At last years GenesisCare Clinical Collaborative in Adelaide, our Director of Clinical Strategy, Matt Hickey, delivered presentation on what the information guided care co-ordination concept (now commercially referred to at 360 Oncology) and what GenesisCare UK was expecting to achieve, well one year on here we are.
Quality, Access, Efficiency and Innovation, Collaboration, Compassion and Outcomes were all at the forefront of this initiative
Collaboration between Varian and GenesisCare UK began in December 2015 to clinically road-test the suite and now 10 months later we have a system that is functioning and thriving in the clinical environment
Since then there have been several meetings and user group feedback
12 staff members
2 therapy radiographers, 1 diagnostic radiographer, 2 physicists, 1 dosimetrist, 1 pharmacist
2 medical secretaries, 1 administrative officer, 1 manager, 1 receptionist
All staff members have varying degrees of use with computers, oncology patient management systems such as Aria and Mosaiq and time employed with GenesisCare. Not all staff members have direct contact with patients. As the department is small it was imperative to engage with all members of staff so in times of need we can all be utilised.
So from this time last year to now, what have GCUK and Varian been doing?
Meeting in London with centre representatives of the IGCC programme on how the system will work, training and an opportunity to collaborate with the software engineers to express the daily clinical demands of the system (e.g. what would and wouldn’t work)
Initial introduction via Varian- each staff member had one on one training on how to use the website, basic trouble shooting- this took 3 hours. Still finding bugs and errors at this stage. The collaboration with both teams was key to ensure all problems being experienced were appropriately reported and gave the staff at the centres an opportunity to explore not only the clinical portal but the patient portal also.
Centre led IGCC group- At Oxford, we commenced a IGCC group which included a radiographer, centre manager and an administrator. It was key to involve all members of the department so all ideas regarding how to launch this programme to our patients could be discussed. The main responsibilities lie with the administrator as they communicate with the patients first after receiving the booking/referral form and then the radiographer from the moment of CT to when the patient finishes treatment.
Protocol development- Two manuals were created by the Clinical Intelligence Lead- (Eleanor Love) The OX4 protocol was developed as a workflow guide to assist any member of staff within the Oxford centre, but after review other centres have the potential to amend sections of the workflow to suit their needs.
Weekly meeting- The Oxford IGCC team met weekly to discuss any issues with the system, potential patients and to develop the workflow within the centre.
Pilot and Roll out phase- It is all the above work that led to a smooth roll out phase within the centre which took place across 4 of the GenesisCare UK sites.
Three patients were used in the trial period. Originally 6 patients had been selected for the trial period but due to various issues with 3 potential patients they were omitted from the pilot phase.
The pilot patients were between 41-45, female (3) and all had access to a variety of electronic devices that supported the patient portal. The patients were all informed of the system at the time of their CT plan scan, sent 2 emails (1 to verify the email address and one containing a patient manual, a step by step guide on how to use the portal) and within their first week of treatment they received a 30 minute introduction to the IGCC.
On average it takes 5 minutes to set up and verify the account once the automated email hyperlink has been accessed.
It is to be noted that during the pilot phase no palliative or prostate patients were to be included due to the shortness of the treatment schedule and the resource capabilities of the centre.
Calendar- The calendar function allows patients to review any appointments they have which are stored in our mosaiq system as all information is pushed from there to portal such as radiotherapy appointments, Dr reviews and holistic care appts.
Diary entry - The diary entry function is an invaluable feature of the CCC. It encourages patients to self report and therefore track the potential side effects of their treatment. This can either be kept “private” and will only display on the patients portal or it can be shared with the “care team”. This aspect of the portal is invaluable as it gives patients a greater sense of self-management in a treatment pathway that has been historically pre-defined for them.
Feedback- The feedback function of the patient portal can be used as a bug reporting system and can either be sent to Varian or the “care team”. Built in to the IGCC is the ability to watch tutorials on how the system works. This is automatically played on the patients first log in to the system but can be repeated at any time.
Reminders/ To do List- There are pre defined reminders for patients when they first log on to the system but these can be developed further to be suited toward treatment sites (prostate; bladder and bowel prep, rectal patients with concurrent chemo)
Messages- Messages can be sent to the care team- the care team is defined by selecting members of staff and associating them with the patient prior to the patient registering. By having a team cc’d it ensures that any message sent by a patient is always received by a group.
Surveys - (Patient reported outcomes) are scheduled weekly during treatment and a reminder is sent to the patient portal. These can be scheduled with a recurrence of up to 7 weeks (prostate 74Gy, 37# schedule) and have an expiry period of 72 hours after release. After treatment we will schedule these 3-monthly for 5yrs
Patient insight alerts- Having now commenced with routine collection of PROMS the Patient Insight feature of 360 Oncology will populate alerts to enable us to see when patient outcomes are declining or they have unmet needs. This means we can be proactive in our care delivery, provide timely, needs-based engagement and improve outcomes and satisfaction
Personalised- The portal can be personalised by patients submitting information regarding current medication, nominating delegates and by selecting their “3 favourite” icons which appear on the left hand side of the portal.
Screenshot of clinical portal (it works on the principle of pop ups for each new tab opened). NOV ‘16 new release screenshots shown here
Please note, the language developed by Varian was specifically chosen to appeal to a wide range of oncology patient management systems. At GCUK we use Elekta/Mosaiq therefore having only Aria terminology such as “Time Planner, Patient Summary” would be very confusing for those who have not had the opportunity to use the system before.
Charts- Patient Summary (Aria) or Demographics (Mosaiq).
Applications- Documents (both Aria and Mosaiq), shows if and when a patient sends through a document i.e a prescription for a medication that they have queries about or a clipping from a magazine.
Messages appear on the left hand side of the screen, this includes all activity from the patient and clinical portal. E.g. if I send a message to a patient it will appear in the inbox as it is being shared also with myself the “care team” as well as the patient.
There are already fantastic updates and changes developing within the system:
The home page can show all the patients associated with the person logged on to the system to give an overview of all tasks at hand.
The surveys that patients complete can be displayed as a dynamic decision aid therefore enabling the care team to track and trend the deterioration or improvement of a patient and provide clinical alerts as to when this event (lowering ECOG score) may occur and how to prevent this.
After gathering all this intelligence, 360 oncology then populates the data and measures how patients of similar treatment technique or primary oncology site scored against each other therefore providing a “normal” response.
It is fantastic to have a wide range of features to use but how did we collect and correlate the data?
Semi structured discussion- As the lead of the IGCC, the patients recruited were having daily radiotherapy so informal discussions regarding the patient portal occurred frequently. This allowed me to monitor that the patients were still using the portal and accessing the features that they may require without ease.
Observation- I was able to observe the Patient Portal when a patient was showing me the features but similarly, any time there is an “update” such as a new message, diary entry or digital upload from the patient it is shown in the “care-teams” inbox. This was used to monitor the level of use from the patient and other members of the care team.
Written feedback- During the pilot phase the patients were encouraged to provide feedback both via the messaging tool and standard email. The feedback was then discussed locally and forwarded on to the Clinical Intelligence Lead. This was also discussed at the weekly CCC meetings between centres.
As the data was qualitative in nature and based on experiences of individuals it cannot be scrutinised into correct or incorrect categories. This is very important to remember as the experience of each individual may differ and produce different outcomes.
Feedback from all three patients was both positive and constructive and was always welcomed in order to improve the outcome of the patient portal experience, it was recorded on a local spreadsheet, filtered into levels of severity and incidence and cascaded accordingly.
The evidence showed that there was a positive correlation between patients who accessed the system more than twice per week (left diary entries and messages) were significantly more inclined to independently provide updates to their health needs. The CCC has shown to improve patient involvement with the care team, in what is a life changing event patients are able to collaborate with staff with greater ease
Initial positive feedback included; The use of the portal across many electronic platforms- it has to be noted that at the this present moment in time the surveys section is not available on tablet or smart phone only p.c. It fits into their lifestyle more appropriately.
Diary entry feature was easy to use, practical and a good way to self declare and have more control over my (patients) journey.
Ability to contact staff when running late- key if you have ever experienced Oxford traffic.
Constructive feedback: To have insurance information visible on the platform such as customer number.
To receive notifications when someone has sent a message or reminder into the portal- similar to the social networking site that rhymes with “racebook”.
Patient compliance: Trying to ensure that all patients continue to use the system past the original induction phase can be challenging. It has been noted that for those patients who struggle to register themselves on to the system this automatically deters them from future use. By having more staff trained on the system they can deliver the introduction sessions and answer questions and concerns- collaboration is always key when implementing change.
Updates to the system: With each major update to the system it will improve the user experience both clinically and to the patient. If the update were to show that more training would be required to use it then it would have to be factored in and training times planned in advance to ensure minimal disruption to the service. With appropriate protocols for each centres working patterns this can be achieved with ease.
Management of patients: With more patients being enrolled onto the CCC system there may be challenges with monitoring the workflow process and who takes responsibility for what aspect of the workflow. At this moment in time, as only radiotherapy patients are being enrolled onto the system it is the primarily responsibility of myself- a radiographer to organise their registration and the management of other staff on who will be able to introduce the patients to the system, etc. As the system develops there may be scope for more of these current human tasks such as scheduling surveys, monitoring compliance, observing diary entries to become computer based with automatic reminders being sent to patients to complete aspects of the patient portal and based on their appointment schedule to “know” when to schedule the appropriate surveys.
We are also doing a workflow and resource review to look at having local patient engagement performed by the Rads but all clinical alerts and admin centralised to two ‘survivorship coordinators’
Use of system internationally: As the system is so simple by design and has especially been developed to be used by a wide patient cohort there is no reason why it cannot be used across a variety of radiotherapy departments regardless of their current Oncology patient management system. There may be future scope to develop the software in a variety of languages (such as Spanish) and perhaps even more long term to provide the product across both the private and the public health sector, although the public workflow pattern may be a little different from what we would be using.
Clinically the IGCC can provide ease of access to clinical teams regarding patient submitted outcomes of their treatment. It is these outcomes updates that are reported across a number of months and even years that have the potential to influence change and practices to the radiotherapy community, to improve the outcome of all patients in the future.
However, more importantly, our patients can have the confidence that they remain “connected” to our network and can gain access to our services whenever it is needed. This is revolutionary.