At the ACCC Annual Meeting and Cancer Center Business Summit (March 4-6, 2020; Washington, DC), Amy R Ellis, director, quality and value-based care, Northwest Medical Specialties (Tacoma, WA), was featured on a panel of diverse speakers to address the landscape of digital technologies in oncology.
Journal of Clinical Pathways spoke with Mrs Ellis regarding her role of overseeing value-based initiatives at a community practice and the use of innovative tools and technological solutions to support practice transformation toward value-based care.
Can you explain your role as the director of quality and value-based care at Northwest Medical Specialties? What value-based initiatives do you oversee?
Mrs Ellis: Northwest Medical Specialties is a physician owned community oncology practice employing 21 providers – 10 of whom are medical oncologists and the remaining 11 are advanced practice providers (eg, physician assistants and nurse practitioners).
Because we are smaller in nature, my role is very diverse. I oversee all of our quality initiatives and all of our value based care programs, including ongoing contracts that we have with various payers.
We are an Oncology Care Model (OCM) practice, and I oversee the entire OCM operation.
I also manage our care coordination team. Northwest has five care coordinators who are responsible for making sure different things are happening appropriately for patients, whether that be closing the loops on their referrals or ensuring that the medication reconciliation is appropriate and showing dose, route, and frequency for every medication.
Furthermore, I manage our social work and patient navigation teams. This role allows me to manage the “bigger picture” of where are we now and where we should be heading to stay ahead of the curve in value based care.
Would you categorize the care that you provide for patients as "multidisciplinary?” Do you use multidisciplinary strategies in your oncology care?
Mrs Ellis: Yes, we absolutely do. Multidisciplinary care is one of our strategic initiatives for value based care. Our patients come to us with a host of issues, not just cancer. In order for us to be successful in value based care, we have to understand what issues they already have by the time they come to see us. Perhaps they have financial, transportation, or psychosocial or mental health issues. If we want to bring them “value” care, we need to approach their treatment from a holistic perspective.
That is why we have in place a multidisciplinary team. One important role is the patient navigator, which is responsible for staying on top of food, housing, electricity bills, etc.
Social workers are also a critical component of the multidisciplinary team. Our social workers are clinically licensed and experienced in oncology, but they are also specifically trained in mental health. They teach our patients how to cope with having cancer and all of the associated baggage to enhance their mental health.
Care coordinators are tasked with making sure all of the various aspects of patient care are being met. To use an example, diabetes cardiac issues are not managed at Northwest. If patients come to us with these types of issues, we have to rely on the providers that take care of those comorbidities. Say we want to start a patient on a certain chemotherapy regimen that is likely to affect their cardiac function. In this case, it is vital that we work directly with the treating cardiologist to make sure that it is okay to start the regimen.
It is very easy to place this referral electronically. Let's say the cardiologist receives it, but has a difficult time reaching the patient via phone. There is no way for us at Northwest to know that the cardiologist is having a difficult time communicating with the patient unless we have a care coordinator in place to monitor these communications. Care coordinators always have an eye on our “referral loop.” They will say, “Cardiology received the referral 2 weeks ago. Why hasn’t the patient been scheduled?”
Then, the care coordinators will call the cardiology office to inquire about why the patient has yet to schedule an appointment. Once the cardiology team tells the care coordinator that the patient will not return calls, the team on our end can call the patient – who is more likely to answer a call from us because of a pre-established relationship. The physician can then explain why a cardiology appointment is critical in order to start the chemotherapy on time, and then help the patient to coordinate an appointment.
If we do not have our care coordinators spotting these issues, then our patients would regularly forego necessary outside treatment. An example like this helps illustrate why our multidisciplinary team must work together and why their efforts are so crucial for optimal patient care.
What are some of the largest concerns or challenges you face in keeping your community practice positioned to succeed in a value-based world?
Mrs Ellis: At Northwest, we face a lot of challenges, chief among them being we do not have our own surgeon nor do we have our own imaging technology. Larger practices and academic centers not only have many surgeons, but also their own PET scanners, CT scanners, and ultrasounds. Thus, they are able to manage care coordination and costs much more easily, whereas we rely on our community providers for surgery consult, port placements, and other key items of cancer care. In other words, we have to work harder to keep streamlined care coordination relationships with other community providers, who are often not included in our EMR.
Another more obvious challenge is keeping on top of the cost of drugs and novel therapies. We have patients in need of CAR T therapy or immunotherapies and oral oncolytics. Transitioning to more frequent oral oncolytic prescribing is accompanied with the challenge of making sure patients adhere to therapy.
It is important that payment models account for the growing cost of these drugs, but at the moment they do not.
How have you begun to utilize innovative tools and technological solutions to support practice transformation? What are some specific tools or solutions that Northwest has employed?
Mrs Ellis: While Northwest does not have the resources of larger cancer centers, we have invested significantly in technology. We have eight to 10 different tools we employ, one of which is Navigating Cancer for our care management platform.
Our EMR is a legal medical record and is not currently designed to be intuitive or interactive. Frankly speaking, it is difficult to use for care coordination. The Navigating Cancer tool allows our team to literally “care manage” a patient. We use it for triaging as well as for population health.
We also use it for tracking oral adherence through a function called Health Tracker – a patient reported outcome tool that allows registered patients to receive daily check ins and asks if they took their medication today or if they having any symptoms. Patients can sign up for the symptom tracker only or they can be sent these prompts at whatever time of the day they choose. Any symptoms that a patient reports comes through on a dashboard for our triage nurses to manage.
Additionally, we have invested heavily in artificial intelligence to help us identify our high-risk patients. We partnered with a company called Jvion. They developed an artificial intelligence tool that identifies patients that are at high risk for clinical or socioeconomic factors like depression, pain, 30 day mortality, etc. Our care coordinators are responsible for using that tool, finding the high risk patients, and passing along the information to the clinicians.
We have a few other tools, such as a tool called PreManage that allows us to see our patients in the ER in real time. As soon as patients visit the ER, they populate on a dashboard for us, which allows us to manage our ER visits and try to prevent readmissions.
Furthermore, there are several analytic tools we use. Some are used for our OCM analytics – all of the hundreds of thousands of claims that we receive are put into a dashboard. It populates in a meaningful way and allows us to determine ways we can improve, whether that be end of life care or resource utilization.
There is a separate tool that looks at OCM claims and our practice management data, including all of our real time billing data and EMR data. It allows me to see which clinicians are prescribing the most denosumab, for example, or the most palbociclib. I can query the system in real time to better understand what our utilization looks like.
While all of these tools have been beneficial to the practice, the care management tools have been particularly helpful. They have helped us significantly reduce our ER visits and inpatient admissions, as well as improve the patient experience. From there, the care management tools have allowed us to look at utilization and analyze our data to use for quality improvement.
You have mentioned that both Navigating Cancer and the Jvion artificial intelligence tools have helped with reducing ER visits and inpatient admissions. I am curious if the accumulated data from these tools have led to measurable improvements in quality and cost metrics. Do you have data to show that these tools are helping you meet your quality standards?
Mrs Ellis: Yes, we certainly do. We have now almost 4 years of OCM/Medicare claims data that show how much we have improved on ER visits, inpatient utilization, cost, etc.
Aside from that data, Jvion pulls data directly from our EMR that provides us a return on investment profile. Jvion has used the data in our EMR to show that we have significantly increased our hospice referrals, palliative care consults, and depression diagnoses. To date, many oncology practices struggle with end of life metrics and timely referrals to hospice.
What are some other innovative or technological applications you plan to use across the Northwest network in the near future?
Mrs Ellis: The hope is that a physician’s decision-support tool could make things better and smoother in our practice. I have been looking for the right solution, but have yet to find anything that meets our vision.
Whether it be genetic testing, molecular testing, or the countless options for first-line therapy available for certain cancers, there is so much that our doctors have to stay on top of while managing the burden of EMR documentation. In the EMR, there are hundreds of data points, so it is very easy for things to be missed in the medical records. Therefore, finding a decision-support tool is becoming a priority for me, whether it be a dashboard that is integrated into our EMR or a separate program altogether.
We have yet to decide whether to partner with a vendor or build one from scratch. Nonetheless, a decision-support tool is definitely something that is on our horizon.