By Dr. Christopher D. Jahraus
A leading trend in cancer therapy over the past 20 years is our increasing ability to develop and deliver personalized therapy tailored to provide optimum safety and efficacy based on the unique needs of individual patients.
Without a doubt, personalized cancer therapy requires a focus on the person – identifying aberrations in specific cells and biologic pathways that give rise to the cancer, considering other health issues or co-morbid conditions that may limit efficacy or lead to unwanted side effects, and understanding the person’s personal priorities and values. A parallel trend that enables individualized therapy is the increasing personalization of technology. Prior to the advent of smart phones and the development adaptive algorithms customizing processes to a person’s individual preferences, tastes, and needs, technology was often seen as a cold intruder into the person-to-person relationship between patient and physician.
Personalized cancer therapy is highly complex, involving multiple therapeutic modalities and schedules that vary based on tumor location and cellular and molecular subtypes. In 2020, providing personalized radiation oncology solutions in a time- and cost-effective manner takes more than just medical savvy. In fact, technology today is an enabler for more personalized care rather than an obstacle to it. Computer software innovations that immediately factor in special patient data, clinical regimens, and pharmacy information can ensure the capture of essential patient data, development of optimized treatment plans, and the timely and safe delivery of personalized, precision radiation medicine regimens.
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Today’s innovative software solutions may be especially important for sole practitioners and physicians in small medical practices. Physicians in these settings pride ourselves on recognizing their patients as individuals with very specific needs, but still must comply with data aggregation and reporting requirements that are needed for treatment and for regulatory oversight. Smaller practices may not have the resources for large administrative teams that focus on chart transcription, scheduling, and billing, leaving physicians struggling to balance delivery of excellent patient care with taking care of the paperwork. New technologies are a critical solution to this challenge. By harnessing the most up-to-the-minute knowledge of patients as they move through the treatment journey, these new technologies enable more personalized care management without placing additional demands on the physician time.
A sole practitioner’s perspective
As the sole practitioner at Generations Radiotherapy & Oncology PC (GenXRT), my ability to spend time directly engaged in personalized patient care that renders optimal outcomes on a holistic level is challenged by the growing complexity of cancer therapies, but moreover by the increasing demand on my time for collecting and documenting patient and procedural data. To address these challenges and reduce the amount of time that my staff and I spend on paperwork rather than patient care, I have been an early and avid adopter of new technologies that reduce clinical workflow inefficiencies, ensuring that my patients receive high quality, next-generation radiation therapy and allowing me to spend more of my time directly interacting with patients.
There are a number of challenges that smaller practices such as mine currently face in streamlining clinical workflows and optimizing cancer care outcomes in the age of multi-modal therapy and increasing regulatory requirements. My staff comprises one nurse, one biller/coder, and one manager, in addition to the technical team, to manage and oversee all of the practice’s documentation, billing, and administrative paperwork for around 200 patients annually. These support staff must continuously operate at peak efficiency; and that is rarely restricted to a 40-hour workweek. Additionally, as a smaller practice, we have less excess capacity in our radiation delivery systems than larger practices or care centers. As a result, we must manage our scheduling precisely to ensure that patients receive treatment on time and that equipment is not sitting idle. Innovative technologies can address these challenges, including the use of mobile apps to review and approve documents and tasks, and to provide visibility as to where critical documentation might have been missed or forgotten due to other clinical priorities.
A case study in innovation
In August 2019, GenXRT became the second clinic site and first sole physician practice in the United States to implement a cutting-edge technology solution – MOSAIQ SmartClinic - designed to streamline the care delivery pathway. Use of this innovative digital solution allows every member of my team and me to see where each patient is in his or her care pathway in real time, receive mobile alerts 24/7 when tasks need to be completed and facilitate communication among the care team, including referring patients to physicians outside of GenXRT, reducing delays in clinical decision-making and care delivery. The ability to manage all aspects of my patients’ care through a single digital platform is due to several key features within SmartClinic that can be customized to integrate smoothly into my existing clinical and office workflows.
First, SmartFlows watch for specific actions and respond intelligently to them. For example, there is a “watcher” for each patient’s radiation dose. After the first fraction of radiation has been administered, the watcher creates a weekly physics check (Physics Checks 1-7) and includes the Physics Check Form from SmartForms.
SmartForms is a feature that aggregates data and allows me to create appropriately customized pick-and-click-documentation. Documents created in SmartForms pull data directly from the patient’s from electronic health record (EHR), reducing the need to enter data that we have previously captured and minimizing data entry errors. The Synopsis tab, the gateway to SmartForms, provides a one-shot overview of the patient and his or her progress through treatment. In a single screen I can access the right patient data whenever I need it. Importantly, it is designed with minimal click navigation to enable ease of use for every member of my team.
Another key feature of SmartForms is that it allows any process or data set to be documented reproducibly and with minimal staff time. Automated, logic-driven documents with “if/then” logic ask only pertinent questions (i.e. if a patient answers “no” to question about being a smoker, none of the smoking-related questions will be asked, whereas they will be included if the patient answers “yes” to being a smoker). Each form can be completely customized for individual departments, and there are separate patient-facing and physician-driven formats specifically designed for ease-of-use for whoever is completing the form. All forms are digitally shareable both within my practice and with external care providers. The latter point is especially important for patients undergoing multi-modal therapy who may receive care from a medical oncologist or surgeon outside my practice in addition to the radiation therapy that my practice provides. Our SmartForm patient consent and status check/office treatment visit (OTV) note forms demonstrate how each form can be customized based on the data we need to collect and the person completing the form.
With a small administrative staff, minimizing redundancy in data collection is critical to operating my practice efficiently. The SmartBoards feature of SmartClinic presents process data in a format that can be customized by user role (physician, billing, physics, dosimetry, etc.), conveying the same data in a role-dependent manner and emphasizing information that matters most to each individual member of the team. Rather than collecting data de novo for each user or function, which is highly inefficient and introduces opportunities for data entry errors, SmartBoards function as a digital version of the typical white board that is used to track patients and to identify tasks for specific team members to complete.
Unlike a physical white board, SmartBoards provide a customizable, real-time snapshot of workflows based on role. I can see all the steps in the treatment process for a single patient, from simulation to treatment, billing, scheduling, etc., while my billing specialist can simultaneously view care episodes that are ready to be billed across our entire patient population. Similarly, my scheduler can quickly view availability of specific radiation delivery systems and relevant staff, ensuring that all physical and personnel resources are ready when the patient arrives for his or her appointment. Importantly, SmartBoards allow me to visualize potential bottlenecks in our clinical workflows and, unlike physical white boards, they update in real time as tasks are completed, so I always have the right information. SmartBoards also provide the ability to trigger real-time completion of relevant SmartForms, ensuring that we are collecting and documenting the appropriate data at every step in the treatment process.
SmartBoards are also highly flexible and not limited to the simulation to start process. In my practice, I have incorporated SmartBoards into each one of our clinical processes, including, as an example, Sim – Ready to treat. The SmartBoard can be customized to display by patient, attending physician, diagnosis, etc., and in this example shown, the display by patient. The status of each step in the patient’s treatment plan is easily identified with a green check for completed steps or a red X indicating that an action is needed.
The implementation of SmartClinic has had a positive impact on my practice. Our automated documentation and tracking have greatly improved without sacrificing note quality. Despite a 35% higher patient load in 2019, 40% more on-treatment visit (OTV) notes were completed within 24 hours of the OTV and 13% fewer patient OTVs were missed within the allowable five-day window (Table 1).
Table 1: Comparison of OTV Notes completed within 24 hours or missed before and after implementation of SmartClinic
Factors to consider when evaluating new technologies
With increasing financial pressures, it goes without saying that smaller practices should be careful when investing in new technology, and should consider several factors as part of their decision-making process. First, consider how a new technology will impact patients, both with respect to outcomes and your ability to provide more holistic and personalized care. Understand the upfront and operational expenses of any new technology, including time to amortize the initial cost of implementation and any recurring or ongoing costs. Making sure that your practice has the ability to derive maximum benefit from the technology will help you avoid implementing technology that can’t be fully implemented due to personnel or cost constraints or because it doesn’t address your specific challenges or clinical needs. It’s also important to assess if the vendor provides training/support both for implementation and ongoing needs, and if your existing staff have the expertise, and are willing to learn how to implement and use the technology for maximum benefit and efficiency. Also consider how the technology may improve your practice’s competitive position within your local/regional care markets.
Small practices can deliver big benefits to patients
The healthcare IT landscape is evolving, especially as artificial intelligence and machine learning are increasingly incorporated into EHRs, along with clinical decision-making support tools and complex radiation delivery systems. While older generations of healthcare IT systems were designed primarily to simplify the management of large patient populations, the increasing complexity of cancer care means that technology is a critical component for optimizing care and efficiency for practices of every size. Every cancer patient deserves the best that personalized radiation medicine can offer. Adopting new technologies that streamline workflows, reduce time spent on administrative tasks, and maximize time spent directly engaging with patients can be an effective way to achieve this important goal.
About the author: Christopher D Jahraus, MD FACRO, is the president of Generations Radiotherapy & Oncology PC