Michael Fradley, MD, medical director of Penn Medicine’s Cardio-Oncology Program, discuss opportunities to move the field of cardio-oncology forward through the implementation of standardized practices across health systems. Dr. Fradley specifically highlights the development of clinical pathways and outlines how to overcome potential barriers.
Related Links: Twitter @PennMDForum Dr. Fradley’s physician profile
All right. So I mean uh spend about the next 15 minutes discussing opportunities to move the field of cardio oncology forward via the implementation of standardised practice across health systems. So my disclosures, so you know, while administrators may view standardized care as a way to achieve efficiency and high quality patient care. Physicians have historically viewed it as a mandate that goes against their interests and autonomy as well as the interests of the patient. Standardizing best practices is an important part of delivering effective, safe and affordable care and benefits of standardization include consistent outcomes, labor savings, reduced waste, improved efficiency, improve patient safety and reduced costs. That being said, personalization remains an integral part of patient centered care. Advocates of personalization do not want to see a one size fits all approach to healthcare, believing that personalization can enhance the patient experience and overall patient engagement. But I think that there is room for standardised practice and personalization to coexist standardization can actually enhance personalization by eliminating unnecessary or redundant work and eliminating provider guesswork, which ultimately frees up time to focus on the more complex and difficult issues that you know that do not follow a specific management algorithm. So there are various ways to implement practice standards from the development of clinical pathways, which I think is what most people start with then to the to the development of order sets, dot phrases and smart phrases as well as the use of the Nudge unit. The most common method to standardize clinical practice is with the development of clinical pathways which are evidence based, multidisciplinary management plans, which identify an appropriate sequence of clinical interventions, timeframes, milestones and expected outcomes for a patient group implementation can ultimately reduce variability in clinical practice as well as improve outcomes. And the deming cycle, which is a continuous quality improvement model can really serve as a framework for clinical pathway development and it consists of a logical sequence of four stages plan. Do study and act, and I think an important point of the Demings theory is to start out small, check the results and then act by broadening the reach of a pathway that's deemed to be effective. Now there's various ways that clinical pathways can improve care. First and foremost, they can decrease unwarranted care variation with evidence based decision support. And this is especially important when you consider delivering care by multiple providers at multiple different practice sites and pathways ensure patients can receive consistent care across and institutions care delivery network, regardless of whether they're treated the academic medical center or at a community practice. And we all know that it can be difficult to stay abreast of the many different complications and recommended testing for various cancer therapeutics. For example, this is a study from Dr Katie Ruddy at the Mayo, where her group showed that only 36% of patients had surveillance cardiovascular testing in the year following completion of anthro cycling based chemotherapy. Despite this being recommended in the ASCO guidelines, the numbers were a little bit better for breast cancer patients and worse for the patients who received an three cyclones and had lymphoma, but clearly pathways can help to ensure appropriate monitoring for these patients. Additionally, pathways can minimize care coordination gaps, which is particularly important for cardio oncology patients who have a multidisciplinary team of care providers. An integrated approach not only helps patients feel more supported throughout their care journey, but also improves healthcare economics because it's estimated that around $45 billion dollars is wasted every year as a result of gaps in care coordination. We know the pathways can minimize avoidable emergency department visits, which obviously drives up health care costs and can optimize practice patterns with the use of data analytics and finally, they can actually promote the development of precision and personalized medicine. And this can be really seen particularly in the oncology field with the use of specific uh tumor markers and different testing to sort of personalize the cancer approach based on their specific to us. So we've actually developed some preliminary cardio oncology pathways here. It's here here at Penn and we really focused initially on patients treated with VCR able tyrosine kinase inhibitors. And this is the first pathway, it's for relative And this is the 2nd pathway for Pinatton. Now there are clearly barriers to pathway implementation and busy clinicians may not have the time to refer to them. And I think you can see from the two clinical pathways that we've developed, they can be dense and cumbersome to follow. and I think that's oftentimes one of the biggest barriers to pathway implementation. Um it's just it's just not practical from a time standpoint to go through there and follow arrow after arrow. There can also be infrastructure issues and a lack of financial incentives for care coordination, despite clear long term cost savings. And there's obviously the possibility of provider resistance due to concerns about autonomy and practice norms that often promote clinicians to act in silos. And finally, pathways are meant to be evidence based and clearly definitive evidence is often lacking in the field of cardio oncology. So the ability to really create pathways can be limited by the fact that this field is still something that is, is evolving. There are some creative ways I think, to overcome the challenges that exist with a pathway. Um uh for example, cumbersome pathways I think can be converted into dot phrases or smart phrases as well as standardized order sets. And this really helps the clinician so that they don't have to refer back to the arrows and the flow of the, of the pathway. And I also want to talk a little bit about how nursing care coordination can be particularly helpful. So dot phrases and smart phrases help with the adoption of these clinical pathways. And this was a study from chop that looked at the conversion of their diabetic ketoacidosis, iCU admission pathway into a dot phrase. So you can see that a lot of people knew about the pathway and its existence, but not many people were actually utilizing it. And after implementation of the dot phrase into the medical record and into epic The percentage of avoidable pick you stays for deka decreased from 4.1% 2.5%. Moreover, there was also a decrease in ward to pick you transfer. So it wasn't simply that they were reducing the number of pick you stays and then just requiring them to go back to the picky because they were going to the floor. In fact there was fewer transfers from the war to the pick you as well and they can also decrease post visit work in the outpatient setting. I think a lot of times we think about this in the inpatient world. But this was a study that looked at implementing a. Bs dot phrase to inform patients how to specifically navigate their care needs especially as it related to medications and study results. Um And we all know that you know oftentimes we have our own unique A. V. S. Is that we give to patients. But when when this study looked at a standardised practice, phone calls were significantly reduced which led to reduced in between visit workload for clinic staff and providers. I do want to point out that we actually have a smart phrase at Penn that was developed by dr Carver. Um If you type in cardio into the smart phrase box cardio oncology note template can be imported with drop down in quick pick options. Um It's a relatively simple smart phrase but it can and should be utilized for all of our cardio. New patient visits. And in this case particularly to track baseline metrics such as cancer type reason referral etcetera. Which can then help us I think to refine and hone our individual practices going forward. So I really encourage everyone who's seen cardi along patients to um to use this when they're seeing a new patient. And I'm sure you all know about the innovative Pen Nudge unit which is obviously transforming healthcare delivery. Um So this was a study that looked at three primary care practices at Penn um and implemented an active choice intervention in the electronic health record. That prompted medical assistance to inform patients about cancer screening during check in and then template ID orders for clinicians to review and activate. And it was associated with a significant increase in clinicians ordering appropriate breast and colorectal cancer screening tests. So you can see how we probably can and should be working with a Nudge unit to help us establish some of these cardio oncology specific initiatives, for example eco ordering or or laboratory ordering. And finally I do want to touch on how important I think it is to rethink our use of nurses and work to bring a true cardio oncology. Nurse coordinator to our system. Nurse coordinators can help to standardize care delivery through patients and staff education care coordination, the triage of urgent cardiovascular issues and the development of nurse driven protocols. And all of this leads to increase patient provider as well as nursing satisfaction and really can be highlighted as part of nursing practice development. And we know that there's data confirming that nurse care coordination can lead to improved outcomes. This is a study of a nurse coordinated cardiovascular prevention program, not specifically cardio on, but I think it can translate in which nurses provided general lifestyle and dietary advice as well as counseling on smoking cessation, physical exercise and in collaboration with a provider treatment of blood pressure and lipids. And as a result of the nursing intervention, 10 year cardiovascular mortality risk was significantly lower at one year for those that were enrolled in the nurse driven program compared to control patients. I think that we start to standardize our cardiology practice. This will this will really fit nicely into this concept of the medical neighborhood. Medical neighborhoods are an offshoot of the medical home concept, which promotes a comprehensive, coordinated and integrated care approach uh by using more effective ways to manage acute and chronic conditions and promote health and reduced costs. And really this has traditionally been focused in the primary care domain, but it's been gaining a lot of traction in various specialties, including cardiology and oncology. And I think the cardio oncology practices can work from the same blueprint to make care more accessible and efficient. And essentially they will all reside in the same medical neighborhood, facilitating navigation for a patient population as well as standardizing care. So in summary, standardized cardio oncology practice is possible, and I think it can be achieved with a multidisciplinary input in pathway development. I think we need to actively work towards incorporating a true nurse coordinator into the cardio ecology service, as well as leveraging some of the unique technology that we have available to us, such as the Nudge Unit, to ensure pathways are more uniformly adopted across the system.