The delivery and financing of oncology care have changed rapidly in recent years, posing challenges for oncologists and their practice administrators. In an effort to improve healthcare quality, coordination, and efficiency, a number of novel payment mechanisms and cancer care delivery models are being developed and implemented. One such model, the Oncology Patient-Centered Medical Home (OPCMH), has been developed to help oncology practices enhance the value of cancer care. OPCMH was pioneered by John Sprandio, MD, and his colleagues at Consultants in Medical Oncology & Hematology (CMOH), a 9-physician medical oncology practice. CMOH was recognized by the National Committee for Quality Assurance as a level 3 Physician Practice Connections–Patient Centered Medical Home in 2010. CMOH was also certified in 2010 by the American Society of Clinical Oncology via the Quality Oncology Practice Initiative.
Q: What factors prompted CMOH to re-engineer its cancer care delivery processes more than a decade ago?
John Sprandio (JS):We were driven by the desire to enhance the consistency of care we were delivering and to differentiate ourselves in a competitive market. We took a critical look at our performance as a practice and whether we, as a group of 9 oncologists, were clinically integrated. We saw a great degree of variability in the way members of our care team engaged patients and the way our physicians delivered patient care. We needed to standardize and streamline variable processes that individual physicians had in place, but lacked a mechanism that could fix accountability to responsible members of the care team. As physicians, we also realized that we were bogged down by an increasing number of clinically irrelevant activities, such as inputting data into electronic medical record systems that did not match our workflow and working with third-party vendors seeking to implement payer-imposed pathways. In addition, we were saddled by documentation burdens, messaging and workflow interruptions, and a lack of systems or models of team-based care to support clinical work. These and an increasing number of other “time-stealers” distracted us from our primary focus as physicians––to establish and maintain personal relationships with patients and to make complex medical decisions.
In order to refocus and prioritize our physician activities, we established 8 goals: (1) streamline our processes of care; (2) standardize roles and responsibilities of the care team members; (3) minimize clinically irrelevant physician activity; (4) engage patients and their families more fully and consistently; (5) fix accountability at the locus of control and responsibility within the care team; (6) select quality and practice performance metrics responsible for driving desired patient outcomes; (7) develop supportive information technology that facilitated this re-engineered model of care; and (8) deliver real-time data to our physicians to progressively improve performance.
Q: How important was the role of technology in facilitating change?
JS: We implemented an oncology-specific EMR in 2004, but soon found that paper chaos was replaced by digital chaos. Poor information management was a huge barrier to meeting our stated goals. We were forced to spend more time in front of a computer screen than we spent in front of our patients. Our activities were focused on compliance and billing rather than on the collection and sharing of consumable, pertinent clinical data.
To address the disruption in workflow and process caused by the limitations of the available technology, we created a software application known as IRIS that overlaid our oncology-specific EMR. IRIS has evolved and serves as a platform for process standardization and workflow. IRIS facilitates the integration of workflow, data collection, data presentation, provider response to data, documentation, and communication. Physicians are able to concentrate on maintaining highly personal relationships with patients, have all data necessary to make increasingly complex medical decisions, and have the ability to do this more efficiently. We have accumulated more than 5 years of internal practice data documenting an improvement in the consistency of services, an improvement in quality, and a reduction in unnecessary resource utilization.
We continue to add features in response to physician information, communication, and documentation needs, engaging physicians to become more accountable for the quality and the cost of care.
Q: How has the OPCMH concept continued to evolve? What changes has your practice made as part of that evolution?
JS:At the start of our journey in 2004, we did not have the goal of becoming a medical home. The Joint Principles of the Patient-Centered Medical Home in primary care were not established until 2007.1Our efforts were initially very physician-centric; however, the physician-centric activity evolved into a very patient-centered care capability.
We will continue to evolve IRIS from a technology and functionality perspective. On the technology side, we are working with partners to interface IRIS with other EMR vendors and to enhance analytic capabilities.
Methods of data collection and distribution are evolving; we are focusing on data that are reflective of patient activities that are complementary to the practice of PCMH-related service capabilities, the documentation and tracking of comorbid conditions, and the sharing of pertinent information directly to and from the oncology care team and other physicians responsible for patients’ comorbid conditions.
Patient engagement is evolving, and technology is playing a major role. Two-way patient portals are facilitating communication: they enhance patient ability and accountability for reporting symptoms in a timely fashion, educate patients about what to report, and give patients an avenue to clinical care.
Enhanced patient engagement and education are the cornerstones of the OPCMH model. These activities will evolve through continuous process improvement and through the progressive application of technology.
Q: Community oncology is under tremendous financial pressure today. How has the implementation of the OPCMH concept helped to keep your practice fiscally competitive?
JS:Our practice went through a difficult period. When our patients experienced more complete and consistent office visits, resulting in less office visits per chemotherapy patient per year, fewer emergency department visits, fewer hospital admissions, and less chemotherapy utilization at the end of life, we as a practice experienced less revenue. We successfully reformed the way we delivered care, but we did it in a fee-for-service environment that did not recognize the quality or the level of service. Thankfully, oncology payment reform is now catching up with care delivery innovation. There are a number of examples nationally that have shown early promise. In the recently proposed Oncology Care Model, the Centers for Medicare & Medicaid Services will recognize the economic value of true practice transformation.
Early in 2014, we secured a contract with our largest payer. This contract, along with another payer contract (in its fourth year of operation), covers approximately half of our patient base. We expect to gain ground economically in the second half of this year when we can hopefully opt into the Oncology Care Model for a large portion of our Medicare patients.
Q: How has the role of nurse practitioners (NPs) evolved at CMOH since the implementation of the OPCMH?
JS:Our NPs are deeply embedded in the care team, with defined but flexible roles and responsibilities. Our NPs work in close partnerships with the oncologists.
I depend on my NP tremendously, but I also have full oversight and visibility with every action because of the systems that we have developed. This results in a collaborative, learning relationship that drives consistency of care.
Q: What are the roles of the practice administrator and nonclinical support staff in supporting operations at CMOH? In the OPCMH setting, how is business management different from traditional practice models?
JS:Practice administrators and nonclinical support staff play a critical role. They must understand the OPCMH working model and the goals we are striving to achieve. There is also a reassignment of roles and responsibilities; for example, we trained administrative assistants to become lay patient navigators who are responsible for scheduling every appointment and tracking them to completion.
We have a well-scripted patient orientation intake process with dedicated staff who align our patients’ activities with our patient-centered practice model. Our billing specialists have become financial counselors who serve as the portal to the patient’s ever-changing benefits and rising out-of-pocket expenses. It is their responsibility to coordinate assistance for patients in need.
As care delivery processes evolve on the clinical side, there are complementary and supportive changes on the administrative side, and we rely on nonclinical staff to keep pace with the changing needs of our physicians, patients, and insurance regulatory changes.
Q: How do you see the OPCMH model continuing to evolve in the next several years? What will be the drivers of change?
JS:With an oncology PCMH-like model in place and having technology-supported standardized processes of care as a foundation, we envision the enhancement of data collection and presentation, and the flow of progressively accurate and personalized patient information among all the stakeholders who are involved in caring for this complex patient population.
Our practice transformation company, Oncology Management Services (OMS), is in many ways contributing to the evolution of the clinical model and the associated value-based payment reform needed to align patient and provider activities. OMS provides a spectrum of services that includes practice assessments, facilitation of transformation, clinical tools, and technology support.
EMR platforms may soon open up to innovation, similar to our IRIS oncology software application. We can anticipate the expansion of technological capabilities to help physicians execute care more consistently and efficiently and move past the chaos that often defines the physician work environment today. I am very excited about the future of oncology care and the practice of medicine in general.
- American Academy of Family Physicians. Joint principles of the patient-centered medical home.www.aafp.org/dam/AAFP/documents/practice_management/pcmh/initiatives/PCMHJoint.pdf. Accessed February 5, 2015.