How TN Oncology Used ePROs to Scale Oncology Care Management

In order to succeed in its value-based contracts, TN Oncology recognized it needed a tool to monitor and engage patients outside of the clinic. However, with limited staff, a telephonic care management solution was not enough to reach its more than 70,000 patients.

Dr. Dickson, TN Oncology’s Chief Medical Officer, saw developing an ePRO program as the answer. The program would utilize a scalable, electronic tool to make it easy for the care team to reach out to patients, and patients to communicate with the practice.

Define ePRO program scope

At the onset, TN Oncology defined a clear purpose for their ePRO program: streamline communication between the patient and practice by creating one place where patients would be able to go to for everything (e.g., responding to patient questionnaires, communicating with pharmacists, tracking medication compliance, and ideally participate in pharmacy and clinical trials). The program was scoped to focus on bidirectional communication between the patient and practice for any necessary interventions and not for the technology solution to provide in-platform clinical advice or solutions.

Advice from TN Oncology

Sample questions to ask before starting an ePRO program:

• What is the goal of your ePRO program?
• Who will be the primary users of the system other than patients?
• What use cases do you want to track patient data for? E.g., value-based contracts, patient experience initiatives, quality improvement projects

Leverage program goals to build buy-in

With a clear purpose and scope, Dr. Dickson was able to more easily build buy-in for the new program. Below are examples of how TN Oncology tailored messaging to get program buy-in based on stakeholder.

Physicians: Dr. Dickson illustrated that the program would not add complexity to physicians’ day-to-days. Instead, it could reduce the number of patient messages physicians should have to respond to in the EMR (since care coordinators would be the first responders to patient questions). In addition, it could reduce the number of patients admitted to the hospital and consequently the need to round in the hospital as often.

Chief Financial Officer: Dr. Dickson illustrated how the cost of the technology would be offset by the savings achieved through monitoring patients more closely. The key was illustrating anticipated avoided costs and the reduction in unnecessary utilization of services. To avoid costs associated with hiring new FTEs, TN Oncology leveraged existing care coordination nurses to staff the ePRO program.

Advice from TN Oncology

We had to lay it all out cost by cost. For example, here is the number of high-risk patients and here is the hospital admissions costs. We had to show not just the cost of the technology, but also the cost of the care team. We used existing nurses.

Dr. Natalie Dickson

CMO, TN Oncology

With consensus on the decision to implement an ePRO program, TN Oncology spent the next two years identifying a technology vendor.

First, they defined specific use cases the technology platform would have to serve in order to achieve their ePRO program’s goals and scope. For example, they knew the platform would have to be able to collect data for value-based contracts. Next, they used those use cases to develop specific criteria to evaluate and rank potential vendors, such as the ability to perform data analysis and integrate with the EMR. TN Oncology assessed five vendors before deciding on a partner. Finally, the vendor spent six to twelve months working with TN Oncology to understand their workflows and adapt the platform accordingly.

Finding the appropriate partner to build the ePRO program was critical to the success of TN Oncology’s ePRO effort. The organization did not compromise on finding a vendor who had a good technical team, understood clinical workflows, allowed for the necessary data analysis, and offered the ability to customize the tool to changing program needs. For example, many of the vendors TN Oncology assessed did not allow them to access and analyze collected data. This was a nonstarter for TN Oncology since data analysis would be critical to understanding patient voice and measuring the success of quality improvement projects.

Advice from TN Oncology

Don't rush the process. I'm glad we implemented the program slowly because it gave us time to get what we wanted from the vendor.

Dr. Natalie Dickson

CMO, TN Oncology

Instead of hiring new FTEs to staff their ePRO program, TN Oncology combined their existing care coordination and triage teams to manage the ePRO platform. They also moved to a centralized staffing model, which enabled the clinics to focus on being patient-facing without adding too much ePRO-related work. The new centralized Care Transformation Team created more accountability for the ePRO program and improved communication between individual care coordinators. Long-term TN Oncology sees the centralized model as critical to their program’s growth and ability to scale.

Benefits TN Oncology realized with a centralized staffing model

Better care standardization: The centralized model created a standard way to deliver care in the ePRO platform across 30+ clinics.

Boosted staff retention: Staff can work remotely as needed such as when clinics are closed due to inclement weather.

Reduced clinician burnout: With scoped roles, care coordinators are not pulled into clinic tasks and clinic staff are fully dedicated to patient-facing tasks.

Improved patient experience: Centralizing staffing increased efficiency and allowed nurses to respond to patients more quickly (in 2 hours or less).

While both the triage and care coordination teams jointly monitor the ePRO platform, each team’s purpose is different. The triage team plays a more reactive role by responding to patient-initiated requests such as when a patient reports symptoms and needs immediate clinical guidance. In contrast, the care coordination team plays a proactive, navigation role by identifying patient needs and symptoms early on.

Data analysts and health economics researchers support the team through performance improvement and data tracking. For example, the data analysts and researchers assess outlier hospitalizations and whether they correlate with processes like physician continuity

TN Oncology defined “workflows” for every stakeholder that would interact with the ePRO program. With clearly delineated clinical roles, TN Oncology scaled the ePRO program from five to 34 clinics. Below are lessons from TN Oncology:

Target patients by risk-level, contract, and clinical need

While all patients have access to the platform, only patients in value-based contracts and high-risk patients are actively enrolled in the ePRO program. Today, each care coordinator is assigned 225-250 patients. This ratio protected care coordinator capacity to manage all active patients and allows the program to scale more easily.

Train care coordinators to be first responders

Prior to the program, patients would send questions to physicians through the patient portal or calling the clinic, but physicians were unable to answer in real time. With the ePRO program, care coordinators are trained to be the first responders to patient questions and can provide timely interventions or escalate to physicians, as necessary.

Scope the physician role to be the touchpoint of last resort

To prevent significant impact to clinicians’ day-to-days, care coordinators only reach out to physicians as necessary. Only if patients report a clinical symptom grade of 3 or 4 on an ePRO patient questionnaire does the care coordinator contact a physician or APP. In this model, physicians do not work directly in the ePRO platform but respond to escalated requests via the EMR or TN Oncology’s internal text message platform.

Digital inequity can undermine any ePRO program and TN Oncology understood that their program was no exception. To support patients who lacked internet access, were inexperienced with digital technologies, and/or were uncomfortable uploading information into digital systems, TN Oncology developed “fail safes” to capture and support these patients. These fail safes consisted of various additional touchpoints, ranging from proactively assessing digital literacy at intake, to developing alternative ways of capturing ePRO data (e.g., phone calls to patients’ homes and iPads in the clinic to collect survey responses).

TN Oncology’s ePRO program model ensures digital support and training doesn’t happen only once and instead relies on multiple touchpoints from a range of stakeholders including front desk staff, check-out staff, family and caregivers, and care coordinators throughout the patient’s treatment.

When TN Oncology first launched their program, it took patients about 30 minutes to fill out an ePRO questionnaire, which led many to quit the survey before completing it. TN Oncology made three key changes to improve patients’ experience with the platform and boost patients’ response rates. With these changes, patients now spend only 5 minutes responding to questionnaires.

Create ePRO program awareness at the onset

Key to improving patient response rates was educating the patient about the benefits of the ePRO program throughout their treatment. Today, if a patient is enrolled within a value-based care program, the care coordinator discusses the ePRO program at the outset of joining the clinic. The coordinator will explain how they will be the patient’s main point of contact, how the patient will be sent surveys, and how the surveys help the patient receive better, more timely care within the clinic and remotely. If patients aren’t responding to questionnaires, the care coordinator will call the patient and reiterate the importance capturing the patient’s ePRO data.

Advice from TN Oncology

1. Include patients and caregivers in the development of the ePRO platform and patient questionnaires to ensure the user journey is easy for patients and relates to their lived experiences.
2. Analyze the data on how patients interact and engage with the patient questionnaires. For example, track how many patients have filled them out, opened them, and not opened them; where do patients stop filling them out; how much time are patients willing to spend before exiting a survey.

Adjust questionnaire length to individual patient needs

TN Oncology discovered that some patients with few to no symptoms were stuck filling out questions that didn’t apply to them. TN Oncology adapted the patient questionnaire to first ask, “are you experiencing any symptoms?” If patients answer no, the questionnaire soon ends. If patients respond ‘yes,’ they have the ability to choose from twelve symptom categories such as GI, fever, etc. Additionally, TN Oncology eliminated free-text fields to save patients’ time and to ensure quantifiable data.

Engage patients with bidirectional feedback

Because timely clinician feedback creates an incentive for patients to respond to questionnaires, TN Oncology requires a two-hour-or-less response time for care coordinators to respond to patients during business hours. Looking ahead, TN Oncology is looking to establish additional triage capabilities outside of business hours and expand availability of same-day appointments for patients who indicate urgent symptoms on their ePRO questionnaire.

Advice from TN Oncology

Patients appreciate the proactive approach, such that if we took the program away now, we’d have an uprising with our patients.

Dr. Johnetta Blakely

CMO, TN Oncology