System Requirements for Value Based Oncology Care
Steep Turns – A Lean Approach
September 7, 2014
David Scrugham, Wes Chapman, Aaron Lyss & Gina McKinney
Preface: In “THE BRAVE NEW WORLD OF ONCOLOGY ACO’S – INVERTED INCENTIVES & INVERTED IT SYSTEM REQUIREMENTS” we discussed the requirements for a functional IT system in value based care (VBC). In this article we take a look at what we are actually doing using lean principles to adapt a fully functional oncology fee-for-service (FFS) system to a VBC model, while still maintaining the full FFS capability.
Steep Turns – An efficient approach to systemic change
We have been working for the last several months on an IT systems design project at Tennessee Oncology, whose purpose is to allow for the creation of an oncology patient centered medical home, while not degrading the existing FFS capability. Tennessee Oncology is the second largest independent provider of medical oncology services in the US. The basic project goals are:
- Facilitate the four basic Medical Home Requirements, providing systems for: a) Evidence Based Pathways, b) the development and use of Care Plans, c) Patient Management – particularly telephonic triage, and d) Palliation.
- Maintain and not disturb the existing functionality of the existing FFS IT infrastructure.
- Add as few new software/hardware systems as possible, and spend as little as possible while still ensuring that the system would be durable and scalable as it went through the test/pilot/production cycle.
- Use systems that can benefit our clinical partners and referral sources in their requirements for patient management, cancer registry and meaningful use functions.
- Build as little as possible and only those functions that really add value to patient care.
Where We Started
Shown below is the basic starting system diagram. It includes a fully functional and efficient patient management and billing structure for medical oncology, including integrated labs, pharmacy and RIS. The initial system includes virtually no “home grown” technology and provides a reliable, auditable and functional operating environment.
Starting IT System
We settled on the use of 3 outside systems/providers including:
- Via Oncology™ for Evidence Based Pathways. First, the Via system is cloud based, and offers a solution requiring minimal installation of equipment and capital risk. In addition to evidence based pathways for medical oncology, we found that the Via Oncology system allows for the systematic development of Care Plans, with certain features applicable to Palliation and Patient Management. The Via system provides some integration into our EMR, and facilitates the addition of clinical trials – a very important part of the clinical care offering at Tennessee Oncology.
- Clinicast for patient risk stratification and analytics. Clinicast offers an oncology specific, cloud based patient/practice analytics system based on clinical data. We examined a number of systems that operate on payer based data, and found that they offered poor analytics and were extremely expensive. Furthermore, we found that our payer partners already have patient risk stratification models that they are generally willing to share – but they don’t like them because they are based on payer data – which is non-specific, always late and frequently contradictory.
- We have an opening in our new system for an external data analytics portal, for which a vendor has yet to be chosen. We have a mountain of data sharing requirements/opportunities with our clinical partners, which we are just beginning to fully understand. There are a large and growing number of practical “small data” sharing requirements on which we are focused with our clinical partners. Additionally, there are a vast numbers of data points that are required by Federal, State and Professional regulatory bodies that can be effectively shared between provider-partners. Data sharing is a real opportunity to reduce cost and aggregate administrative burden, while improving patient care.
- Finally, we are undertaking the building of a seminal stage patient management system, starting with telephonic triage. At its core this system needs to provide three things: 1) Timely and effective patient triage, 2) Two-way patient engagement outside of the 4 walls of the clinic, especially off-hours, and 3) Avoidable hospital admissions and ER visits on an out-patient basis. We have looked everywhere for a good triage system, integrated with our EMR, and simply haven’t found it. In a larger sense, we are looking at this as a patient reported outcomes system, with triage simply being the most critical patient interface for outcomes reporting. In order to grow into something more important, the triage system will need to offer multi- modality reporting for patients, and for different settings and purposes. Our design will incorporate this required flexibility in a cloud based solution.
Future State – Lean Functionality Enhancement
One interesting aspect of patient management systems and the technology needed to facilitate their effectiveness is that these are not problems for which big data solutions are required. These are simply operational challenges posed to current workflows of community oncology practices that require “small data” solutions. Furthermore, it is critical to note that the system that we are designing relies heavily on good data integration with our provider-partners. This is a design based on mutual benefit, but will have a major potential benefit outside the envelope of current expectations.
Integrating the data collection system across providers is the only way to collect the robust clinical data required by pharma and medical device companies. The detail and complexity of data required by these industrial companies simply can never be provided from a single vector of oncology care – it requires data from all partners in the care ecosystem. It is for this reason that the most successful pharma and medical device data partnerships have been developed with integrated health systems. We hope to have Tennessee Oncology uniquely positioned with our provider-partners to benefit from the care improvement and commercial opportunities afforded through careful and well executed data sharing.
Systematizing the technical and operational elements of patient management is not technically complex, capital-intensive, nor big data-driven. Rather, it is the single most meticulous, valuable, and essential aspect of the oncology ACO.