are reluctant to accept these offers. Consider that friends, family, and neighbors really want to help. People will often say, “If there is anything I can do, let me know.” Take advantage of the offer!
  • When asking someone for help, you may want to go over a list of things you need assistance with, letting them choose what they’d like to help with.
  • Some people report being the sole caregiver serves to increase stress and may cause tension within the family. One caregiver’s solution to this problem was to create a weekly calendar where family members could record the tasks they performed for their mother with cancer. This way, tasks could be spread out evenly among her children.

Offer some coping strategies for the caregiver, including:

Set Boundaries. Primary caregivers tend to absorb the entire caregiving role. Care recipients often go along with this, preferring the care of the primary caregiver to that of a less familiar family member or a stranger.  You cannot do everything; set limits on what you can do yourself and what tasks can be delegated to others.

List things you need for self-care. Make a list of activities that will provide a pampering break from your caregiver responsibilities. Give your morale a boost by such activities as taking a hot bath, exercise, going out for a meal, or reading a book.  Post this list as a reminder to yourself and others in the household.

Plan for respite care. Obtaining those short breaks for self-care requires a plan for others to care for your loved one. Your plan should include the type of care required, hints/suggestions on giving the care so that routines are not severely altered. The plan should also include how often and for how long a time period the respite caregiver will be used.

Make time for laughter. A funny movie, a visit from a fun-loving friend, reading a book authored by a humorist, sharing a good joke can really help lighten things up. Humor helps keep frustration in perspective and minimize anger.

Keep in touch with friends. When caring for a loved one, the primary caregiver’s social life is often the first thing to go. You may think you do not have either the time or energy for keeping up with friends; however, it’s been shown that caregivers who remain socially active experience less depression and physical illnesses. Socially active caregivers are less overwhelmed by the responsibilities than their counterparts who turn down social invitations and lose contact with friends.

Shift gears. When you begin to feel rushed, you need to slow down. Researchers have found that hurrying often actually slows down caregiving activities. For example, rushing can led to delays caused by dropping items, spilling liquids, and misplacing keys, just to name a few. Try to slow down during caregiving and take time to relax throughout the day.

Keep it in perspective. Take time to read the morning paper or listen to the news. Staying abreast of what is happening in your community and the world helps put your problems in perspective. If the major topics of conversation in the house are focused on the health and care of your loved one, plan to set time aside when the conversation centers on some other topics. Mealtime is a time when this works well. Everyone participating in the meal can agree in advance to discuss other topics.

Plan for occasional indulgences and rewards. We all need some occasional pampering to maintain both physical and mental health.  Take time for your favorite snack, listen to music, or just take some “alone time” and enjoy whatever makes you smile.

Join support groups.  Members of a support group offer you understanding at a level others cannot because they are going through a similar experience.  They have real-life experiences to share including tips on how to cope.

Source: Caring to Help Others, A Training Manual for Preparing Volunteers to Assist Caregivers of Older Adults, 2000.


Stay tuned for Part Two: 25 Tips for Caregivers.

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

How Navigation Can Help in Decreasing Readmission Rates and ER Visits

By Tricia Strusowski MS, RN

Patient Navigation Healthcare CompassFACT #1: The last place that cancer patients and their family want to be is in the hospital. Hospital stays also increase the chances of hospital-acquired infections, which can result in a longer length of stay and complications.

FACT #2: Patients and family members do not feel well equipped upon discharge from the hospital, especially when it comes to how to handle procedures at home such as dressing changes, central lines, injections, and drains, just to name a few. Medications can also be very confusing, in particular when there have been changes—adding or removing medications, and/or dosage changes.

How can a nurse navigator help? Let’s start by reviewing the roles and responsibilities of the navigator, which often encompass the following:

  • Coordinate the care of the patient and family from pre-diagnosis through survivorship or end-of-life services, removing barriers across the continuum
  • Provide education and access to clinical trials, utilizing proper health literacy techniques
  • Improve patient outcomes through education, psychosocial support, and performance improvement monitoring
  • Collaborate and facilitate communication between patients, family members/ caregivers,
    and the healthcare team
  • Coordinate care across the continuum with the healthcare team
  • Provide cancer program and community resources, and follow-up
  • Participate in multidisciplinary clinics, tumor conferences, and cancer committee, functioning in the role of patient and family advocate

Given these responsibilities, how can nurse navigators help keep our patients out of the hospital?
First, we need to listen to our patients and their caregivers, and we need to share their story with the entire healthcare team. What are their specific concerns and educational needs? Keep in mind that these may have little or nothing to do with their diagnosis or plan of care. A comprehensive assessment of needs is essential for patients and caregivers to become empowered and successful during cancer treatment and to prevent avoidable admissions and ER visits.

Here are helpful tips for navigators to understand and meet these needs:

Patient and Caregiver Education

  • Discuss the preferred learning style of the patient and caregiver during the intake process
  • Create a disease-site-specific patient appointment checklist that includes information on why their appointments are important
  • Use decision-aid tools to empower the patient and caregiver with the appropriate questions to ask their providers and healthcare team
  • Proactively screen your patients for specific support service needs, e.g., dietitian, social worker, etc.
  • Provide safety tips for the home environment or have a home assessment completed
  • Use the same educational materials across the care continuum to decrease confusion for the patient and family
  • Teach patients/caregivers about reportable side effects and adverse reactions and when to call the physician
  • Provide support, resources and guidance for the caregiver as well as the patient
  • Increase contacts/calls with high-risk patients, our “frequent flyers”
  • Use home care resources to educate patients and their family on new procedures or information on their diagnosis and treatment as outlined by their provider
  • Provide community resources for the elderly and disparate population to set them up to succeed at home, e.g., Meals on Wheels, transportation services, child/elder care, etc.

 Clinician Education

  • Provide staff with health literacy training including “teach back” methods for educating patients (for example, the “Ask, Tell, Ask” method outlined in the Institute of Medicine report, Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis)
  • Provide medication reconciliation list/guidance and have patients explain their medications and fill their medication planner
  • Incorporate morning reports for the support staff to proactively identify patient needs and the need for phone calls to patients from the appropriate disciplines
  • Initiate early referrals to palliative care for education and symptom management
  • Initiate early goals of care and advance directives discussions
  • Incorporate rounding with inpatient multidisciplinary staff to discuss discharge disposition, barriers to care, length of stay (LOS), discharge delays, carve-out days, and follow-up calls for 24-48 hours after discharge
  • Monitor the patient’s treatment based on national standards and guidelines
  • Create disease-site standing order sets, physician profiles, pathways, and guidelines with timelines when appropriate
  • Research opportunities for creating an oncology medical home or oncology ER/urgent care triage process with protocols
  • Develop plan for avoidable ER visits, i.e., constipation, nausea/vomiting/diarrhea, pain and symptom management, etc.
  • Provide assistance with depression screening (beyond NCCN psychosocial distress screening)

To measure progress, what reports and metrics would be helpful?

  • Request 30-, 60-, 90-day readmission report with reason for admission/chief complaint
  • Request ER visit report for chief complaint
  • Monitor timeliness of appointments, tests, and procedures
  • Review with patients reasons for any missed appointment and assist in resolving issues
  • Create performance improvement projects and metrics to support decreasing readmissions and avoidable ER visits

Discuss and prioritize these ideas with your multidisciplinary team and watch your avoidable admissions and ER visits decline.

Of note: Many of the above examples also align perfectly with the Oncology Care Model (OCM) practice redesign approach, value-based cancer care, and oncology medical home initiatives. Partner with your navigator as healthcare transitions to patient-centered, value-based delivery models.


Contributing blogger ACCC Member Tricia Strusowski, MS, RN, is a consultant with Oncology Solutions, LLC.

Bridging the Gap and Improving Outcomes

By Susan van der Sommen, MHA, CMPE, FACHE

ThinkstockPhotos-507273299Healthcare is becoming increasingly complex. With emerging payment models, regulatory initiatives, HCAHPS, and the complexity of electronic health records (many of which don’t communicate with each other), the concept of patient care has changed. How often have patients expressed dismay that their care provider seem more focused on the computer screen than on their needs and concerns? The endless entry of data, best practice alerts, and hard stops that are intended to streamline and improve care have unintentionally added complexity. In fairness to the evolving nature of electronic health records (EHRs), they have added benefits, too. They cannot, however, replace the value of human interaction.

In the November/December 2016 Oncology Issues, Connie Savage shares how Cancer & Hematology Centers of Western Michigan was able to address a complex issue that cannot be effectively resolved through a high-tech initiative—the transition of care from the inpatient to the outpatient setting. In today’s healthcare environment it is challenging to add positions that are not either revenue-generating and/or required by a regulatory agency or credentialing body. Yet the team at Cancer & Hematology Centers of Western Michigan was able to build a case to hire an inpatient coordinator who is charged with improving patient, provider, and family satisfaction and provider efficiency while reducing no-shows, hospital length of stay (LOS), and avoidable readmissions. At this program, the inpatient coordinator serves in a role similar to a patient concierge—gathering and sharing pertinent information, establishing patient and provider expectations, and arranging appointments—ensuring that the patient’s experience and transition to the home and/or outpatient setting is comprehensive and seamless. The return on investment is clear: improved patient and provider satisfaction, a streamlined discharge process, a reduction in length of stay (LOS), and a decline in avoidable admissions and readmissions. These outcomes align well with evolving payment models including, but not limited to, CMMI’s Oncology Care Model. It is likely that Connie and her team rely heavily on their EHR; however, they have proven that a technology-driven solution can never replace a caring human touch.


The story behind the story. ACCC member Connie Savage shared her role as inpatient coordinator at the 2015 ACCC National Oncology Conference New Member Meet & Greet in Portland, Oregon. Our ACCC editorial team heard her story and encouraged her to contribute an article to ACCC’s journal, Oncology Issues. Connie also agreed to share her program’s pioneering approach to patient care by presenting a poster at the recent ACCC 33rd National Oncology Conference in St. Louis. Connie’s story is great example of how our member programs are able to showcase their work on a national scale and share their “how-to’s” with other ACCC-member cancer programs. We are grateful to Connie and all our members who take the time to share their innovative approaches to success and ultimately improve care for our patients.

Contributing blogger Susan van der Sommen, MHA, CMPE, FACHE, is Executive Director, DSRIP, Bassett Healthcare Network, and Chair of the ACCC Editorial Committee.

Patient Navigation—Process Mapping by Disease Site

By Tricia Strusowski, MS, RN

ThinkstockPhotos-467463476For this patient navigation blog post, let’s talk about a recent hot topic on ACCCExchange, the online discussion forum for ACCC members: At what point in the care continuum do you initiate navigation and support services?

Many cancer programs have a difficult time identifying when to initiate these services. Cancer programs know that staff are duplicating services, but they don’t want anything to fall through the cracks for patients and their families. At busy cancer programs, staff may be challenged to find the time to sit down and work out these details. Plus, getting all the healthcare professionals together for one more meeting can be a daunting task. Cancer programs want to provide the best experience for their patients while utilizing staff efficiently. One way to support this goal is by involved the entire team in creating a disease-site-specific process map to review the continuum of care; discuss staff roles and responsibilities; identify gaps, barriers, opportunities for improvement; and goals of care—all with the patient at the center of the discussion. Simply put: Increasing communication among the team and decreasing duplication for the patient.

Who Should Participate?

Ideally, the team participating in the disease-site mapping process should be representative of the offices and departments that will touch the patient during his or her journey. Keep in mind: You need to include the “worker bees,” the staff who really know the details of the patient flow. Let’s consider a head and neck cancer patient for example. In this instance, the following individuals should be invited to participate:

  • Surgery
  • Medical oncology
  • Radiation oncology
  • Inpatient unit case manager and/or discharge planner
  • Speech/swallowing therapist
  • Navigator
  • Social worker
  • Financial counselor
  • Behavioral health
  • Rehabilitation/Prehabilitation
  • Dental office
  • Others (We all know there is always someone we forget to invite!)

Plan your first session for 1.5 to 2 hours. Admittedly, this may be a challenge to schedule but it can be done, and the results will be amazing. Utilizing a large paper flowchart (i.e.,15 feet long x 4 feet wide), the group needs to talk through and record the process starting at the patient’s earliest point of entry. Each detail must be discussed, including length of time from one episode of care to the next, delays, gaps, and opportunities for improvement. Encourage participants share their goals during the discussion and write everything down!

Revisit & Revise

Process mapping exercises are not a one-and-done experience. It takes several meetings to review and revise the process map. There may be key individuals or a process that are missed in a previous session; no big deal, add them to the group. A great facilitator is key to keep the team on task and keep the discussion moving.

After the entire disease-site process is complete, overlay when you would like the navigator and the support staff to intervene. Remember: the goal is to provide the intervention as soon as possible, hopefully in a proactive manner so that you are “staying one step ahead of the patient.” Incorporate when you would like to initiate the distress screening process, identifying periods of highest distress for the patient/family.

The draft process map is also an excellent tool to share with the disease-site-specific healthcare providers who are often are not aware of all the details, delays, and opportunities to enhance the patient experience. Further, your process map will also be excellent tool for on-boarding new staff and for succession planning. Review and update your process map on a bi-yearly or annual basis.

 Go Team!

I always share that the disease-site-specific team is like a football team; the better all the players understand everyone’s role and how to best support the patient and each other, the stronger the team will be. Every team always wants what is best for the patient. The mapping process is a valuable approach to not just identify gaps or delays in the care continuum, but to also then go the extra mile to identify “what is best for the patient.”

Work smarter not harder; teamwork makes the dream work!

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Guest blogger Tricia Strusowski, MS, RN, is a consultant with Oncology Solutions, LLC.