As more hospital systems seek to build out their capabilities for inpatient care coordination, oncology service lines are being asked to use the modules provided by large EMR providers (Epic, Cerner, etc.) to navigate cancer patients. In some cases, there is pressure to replace specialty care coordination solutions that are designed to the unique needs of oncology patients and may have been in place for years.
Typically, the request comes from a central administrative group seeking to manage cost pressures and/or to justify the additional expense of EMR oncology modules as they seek to comply with Meaningful Use 3 (MU3) standards. The assumption by finance seems to be that the coordination needs of inpatient, acute care settings (which are naturally focused on utilization management and discharge planning) are the same as those of complex specialties, like oncology (which has longer time horizons and involves multiple providers and outpatient settings). Though both are called care coordination, they are fundamentally different capabilities and so should be called different things – perhaps outpatient specialty care coordination vs. inpatient general care coordination.
This is not to say that EMR-based coordination is a bad thing; in fact, we believe all types of care settings and specialties benefit from care coordination. But the needs of oncology care coordinators and nurse navigators far exceed the basic functionality stipulated by MU3, which may suffice for inpatient settings and relatively brief acute care episodes. That’s especially true relative to Commission on Cancer (CoC) accreditation standards, which far exceed MU3 requirements. Given the importance of CoC accreditation to cancer centers around the country, oncology leaders must help their hospital’s leadership to understand a few key principles and even ask a few hard questions.
General care coordination and oncology navigation are not the same: Oncology navigation has been in existence since Harold Freemen coined the concept in the early 1990s. So it’s not surprising that patient navigation and care coordination in oncology are much more complex and advanced than general care coordination as defined by MU3. For instance, oncology navigation incorporates a wide range of tasks and issues, including multiple cancer conferences, genetic counseling/risk assessment, palliative care, distress management and survivorship. All of these are essential to the Commission on Cancer Standards.
Oncology care coordination is a process – not a one-off event: "A patient navigation process, driven by a community needs assessment, is established to address health care disparities and barriers to care for patients. Resources to address identified barriers may be provided either on-site or by referral to community-based or national organizations." (CoC Standard 3.1)
The implication for technology is clear: care coordination platforms and tools must provide for community needs assessment for patients (retrospective of distress assessment results across patients). At the end of each year, users should be able to look back at barriers and know that your navigation services have these services as "basic" provisions.
It's about the patient and long-term goals – not a set of activities: Oncology navigation requires ongoing distress assessments (CoC Standard 3.2) of patients at pivotal points in care, with survivorship as the end goal. General care coordination from an EMR is primarily about managing events in acute-care facilities, delivering a consolidated view of medical records to support clinical decision making and planning for discharge transitions.
Again, EMRs are focused on capturing data about care interactions within the walls of a single hospital facility, or associated facilities that use the same system. They do not support complex processes or care interactions that happen outside a single facility. And they do not typically define specific outcomes or states of wellness as end goals. Oncology care coordination, by contrast, is structured to reflect the reality of care being delivered across multiple outpatient facilities (each with its own systems) and is oriented toward the specific outcome of survivorship. Specific steps and the overall treatment plan should easily culminate in a Survivorship Plan (CoC Standard 3.3). If your care coordination platform does not do this, it is the wrong one for oncology.
Effective oncology care coordination is both deep and wide: Navigators in Cancer Centers can be closely involved with patients from screening through survivorship (wide). And they can go deep through four or five courses of treatment in addressing issues ranging from regime side-effect management and ongoing patient distress that puts treatment in jeopardy, to patient community issues, poverty and language barriers to utilization management and co-morbidity effects on the cancer. Thus, navigators need a care coordination solution that is very flexible to support many unique workflows.
Asking the right questions
Finally, ask yourself these questions. If you must consider your hospital's EHR, ask yourself these questions when considering if general care coordination will work for your patients:
- Does it support multidisciplinary Cancer Conferences (CoC Standard 1.3)
- Does it help assess and break down barriers to care? (CoC Standard 3.2)
- Does it help guide patients through the system if the system extends outside your EMR implementation (other hospitals, community resources, etc.)?
- Does it facilitate open communication between all members of the care team?
- Does it help match patients with the right support services?
- Does it support continuity of care?
- Does it help document the education of patients and their families?
- Does it help eliminate health care disparities among patients?
- Can it streamline the creation of survivorship plans, without re-typing everything from scratch? (CoC Standard 3.3)
- Is it useful for CoC site visits and to prepare for Survey Application Records (capturing and sharing statistics in support of CoC accreditation standards relative to conference, navigation, distress, survivorship)?
- Can it bring together all relevant data from different systems to provide a single, "whole patient" view?
The bottom lineBecause of its complexity, oncology care coordination requires much more than the basic functionality that may be enough to support mainly inpatient, acute care coordination and to meet the minimal MU3 standards. Thus, there is real risk in assuming that the care coordination features offered by EMR vendors (which are focused on clinical decision support and utilization management within single or relatively few facilities) can effectively replace care coordination systems and tools that have been purpose-built to support oncology – especially when those solutions have been crucial in streamlining CoC accreditation.