Oncology News: Just What the Doctor Ordered — Leveraging Technology to Personalize Radiation Oncology
By E. Ronald Hale, MD, MPH
Radiology Today
Vol. 20 No. 7 P. 10

When treating a cancer patient, it is important to view a radiation therapy episode of care as a complex continuum that comprises multiple steps from first referral, through consultation, treatment planning, treatment delivery, and the 90-day global follow-up period. Developing personalized radiation therapy regimens that are optimized to meet each patient’s specific needs requires new paradigms that focus on long-term patient outcomes and address the continuum of care holistically, while enabling standardization of procedures and techniques to improve safety and decrease the cost of care. A key challenge to this holistic approach to care is that current EHR technology and health care reimbursement paradigms artificially divide the patient treatment journey into dozens of data entry points and billing codes. Evolving EHR technologies using diagnosis- and stage-specific care paths, combined with new reimbursement practices involving bundled payments, are enabling personalized approaches within radiation oncology that also offer improved safety and efficacy.

Recently, health care reimbursement strategies have shifted toward bundled care rather than reimbursing for every interaction between a health care provider/center and a patient. This shift is a powerful driver for enabling physicians and care centers to take a holistic approach to radiation oncology that focuses on the continuum of care rather than individual components of care. Importantly, newer reimbursement practices are now aligned with the growing body of clinical data supporting hyperfractionated regimens that enable shorter courses of treatment. As a result, physicians and administrators are placing greater priority on increasing the efficiency with which care is provided to each patient and across all patients the care center serves. Advances in EHR technology that enable standardized care pathways and give clinicians the power to manage patient care 24/7 from any location and multiple device formats are critical drivers for achieving increased efficiency while optimizing patient care and outcomes.

Personalizing Treatment Pathways
To further this goal, clinicians at Kettering Cancer Care have taken a leadership role in a collaborative effort to develop MOSAIQ SmartClinic, a novel EHR technology that enables treatment delivery through a diagnosis- and stage-specific care path. This technology enables transparent visualization of the entire patient care process, from initial referral to 90-day global assessment, for each patient. This is a critical advance over current practices that artificially reduce the patient journey to a series of small EHR data entries that can make it difficult to put any interaction within the health care system into the context of an individual patient’s long-term treatment needs and goals.

The system has been developed in collaboration with clinicians at several leading cancer care centers and is designed to address the needs of those who treat cancer patients every day. The software automatically pulls diagnostic and medical history data from the patient’s EHR to simplify data capture and entry and synthesize EHR data into real-time clinical information. The system supports the development of complete care path protocols for specific diagnoses and stages. This enables automated, standardized practices that allow one set of instructions to be used consistently across all patients with a given type/stage of cancer. Importantly, these standardized care path protocols are flexible and can accommodate patient-specific adaptations.

The first such protocol developed at Kettering Cancer Care is for patients undergoing radiation therapy for early stage, right-sided breast cancer. This protocol automatically pulls information from the EHR about a patient’s age and includes a prompt to assess the patient for potential pregnancy if she is less than 50 years of age. It also pulls information from the EHR about prior radiation exposure and, if the patient has previously received radiation therapy, the system proactively provides prompts to ensure that the radiation treatment protocol is adapted to remain within radiation dosing guidelines. This diagnosis-specific protocol also includes information on dose/fraction parameters, coverage parameters, and organs at risk (OAR) avoidance parameters for the treatment of right-sided breast cancer. Automated inclusion of these parameters helps simplify development of the treatment protocol and ensure that a safe and effective dose of radiation is delivered to the tumor while protecting healthy tissue.

Eventually, MOSAIQ SmartClinic will include care path protocols for all diagnostic states. The protocol for left-sided breast cancer will include many of the same features as the protocol for right-sided breast cancer but will have critical adjustments with respect to the OAR avoidance parameters to reflect differences in the position of the heart and other organs relative to the right and left breast. Care path protocols developed for the treatment of lung cancer will similarly be stratified by specific diagnosis and stage. For example, protocols for early- and late-stage lung cancer will differ based on the potential for prior radiation exposure in later-stage disease, while those for small cell lung cancer and nonsmall cell lung cancer will differ based on the current treatment guidelines for each type of disease.

The development of these individualized care path protocols is facilitated by the ability to cut and paste content from one protocol to another within the system. For example, once the process for active breathing control is defined in the protocol for right-sided breast cancer, it can simply be copied and pasted into the protocol for left-sided breast cancer or any other protocol in which active breathing control is used. In this manner, new EHR technology allows the attainment of two seemingly contradictory but important objectives: developing standardized processes that can increase the efficiency with which care is delivered and allowing protocols to be tailored to the needs of each patient.

A key benefit of taking a holistic approach to each patient’s complete care pathway is that it reduces treatment delays through several mechanisms. First, taking the long view of the patient’s care continuum helps ensure not only that the care team focuses on the next appointment but also that tests, reports, documentations, etc, are completed in a manner that ensures subsequent components of the care path can be executed on time. This helps reduce potential delays at the level of the individual patient.

Importantly, improved efficiency of care delivery resulting from the personalized care path approach helps to drive greater operational efficiency for the care center as a whole. This is due to several factors. The increasing trend toward hypofractionated regimens reduces the amount of time that each patient spends in treatment, which reduces the patient treatment burden and the amount of staff and equipment time needed for each treatment session. This reduction in per-patient treatment time increases the number of patients the care center can treat in a given period of time. In turn, increased patient throughput gives more patients access to care at a given treatment center. Increased throughput is also essential for enabling cancer care centers to transition to a business model that is sustainable in the age of bundled care reimbursement.

Leveraging technology to treat each patient as a unique individual rather than the sum of his or her treatment fractions is the key to improving patient outcomes and health care economics in radiation oncology. In this manner, continued innovation in EHR technology is a prescription for success.

— E. Ronald Hale, MD, MPH, is the network medical director for radiation oncology at Kettering Cancer Care in Miamisburg, Ohio.