Oncologists discuss their experience and best practices with phone triage programs.
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.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.
What do people call about? "Everything," said Tracey Weisberg, MD, of New England Cancer Specialists. "'I'm nauseated and the pills didn't work.' 'I have a fever.' 'My eye is red.' 'My leg is swollen.' 'I have pain in my belly.' 'I pee blood.' 'I see blood in my bowel movements.' 'My joints hurt.'"The causes and results vary just as widely, she said. "These are either potential manifestations of toxicities to treatments that we give people, or manifestations of cancer recurrence, or another medical problem—nothing to do with cancer," Weisberg said. "The triage system takes you through the decision-making tree and gets the right stuff done for the patient in the right time frame. Maybe the end of the triage pathway is reassurance and, 'Keep your next appointment, which is scheduled in a week,' or maybe the triage pathway is, 'I'm arranging for you to have a chest X-ray at 2:30, and you’re going to see one of our providers at 3:15.'"
Weisberg's practice got a systematized phone triage program just recently as part of the Come Home Project, a value-based, coordinated-care initiative by Barbara McAneny, MD. McAneny, the chief executive officer of New Mexico Cancer Center, received a roughly $20 million grant from the Center for Medicare & Medicaid Innovation in 2015 to implement an outpatient care model she had developed over the years in seven practices. New England Cancer Specialists, in Maine, was one of those practices.
The Come Home model included a standardized, computer-based decision support tool for triage nurses that had algorithms for 38 common symptoms. "Supporting the triage pathways are the 12 clinical treatment pathways intended to help standardize treatment, so outcomes can be reported," ASCO wrote of the Come Home model two years ago. All of the Come Home practices ended up reducing ED admissions, Weisberg said. At New England Cancer Specialists, about 34% of patients visited the ED before Come Home; after, the figure dropped to 17%, she said.
Now, New England Cancer Specialists is developing new algorithms for the phone triage program focused on drug toxicities—specifically, immunotherapy toxicities, Weisberg said. "I don’t know how we would run our practice without that phone triage system," she said. New England Cancer Specialists gets its treatment pathways from Innovative Oncology Business Solutions, an ASCO-endorsed company that collaborated with McAneny on the Come Home project. Another pathways company is Via Pathways, which Ellis' practice contracted with to build its phone triage software. If that software is a success, Ellis said, Via plans to make it available to customers.
Whether practices contract with an existing pathways company or build their own, it's important to have them on the computer, Weisberg said. "Any practice could create pathways, but you don't want them to be on paper—you want them to be integrated into your electronic records so you have a way to capture data and see if the pathways are working the way you want them to," Weisberg said.At New England Cancer Specialists, triage nurses use double screens—pathways on one screen, records on another. "They can see what meds [patients] are on, what chemo regimen they're on," Weisberg said. Having accurate information and a complete care management plan in front of a nurse is essential, Sprandio agreed. "And tracking the disposition of every symptom-related call is essential—that’s how we learn," Sprandio added. "We have changed the algorithms probably at least 15 or 16 times since we established them."
Though phone triage is nothing new, systematizing it has caught on in a big way recently, Sprandio said. "Every oncology program, institutional program, and community-based practice is interested in developing and implementing these," Sprandio said. "This is a way to drive patient efficiency and a way to drive practice efficiency."
It's also, as Ellis noted, a way to save money. As CMS wades into a payment model that reimburses providers based on outcomes, it becomes more imperative to focus on cutting costs, he said. "As Congress asks us to do more with less every year, we have to determine how to best spend our money, and we better make sure we’re spending our money on where it’s best for quality care," Ellis said. "Taking care of things before they get bad with a good triage tool helps."
With CMS leading the way in the public sector, private payers are increasingly turning to value-based care models. It leads to a big question for oncologists, Ellis said: "Are they going to deny you because people land in the hospital too often?"
But value-based models also could, potentially, lead to an outcome that Sprandio said would benefit both payers and providers: standardized care. That starts with solid treatment pathways implemented throughout the practice: at the point of care, in care management plans, and during phone triage. "The insurance industry as a whole applauds greater accountability, consistency, and standardization," Sprandio said. "All these things are good for patients, too, by the way. I've convinced many of the practices I've worked with since 2009 that when practices transform this way, they meet some of the common goals of payers and of patients."