Exploring the Implementation of Quality Care Programs for Patients with Myeloproliferative Neoplasms - Episode 10
Michael Reff, RPh, MBA; Kathy Oubre; and Ruben Mesa, MD, discuss how telehealth, technology, and innovation have increased patient adherence and created touch points with patients with MPNs.
Bruce Feinberg, DO: Jamile says that my goal begs for a technology part to the solution. You can create the PQI [positive quality intervention], but if you do not have the technology solution that allows them to be realized, then you have a breakdown.
Michael Reff, RPh, MBA: Absolutely, that was well described. Across several or all of the oncology practices in different settings across the country, we have seen the medically integrated team lean into the technology and the innovation that has come from the crisis that is COVID-19 [coronavirus disease 2019], with telemedicine increasing and ramping up at light speed in real time, which gets implemented through practices.
Some of the practices may have had a bit more of a robust infrastructure, where they had adherence baked in or dialed in with their electronic medical records [EMRs]. You then saw a lot of other practices recognizing their need to ramp up their infrastructure around adherence, knowing that the patients did not necessarily want to come to the on-site visits. They relied on those face-to-face interactions. Practices are leaning into the technology, whether it is telemedicine or telepharmacy. At the same time, they are taking a harder look at their infrastructure around adherence and whether they are capturing data. I am being specific here, but for example, when a patient starts the medication, not necessarily just when it is dispensed or when it is prescribed, but when does a patient start that therapy? They are then tracking adherence from the start date of that oral therapy, specifically.
They are then having touch points with those patients on specific days, depending on 2 factors that are part of our quality standards, and that is not only the dynamics and the specifics around a particular medication, but also the specifics around the patient. When a practice takes a look at the patient dynamics and the therapeutic dynamics, you can better track adherence, which is compliance and persistence, as we know. That helps frame the issue with how practices have leaned into the technology and have understood the importance of adherence that came out of this. One of the silver linings is ramping up our adherence work with oral therapies.
Bruce Feinberg, DO: Kathy, in frontline community practice, it is probably even your job. What are you doing; did the EMR have the capability? Can you build in the ticklers file systems? You can easily schedule, but what happens when they do not show up, or whatever else is going to be involved? It is not just a matter of getting them seen, but there is also a blood count. Even if they do not get seen, they need to get the blood count. What did you have to build? Did you have to create something new? Did you have to do something to upgrade technology? What was the dependency upon technology to be able to realize a solution?
Kathy Oubre: In the beginning, it was my lack of education of what our EMR could do for us, and I think most people would say that. We have probably all used that EMR with maybe 30% of what it is capable of, but COVID-19 pushed us fast to learn a lot more about it. In the beginning of COVID-19, no one was going to the doctor, and in our world, that could be catastrophic for patients. We were running no-show reports every 48 hours, and there are a lot of adherence buttons that you can add into the EMR that are there. To Jamile’s point, if someone does not show up, it is almost like hitting the snooze button on your alarm clock: it will pop up 2 days later and say, “Call Mr so and so. Remember: he did not show up, or he canceled his appointment.”
It is following all of those metrics such that, for us, the no-shows stay with the front desk. After 2 no-shows, they then go to the nurse. If they cancel their appointment, those immediately go tasked to the nurse and fall within their workflow. It is about seeing what your EMR is capable of and talking to your team: “Who wants to handle what?” Then follow those decision trees. After 2 touch points, it goes to this person, and then it goes to this person, and then this is how we handle it.
Bruce Feinberg, DO: It sounds like you were doing that as a COVID-19 response.
Kathy Oubre: We were doing a lot of that before in oral adherence, but COVID-19 kicked it up a notch.
Bruce Feinberg, DO: Did that process begin because of the MPN [myeloproliferative neoplasm] program? Was that the beginning of it, or was the program coincidental, alongside it, as you were doing these things?
Kathy Oubre: It was. We were already doing it. It was coincidental.
Bruce Feinberg, DO: It is sometimes easier to do these things in a private practice. Jamile, Ruben, sometimes at large institutions, if you want to have an upgrade in your information technology, it gets into a queue, and you get a note that they will be getting to you in 2 years. Are you able to do similar things? Do you get reports on no-shows? Given that this is a patient population for which there is a timing lead, they are in less frequently. If they fall through the cracks, it could be 3 months before they get seen again because they skip a visit and reschedule for the next 3 months. Is that something that can be caught or is caught?
Ruben Mesa, MD: We [at The University of Texas Health San Antonio MD Anderson Cancer Center] are on Epic EMR system, and those are most certainly things that we have been building into our program. It is an idea differentiated by disease state in terms of expected return or frequency. These are some of the questions of how we optimize them because, for some patients depending upon the disease, a week too late might be a concern, and in others, perhaps it is not. As our technology helps to support us more in terms of trying to dial those things in at the beginning of a patient’s treatment course, that will be most welcome.
Bruce Feinberg, DO: It is interesting because, although the focus is on MPNs, every time you introduce a quality improvement, it has potential to be effective across everything that you do. It sounds like this is one that has the potentiality, and it became clear with COVID-19 that that was a need. For those who may be listening or watching, who may have thought about this as in the era of COVID-19, the recognition is that there are disease states for which this should be a routine process and not just during a crisis. It should be there. That is one of the messages that comes out to me.
Ruben Mesa, MD: Correct. It is an evolution where we now have well-established pathways for not missing new results in our EMR, whether they be laboratory test results, x-rays, etc, that could have fallen through the cracks. This is the more up-to-date issue in terms of return visits not being able to fall through the cracks.
Transcript edited for clarity.