John Sprandio, MD
John Sprandio, MD, said he's noticed a funny thing about doctors. In many physicians, medical school nurtures an independent streak that resists standardization. When Sprandio works with community practices to help launch phone triage programs, he often finds that a single medical problem is handled many different ways.
"It's not uncommon for us to go into a practice with 10 or 20 or 42 medical oncologists and find out if you pulled them all together, there could be 30 different ways of managing delayed chemo-induced nausea," Sprandio said. "There could be four or five recipes for 'magic mouthwash' for patients who have mouth ulcers."
Sprandio found the same phenomenon at his own practice, Consultants in Medical Oncology and Hematology (CMOH), before its three Philadelphia-area locations launched a phone triage program in 1998. He and his team realized there was significant variability in how physicians handled clinical situations and even common symptoms. This fascinated them, and they set about developing symptom-management algorithms to form the basis of the phone triage program.
Starting out with three or four algorithms, the practice eventually developed 24. These "pathways" guided nurses as they assessed and assuaged patients, and over time, CMOH's phone triage program became an oncology practice's version of a critical and commercial success. In less than a decade, the emergency department (ED) use rate among CMOH's chemotherapy patients dropped 78%. Patients loved it, it worked, and when the National Quality Control Association recognized CMOH in 2010, it was in no small part due to the phone triage program. Now, Sprandio shepherds community practices toward their own phone triage programs. He spoke "obsessively" on the topic for six years, delivering talk after talk at national conferences.
Sprandio said he has learned many lessons over the years. He chooses a quote from his friend Brent James, a healthcare executive in Utah and Idaho, to express what he considers one of the most important rules: "Don't let the great get in the way of the good." It’s not possible to have a perfect phone triage program right away; what's important is establishing one and doing the work to make it function, he said. Improvements will come.
Standardization Works Best
To heed that lesson, the architects of a phone triage program have to trade individualism and perfectionism for consistency, he said. "You don't all have to debate what thing is best before you start measuring. Just agree to do the same thing, do it systematically, measure your results, and make continuous improvements based on data," Sprandio said. "That’s what we did with our algorithm, and we’re consistently improving it."
Across the Northeast, practices with phone triage systems agree that they deliver consistency to patients, reduce ED rates, and feed practices information on patients’ conditions. Doctors can use that information to improve not only the "pathways" used in phone triage but patient care in general, said Peter Ellis, MD, of UPMC CancerCenter, of Pittsburgh, Pennsylvania.
Ellis' practice systematized its phone triage program just last month after years of scattershot, unrecorded triage calls. Using a software development team from Via Oncology, UPMC created a triage program that contained pathways, electronic medical records, and reminders to follow up the next day. The chain of cancer centers—one of the largest oncology networks in the country—tested the software at three of its busiest locations last summer, then launched it February 13.
Ellis is thrilled. Pressure to keep patients out of the ED weighs heavily on him, especially in the era of value-based care: "Now, not only do I not want them there, but I lose money; the system loses money," he said. But there's also a lightness to his outlook. Recording the symptoms patients call about creates exciting new research opportunities, Ellis said.
"It'll be interesting to know, is it nausea/vomiting that lands people in the ED more often, or is it pain? And which cancers are those tied to—lung, pancreatic? Are those populations that we should study or proactively approach?" Ellis asked. "If we find out that 10% of our pancreatic cancer patients are going to the hospital with pain, we might want to study that group."
Like CMOH’s phone triage program, UPMC's directs patients to nurses as soon as they indicate they're calling about symptoms. Sometimes, patients need to be reminded of a treatment routine. Sometimes, they need to be referred to the hospital. Sometimes, they just need reassurance.