Measurement and Collection of AONN+ Metrics Within an Automated Tumor Board Workflow
Lijo Simpson, MD; Journal of Oncology Navigation and Survivorship
February 27, 2019
Background: The tumor board is the foundation of high-value multidisciplinary oncology care through coordinating teams of specialists. The nurse navigator is often a central hub of tumor boards, with responsibilities involving determining which cases are to be presented, collating patient data, organizing radiology and pathology, conducting conferences, and working with the registry to record what is needed for Commission on Cancer and National Accreditation Program for Breast Cancer accreditation. Traditional methods of managing a tumor board are labor intensive and require approximately 10 to 15 hours of preparation for each conference, taking away valuable patient face time for navigators.
Method: A method to automate the tumor board workflow, called OncoLens, was put in place at DeKalb Medical Center. The platform enabled data requests to be routed to the right specialties without manual intervention. Creation of agendas and conference presentations was automated. A standardized discussion format was put in place, ensuring the discussion and reporting of relevant and necessary clinical and quality metrics.
Result: This resulted in a 90% reduction in time and resources spent on preparing for tumor boards. A 50% increase in cases discussed was observed. The solution streamlined the low-dose computed tomography screening program, resulting in a reduction of time to care plan for a positive cancer diagnosis from 14 to 2 days.
Conclusion: By utilizing technology, the administrative burden of tumor boards can be reduced significantly while improving the quality of care delivered. The OncoLens workflow solution can be utilized to collect several standard metrics in the areas of Patient Experience, Clinical Outcomes, and business performance or Return on Investment within the Academy of Oncology Nurse & Patient Navigators domains for certification.
The tumor board, or multidisciplinary cancer conference (MCC), is the foundation of high-value multidisciplinary oncology care through a coordinating team of specialists.1 The concept of MCC is widely accepted as the gold standard of cancer care delivery across the world.2 The benefits of MCCs include coordination, discussion of complicated cases, education, accreditation, and a forum for communication of emerging technology and clinical trials. The Commission on Cancer (CoC) requires cancer programs to run tumor boards with 80% of the case discussions having to be prospective before any treatment plans are made. The nurse navigator is a central hub of tumor boards at several institutions, with responsibilities involving determining which cases are to be presented, collating patient data, creating an agenda, organizing radiology and pathology, conducting conferences, and working with the registry to record what is needed for CoC and National Accreditation Program for Breast Cancer (NAPBC) accreditation.3
A well-organized tumor board covers several core competencies required for navigators.4 For instance, the input received at the tumor board enables the navigation team to educate patients on the multidisciplinary opinions and give early indications of the treatment plan. Participation also helps increase knowledge of various cancers and treatment options. It is a forum for the navigator to be the advocate for the patient and bring specific issues like health literacy, culture, language, and amount of information desired into the discussion. Participation in tumor boards allows providers to interact with navigators and be aware of their core responsibilities. The navigation team can help educate providers and introduce relevant patient questions (eg, interest in clinical trial options).
Tumor boards are labor intensive today. It is estimated that it takes at least 10 to 15 hours to prepare for 1 conference.5 This includes collecting case details for discussion; coordinating with pathology, radiology, and genetics for additional detail; and creation of agendas and presentation material. After case discussions, responsibilities may include collecting the suggested care treatment plan and relaying that back to the members of the tumor board. In some cases, the nurse navigator may also be responsible for collecting the metrics required for CoC and NAPBC accreditation purposes, although this is often the responsibility of a registrar.
This work creates limitations to the number of conferences held at an institution and the number of cases discussed at each meeting. In addition, it places the nurse navigator in a data collection role as opposed to a patient advocate and executor of the treatment plan.
The DeKalb Medical Center (now part of Emory University Hospital) in Decatur, GA, hosts several tumor boards monthly wherein a multidisciplinary panel of more than 50 physicians and cancer team members (medical oncologists, radiation oncologists, surgeons, pathologists, radiologists, clinical genetics, palliative care, clinical trials, nutrition, social work, pastoral services, and nurse navigators) convene to discuss the care of patients with cancer.
With more than 1200 new cancer cases diagnosed within the DeKalb Medical system every year, DeKalb Medical now runs at least 8 conferences a month across multiple disciplines. The goals were to reduce the administrative burdens around running these conferences, monitor program-specified quality metrics, increase the number of cases discussed, and demonstrate cost savings in the process.
DeKalb Medical reached out to the OncoLens technology team to automate several parts of the process of pulling together a conference. This HIPAA-compliant, mobile and web-based platform enabled physicians and other care providers to discuss and develop treatment plans for their cancer patients in real time as well as support any in-person discussions. Available patient case data were entered into the system by the provider or patient navigator at their convenience through the use of quick-entry templates. This can also be done through direct integration with the electronic medical record. The case was routed to pathology, radiology, and genetics for any supporting information. All case-relevant data were automatically collated into a presentable format for the tumor board. Finally, the cancer coordinator would simply assign the cases to the appropriate meetings for discussion. In addition, DeKalb took advantage of the technology to propagate and educate their providers on key quality metrics and cancer center goals, such as the incorporation of the National Comprehensive Cancer Network (NCCN) guidelines or calling out the need to discuss reproductive counseling for female cancer patients, to ensure that the highest standards of care are met during the discussions.
In addition, the platform provided an automatic clinical trials screening tool that automatically screens all patients discussed at tumor boards for eligible clinical trials. This helps the navigation team to be instantly aware of any trials the patient may be eligible for and prompt discussions with the patient and providers, simultaneously improving efficiency and meeting practice-based learning and improvement goals.5
The platform also enabled the coordination of care with members of a care team directly from the tumor board. Notifications and work queues can be generated directly as a result of the discussion and sent to social workers, clinical trials research, palliative care, or other provider groups.
The time spent by the tumor board coordinator in preparation for each tumor board was reduced from 10 hours to less than 1 hour, representing a 90% decrease in work.5 The ease of entering cases into the platform resulted in an increase in the number of cases discussed. Approximately 283 cases were discussed in 2015. The annual run rate is now 660 cases, resulting from a 50% increase in the number of cases discussed at each tumor board and 3 additional conferences added to the monthly schedule.5 This was accomplished despite the retirement of their full-time tumor board coordinator. Tumor boards are now being managed by a percentage of time across several roles, including cancer registrars and navigators, which is now feasible because significantly fewer hours are required. Direct cost savings achieved exceeded $40,000 in year 1.
The technology enabled the early involvement of clinical trials, genetics, nutrition, and palliative care services available within the DeKalb Medical network because case details were available to them for review as the cases were posted, as opposed to when the agenda was sent out.
The platform, by calling out specific metrics and content, such as automated clinical trials search results, palliative care, NCCN guidelines, and new precision medicine diagnostics, could help ensure that these criteria were being covered across cases. This reduced variability in discussion and improved standardization and quality of care treatment plans.
A physician or nurse navigator no longer has to wait for more than a week to present a case but can now submit a case he/she saw the day before in time to significantly impact the treatment plan.
Also, location is no longer a barrier. Physicians located at the more remote Hillandale campus can now participate in these cancer conferences, enabling providers and patients to have access to all of DeKalb Medical’s expertise.
The nurse navigator team at DeKalb Medical also decided to utilize the OncoLens platform to improve the management of incidentally found lung nodules on CT scans with a designated care team. Typically, these took at least 2 weeks for discussion among the thoracic surgeon, pulmonologists, lung navigators, and radiologists to determine a treatment plan. With the new system, the time frame for presenting and discussing cases has been shortened to within 2 days from an earlier 14 days, which significantly reduces any delay in treatment. This was accomplished via the online sharing and review of case information and findings and multiple providers providing their opinion online on the system. The results were then shared with the patient much sooner, resulting in better patient engagement.
Nationally, nurse navigator programs are diverse, depending on the patient populations they serve, the specific administrative environments, and expectations within programs. In this scenario, it was hard to capture the impact of navigation and discuss ways to improve the navigation process. In a landmark paper, Strusowski et al4 published standard metrics in the areas of Patient Experience (PE), Clinical Outcomes (CO), and Return on Investment (ROI) using the Academy of Oncology Nurse & Patient Navigators (AONN+) domains for certification. This helps measure the success of navigation programs and create a baseline for programs to improve on. However, collecting information regarding these metrics is a new workflow challenge that cancer programs must meet. Ideally, it is helpful if these metrics can be collected within existing workflows so as not to add additional administrative time.
Utilizing the OncoLens tumor board and decision support system enables the nurse navigator team to collect several standard metrics in the areas of PE, CO, and ROI within the AONN+ domains for certification. Navigator participation in tumor boards can be collected for every patient discussed providing valuable insights to cancer programs (Tables 1-5).
Early involvement of nurse navigators during tumor boards can enable the development of higher-quality, patient-focused care treatment plans. By utilizing technology, the administrative burden of tumor boards can be reduced by up to 90%. Platforms such as OncoLens can help improve the quality of care because it helps to standardize the discussion across the system by ensuring all necessary aspects of care are covered, including palliative care, NCCN guidelines, and clinical trials. Clinical trial accrual numbers can be increased by the real-time search and discussion of clinical trials for the patient. The number of cancer conferences and cases discussed can be increased substantially with the reduced workload. Most importantly, the nurse navigator can take on the lead role of funneling patient cases into tumor boards, representing the patient, and obtaining the results for further patient discussion and care coordination, resulting in improved patient engagement and retention. The OncoLens workflow solution can be utilized to collect several standard metrics in the areas of PE, CO, and ROI within the AONN+ domains for certification.
- Croke JM, El-Sayed S. Multidisciplinary management of cancer patients: chasing a shadow or real value? An overview of the literature. Curr Oncol. 2012;19:e232-e238.
- Soukup T, Lamb BW, Arora S, et al. Successful strategies in implementing a multidisciplinary team working in the care of patients with cancer: an overview and synthesis of the available literature. J Multidiscip Healthc. 2018;11:49-61.
- American College of Surgeons. Commission on Cancer. Cancer Program Standards: Ensuring Patient-Centered Care Manual (2016 edition). www.facs.org/quality-programs/cancer/coc/standards.
- Strusowski T, Sein E, Johnston D, et al. Standardized evidence-based oncology navigation metrics for all models: a powerful tool in assessing the value and impact of navigation programs. Journal of Oncology Navigation & Survivorship. 2017;8(5):220-243.
- Simpson L, Mathew A. Process improvement and cost savings in cancer care through the utilization of technology in tumor boards. J Clin Oncol. 2018;36(suppl). Abstract e18779.