The following post is a summary of a talk that I gave at the OntarioMD Every Step Conference in London on April 7, 2016.
Most family physicians have noticed that more cancer follow-up is being increasingly downloaded to primary care, especially over the past 5-10 years. Personally, I welcome this change as it allows us to manage patients for which we are certainly capable. However, there are many challenges that need to be addressed with this new trend, especially taking into account the EMR environments that physicians are settling into.
All practices need a formalized process for each cancer that allows for accurate and appropriate follow-up of all affected patients. The transition for cancer patients between specialist care and primary care can often be a juggling act, and it is important to capture all relevant patients for tracking purposes. Management protocols need to meet current standard of care, and should be easily updated to reflect new evidence. Most importantly, any program must be seamlessly integrated into a busy practice, without adding additional clinical or administrative burden.
Unlike cancer screening programs, which require thousands of patients to make one potentially life-altering diagnosis, the “number needed to track” for cancer survivor follow-up is orders of magnitude lower. One patient lost to cancer follow-up can have tragic consequences, and can expose a physician to a medicolegal nightmare.
Most offices have very efficient programs in place using their EMR for monitoring diabetes, CHF, COPD, immunizations and cancer screening, but these are often absent for cancer survivor follow-up. This is partly related to remuneration for cancer screening and immunizations, as well as the allied health staff available to some physicians (not for me) for CHF, COPD, and diabetes management.
Here is a brief framework of how to begin developing a formalized cancer follow-up framework (should be adaptable to most EMRs):
1) Decide on what types of cancer you need to be following (start with bladder, breast, cervical and treated dysplasia, CLL, colorectal, esophageal, lung, lymphoma, melanoma, prostate, pituitary, renal, sarcoma, thyroid, uterine, and add others as appropriate for your practice). Create a standard method of labelling each cancer, whether you use free-form or drop down text, and decide where this text will go (eg. consistently use breast ca in the Problem List, rather than a mix of breast ca/ca breast/breast cancer/breast carcinoma, etc.). Ensure that every user is aware of these standards, and have a glossary of terms available at each clinical workstation.
2) Find the patients who have each cancer. This takes some creativity, as you have to brainstorm every possible way you may have entered each cancer in the past (eg. some of your colorectal cancer patients may have been entered as sigmoid ca, rectal ca, ca colon, etc.) Search for all of the patients with your expanded criteria, and re-label them with your new standards.
3) For each cancer, decide on the most appropriate means of follow-up. What do they require for follow-up for each cancer (eg. imaging, bloodwork, yearly check-up, etc.)? Decide for each cancer whether it would be more appropriate to use a passive reminder system that would show up on routine reports (eg. prostate cancer patients who have not had a PSA in the past year), or whether you want to do active searching for these patients at routine intervals (monthly, yearly, etc.). An example of an active search I use is for lymphoma patients to ensure they have had all of the relevant routine imaging and bloodwork, since I have so few lymphoma patients and want to make sure I am manually checking that my follow-up is accurate. Another question to ask yourselves is how often do you want to be reviewing the evidence to see whether the guidelines have changed for each cancer?
This same framework can be applied to track other pre-cancerous conditions including colon polyps (labelled as tubular adenoma, tubulovillous adenoma, villous adenoma, serrate adenoma, colon polyp, etc.), thyroid nodules, Barrett’s esophagus, as well as a host of other conditions.
A warning: don’t try to do all of this work tonight (as tempting as it may be…). Establish a plan for your office, and delegate tasks accordingly. Re-categorizing all of these patients, with evidence reviews, is often too much for one person, and the tasks can be divided amongst multiple docs or other team members. Set goals for a few months down the road for where you want your office to be, and continually re-establish new goals for cancer survivor quality improvement.
The Peer Leader program is a free program offered by OntarioMD that provides peer-to-peer network support for EMR optimization. Contact OntarioMD for details about being connected with a Peer Leader in your area.