A marked reduction in hospitalizations and emergency department (ED) visits are key metrics for value-based care programs. Quality improvement processes and electronic patient management systems may give practices a way to fully embrace these programs and remain mindful of cost while ensuring that patients receive high-quality care.

Investigators at Texas Oncology, a member of The US Oncology Network, piloted a quality initiative to evaluate health care resource use.

A review of the data revealed that the majority of hospitalizations and ED visits occurred during normal business hours. Texas Oncology investigators considered various options aimed at improving outcomes, such as extended hours, but decided to first determine why patients were opting for visits to the ED when a visit to the clinic may have met their needs.

A second issue worthy of investigation was patient complaints regarding the timeliness of returning phone calls. Changes implemented at the practice prioritized improving the management of patient calls, and required comprehensive insight into call volumes, nurse burden, and callback times. Without a practice-wide system to monitor and track calls across different locations the statewide cancer care provider, which has more than 200 locations and more than 500 physicians, sought to implement uniform systems and procedures.

Once they had determined that delayed callback times often led to ED visits for symptoms that could be managed in the clinical setting, the Texas Oncology investigators began searching for a solution to improve callback timeliness. Their search culminated in a highly successful collaboration with Navigating Cancer, a health care technology company with an electronic patient management system to efficiently track, monitor, and triage patient calls.

Navigating Cancer’s oncology-specific digital health technology includes a care management platform that integrates clinic workflows, enabling staff to easily document, track, and escalate all inbound patient outreach. Overall, the system enables more seamless communication between patients and care providers when patients are away from the clinic. Its implementation was conducted in a stepwise manner across Texas Oncology’s 200-plus locations, beginning in Q3 of 2019 and being completed in Q1 2020. To evaluate improvement in incident resolution times, an implementation study was launched, tracking resolution times for all incidents through December 2020.

For each practice’s locations, call volume was estimated based on clinic volume; triage nurses and operators were reallocated or hired accordingly. Incoming calls were entered into the Navigating Cancer dashboard as incidents. Operators then followed system-generated prompts and routed calls to the appropriate staff based on symptom priority. Incident volume and resolution times were tracked by the system. 

Practice leadership recommended callback time thresholds, aiming for a less than 90-minute resolution for symptom-related incidents. A root cause analysis of delays in callback times was conducted at each location. Plan-Do-Study-Act (PDSA) cycles were instituted and quality improvement processes implemented. For example, improving communication between triage nurses and physicians during clinic hours was a common theme that required changes in communication styles at various locations. Ongoing monitoring and tracking of resolution times enabled a continuous cycle of quality improvement.

The electronic care management platform also allowed the practice to continue the initiative during the COVID-19 pandemic, as staff were able to work remotely. If a potential ED visit was avoided, nurses documented the information and these data points allowed the practice to establish comprehensive strategic action plans for quality improvement.

Navigating Cancer’s technology solution addressed more than 1 million incidents for more than 400,000 patients in just 1 year (TABLE). The results of the implementation were impressive, especially as the pandemic was disrupting health care at the same time. A few of the most noteworthy findings include the following:

Significant growth occurred in the volume of inbound calls to the practice from the first half of the year to the second, likely a consequence of the shift to more remote care during the pandemic. 

Callback times improved by more than 2 hours from the start of the implementation process to the end. This demonstrates the success of PDSA cycles and the collaboration between the practice and Navigating Cancer to continuously drive process and technology improvements. 

More than 60% of symptom-related issues were addressed in less than 1 hour—a significant improvement for Texas Oncology. 

Eight percent of symptom-related incidents resulted in definite or probable ED avoidances following assessment by a nurse. Shortness of breath, vomiting, chills, and weakness were the top symptoms addressed for ED avoidance.

The Navigating Cancer system created robust data to drive quality improvements and provide a foundation for future initiatives. For instance, data played a key role in PDSA cycle improvements, with data from each location being made available to practice directors at all locations. This created friendly competition and drove improvement, as no one wanted to be last on the list.

The investigators are examining data to identify other possible improvements. They are scrutinizing the types of calls to determine whether anything should be done differently based on patient symptoms and outcomes. This includes, for example, how the system could be optimized to appropriately triage and resolve 1 patient’s report of pain vs another patient’s report of nausea and vomiting. 

The investigators are also evaluating data for call routing to develop strategies to improve processes. Patients often ask for a nurse regardless of the issue, as they know the nurse will return their call. By making sure operators have the right tools to route calls appropriately, nurses will only address nursing-specific calls. Other calls will be routed to the appropriate staff for scheduling issues or financial concerns, among other issues, increasing efficiency in all areas. 

Members of Texas Oncology and Navigating Cancer will evaluate the effect of their system against health care resource utilization, measuring both ED visits and hospitalizations. As data are often delayed, information will most likely not be available for analysis until next year.

Focusing on Improvement Activities Can Drive Better Care

Tackling a problem such as ED visits during business hours requires a deep dive into why patients go in the first place and what can be done to address adverse effects before they become unmanageable. 

During this program callbacks were not happening promptly enough, resulting in patients visiting the ED rather than the clinic. Despite tremendous growth in calls and issues during the tracking period, implementing the Navigating Cancer solution and ongoing quality improvement strategies allowed the practice to shorten callback times. Such focused attention on improvements demonstrated that positive changes, even during a global pandemic, are possible. Based on nurse assessment, this improvement is showing trends toward reduced ED visits and hopefully will be verif ied based on claims data sets. 

The successful implementation of the Navigating Cancer solution is a great example of how technology empowers practices to provide better care, improve outcomes, and reduce resource utilization. Texas Oncology’s use of this digital technology to shorten callback times enables patients to be treated in the clinic by a care team they know and trust, rather than experiencing a costly and sometimes distressing ED or hospital visit.

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A marked reduction in hospitalizations and emergency department visits are key metrics for value-based care programs. Quality improvement processes and electronic patient management systems may give practices a way to fully embrace these programs and remain mindful of cost while ensuring that patients receive high-quality care.

Digital Health and Process Improvements   Enhance Community-Based Patient Care 

Practices participating in the Oncology Care Model (OCM), an experimental payment model developed by the Center for Medicare and Medicaid Innovation (CMMI), are incentivized to improve patient experiences and outcomes by providing enhanced services and care while bending the total cost curve. Adhering to the OCM’s requirements—including 5 performance-based quality measures, changes to the electronic health record (EHR) platform, and a new set of data and analytics—is no small feat.

Yet by late 2020, participating practices in The US Oncology Network had achieved the milestone of enrolling 100,000 unique patients in the OCM. They had also delivered more than $122 million in cumulative savings to Medicare over the program’s first 6 performance periods, according to internal documents from The US Oncology Network (

The practices reduced hospitalizations by 7%, reduced emergency department (ED) visits by 3%, and increased hospice use by 5%. Along the way, these practices implemented increased support through patient navigation and social work, team-based care, high-risk stratification patient outreach, and more enhanced services.

The secret to The US Oncology Network’s OCM success comes down to the power of collaboration. The Network, supported by McKesson, has 14 practices participating in the OCM across the United States.

By putting these connections to work and sharing ideas and best practices, The Network achieved successes that hold great potential for patients, Medicare, and the oncology ecosystem as a whole.

Getting Started: Whiteboards and Work Groups

Introduced as a 5-year pilot program (now 6 years, due to COVID-19) to test payment strategies, the OCM presented a challenge on many levels, from handling enrollment and designing treatment plans to reporting quality metrics and integrating IT and data/analytics. The payment model went into effect in July 2016, but The US Oncology Network jump-started its efforts in advance. In late 2015, The Network brought practice leads together for a 3-day workshop, sounding out ideas for how to make the OCM happen and forming workgroups to tackle various components.

Each practice designated an OCM physician champion as well as staff to support the program, including a quality program lead, clinical lead, and pharmacy lead, and a data coordinator if needed. Early on, the various workgroups, leaders, and committees were able to address multiple challenges simultaneously. Enrollment was one such challenge, and to prepare for it, the practices mock-enrolled patients to create a workable process.

Regarding treatment plans, physicians created templates in advance, received feedback from other physicians in The Network, and worked with the IT team to incorporate the plans into the EHR to meet the Institute of Medicine (now the National Academy of Medicine) care plan requirement.

Maintaining Momentum: Calls and Workshops 

To build on its collective energy, The US Oncology Network set up monthly OCM calls with practice leadership, as well as topical workshops. During the calls, practices that are doing well on a certain metric can present their processes so other practices can learn from them. When challenges arise, the practices brainstorm solutions. Workshops have covered multiple challenges, such as improving patient support, technology upgrades, reducing ED visits, shared decision-making, comorbidities, and end-of-life care.

Reducing ED visits is a goal of the OCM, and it’s a great example of the way The Network leverages analytics to improve patient outcomes.

First, we identified benchmark metrics for ED visits, then reviewed the numbers to see how practices compared against other practices, how providers compared against other providers, and how diseases compared against other diseases. Using these analytics allowed The Network to identify opportunities to improve patient care to prevent potentially avoidable ED visits.

Additionally, The Network worked to enhance patient care by focusing on partnering with patients throughout their journey, making sure they understood their treatments options and making care decisions together. Every patient starting therapy received a treatment plan.

Most practices implemented one-on-one treatment review and coordination visits. Post therapy, proactive phone calls were made to intervene early when patients had adverse effects. Psychosocial screening was carried out, with follow-up care for patients if they were experiencing distress. This shared decision-making allows patients with cancer to be active participants in their care.

Among the many resources The Network created to make the OCM manageable for practices were toolkits on such topics as hospitalization and ED visits, depression, pain, advance care planning, and comorbidities. These toolkits offered an at-a-glance look—often with graphs or charts—at the processes and protocols in place to handle such issues as they arise.

For instance, we noticed that pain was a common diagnosis leading to ED visits and hospitalization. Thus, The Network created a toolkit focusing on how every team member can help with managing a patient’s pain, which included educational resources for both care team and patient, assessment tools, and analytics on pain management.

These types of resources make it easy for practices in The Network to see what works and what doesn’t and make any necessary adjustments.

When roadblocks appear, such as a practice having trouble submitting data to CMMI, it’s not uncommon for the practice lead to call another practice and ask for advice. Collaboration is baked in, with regular sharing of tips, tricks, and best practices.

For participating practices in The Network, the OCM mission of improving patient care is now part of daily operations. The US Oncology Network continues to improve processes, although the basics have become habit, and it’s exciting to be able to offer more enhanced services to patients. The patient journey now includes more access to social work, navigation of services, and other support services to achieve the best outcome. The Network has consistently reduced hospitalizations throughout the program and is continuing to find ways to enhance the patient benefits of value-based care.

Tellingly, 50% of OCM participating practices in The Network pursued 2-sided risk in 2020. This means that if a practice performs well with quality and bending the total cost curve, then it can receive a higher amount of shared savings. However, if it does not do well, the practice must pay dollars back to Medicare. Choosing 2-sided risk demonstrates the confidence of these practices in succeeding with the OCM.

As the OCM enters the final stretch of its pilot program, practices in The Network are striving to continually optimize their approach. They have become stronger through teamwork, sharing best practices, monitoring progress over time, and helping each other improve.

More patients, not only those enrolled in the OCM but others as well, can experience better care and outcomes consistent with patient goals and values.

Stuart Staggs is senior director of strategic programs at The US Oncology Network in The Woodlands, Texas. Lalan Wilfong, MD, is vice president of quality programs and value-based care at Texas Oncology in Dallas.

Practices participating in the Oncology Care Model, an experimental payment model developed by the Center for Medicare and Medicaid Innovation, are incentivized to improve patient experiences and outcomes by providing enhanced services and care while bending the total cost curve.

The US Oncology Network Highlights Success With Oncology Care Model

Cancer is a complicated disease that can easily overwhelm patients and their families. Thanks to better screening tools, as well as advanced therapies and treatment options, survival rates for cancer are on the rise. Another factor contributing to better outcomes is better collaboration between physicians and their patients throughout the entire care process.

Cancer care today involves much more than having surgery to remove a tumor or undergoing chemotherapy or radiation therapy treatments. Oncologists are taking a more holistic approach to care that involves psychological, nutritional, social, spiritual, and financial aspects. They also are using new tools and techniques designed to increase patient engagement and enhance shared decision making.

“Patient engagement” is a term used to describe physicians and patients working together to increase a patient’s knowledge about his or her health and willingness to manage his or her treatment. Patients who are engaged ask good questions, understand their disease, and are more likely to follow treatment recommendations and guidelines given to them by their physicians, nurses, nutritionists, pharmacists, and other healthcare providers (TABLE

). They are also better equipped to share in decision making when it comes to treatment options throughout their care journey. Physicians have a better understanding of patient goals and values to align care with the patient’s wishes.

In a 2013 report, the National Academy of Medicine stated that national cancer care had reached a state of crisis, noting that a lack of understandable and easily available information on prognosis, treatment options, likelihood of treatment responses, palliative care, psychosocial support, and the costs of cancer care contribute to communication problems.

 To describe and document these facts, oncologists in The US Oncology Network now generate a treatment plan document with each patient whenever a new treatment is started. They print and give a copy to the patient for his or her information and records. This is proving to be a very useful document, not only for the patient and family but also for the other caregivers in the clinic, because the treatment plan serves as a record of the discussion between the physician and the patient on prognosis, treatment, risks, and expected outcomes.

Another example of a tool used to increase patient engagement is a program developed and used by oncologists in The US Oncology Network called My Choices, My Wishes

. This program combines specially trained clinicians, carefully crafted educational and resource materials, and healthcare information technology to identify patients, store treatment progress and preferences, define and document directives, and honor patients' wishes throughout their care plan.

My Choices, My Wishes starts with a values assessment with the patient. Patients answer questions pertaining to their healthcare goals and the care they desire during their cancer treatment. This information enables the physician to make treatment recommendations that will best meet the patient’s needs and wishes.

For example, at my practice, we recently treated 2 women with the same type of cancer who had very different concerns. One was single, and her primary wish was to remain independent during treatment. Under no circumstances did she want to move in with her only relative, a sister. The second patient’s main concern was pain management. She wanted to make sure that during treatment, she did not experience significant levels of pain. Independence was not important to her. Knowing and understanding these different primary concerns allowed the care team to recommend and execute a plan that would best meet each patient’s individual needs.

Programs such as My Choices, My Wishes that engage patients in their care planning provide many benefits to the patients. Most importantly, they can improve the patient’s quality of life at each stage of his or her disease. These programs can also prompt patients to make decisions while they still have time to carefully consider and discuss with loved ones what gives their life meaning and purpose, rather than making critical decisions about their care during crisis situations.

Ongoing conversations can help patients and their physicians understand and continually define what is important to the patient, because priorities may change. This becomes especially important in patients with advanced cancer.

Patients who have had these discussions often have a better understanding of their end-of-life care options and may choose to stop ineffective chemotherapy, transitioning to comfort care and focusing on palliative and/ or hospice care. The program can also reduce stress for patients and their loved ones, because the patients make known their values.

A provider never wants to hear patients say that they would have made a different decision regarding their care if they had known more. Good collaboration between providers and patients during the process can help make a cancer diagnosis more manageable and result in better outcomes.

Institute of Medicine of the National Academies. Delivering high-quality cancer care: charting a new course for a system in crisis. National Academies Press website. nap.edu/resource/18359/qualitycancercare_rb.pdf. Published September 2013. Accessed December 2017.

A factor contributing to better outcomes is better collaboration between physicians and their patients throughout the entire care process.

Patient Collaboration Can Help Solve "Crisis" in Cancer Care

There is an old saying, “What you don’t know, won’t hurt you.” Unfortunately, when it comes to implementing the CMS Physician Quality Reporting System (PQRS) in a large multidisciplinary oncology practice, nothing could be further from the truth, at least from my personal experience as a medical oncologist at Texas Oncology.

We are an independent practice of more than 400 providers working across 165 sites, and we are affiliated with The US Oncology Network, one of the nation’s largest networks of integrated, community-based oncology practices. I became medical director of quality programs for the practice in January 2015, and one of the first things that landed on my desk was the PQRS initiative, a quality improvement incentive program that provides financial rewards or penalties for reporting healthcare quality data to CMS.

Whereas PQRS was originally an optional program, that is not the case today. Now physicians and advanced practice providers (APPs) who do not provide quality data during the 2016 reporting year may realize penalties as great as -6% of their Medicare reimbursement, which will be assessed in 2018 on all Medicare Physician Fee Schedule charges. By 2021, the penalties or rewards through the proposed CMS quality reporting programs will widen to plus or minus 9%.

There are several ways to report quality data to CMS. In 2014, we chose group-based reporting, which is fairly easy compared with other reporting models. Providers in the group are listed with their tax ID number, and specific metrics are reported. The problem with this model, however, is that nearly 90% of the metrics relate to preventive care rather than things we do in daily oncology practice. Primary care physicians ended up being responsible for most of the results we reported in 2014.

For 2015, we wanted to report on metrics that were more meaningful to oncologists and would accurately reflect the services we provide, so the data could be used to help advance the quality of cancer care. After discussions with The US Oncology Network, we switched to individual-based reporting using an individual reporting model. Each provider would report on 20 patients over age 55, 11 of whom were traditional Medicare patients with an oncology diagnosis tied to office administration of chemotherapy or radiation.

Good Intentions Lead To Difficult Reporting Challenges

It sounded ideal, since we would be reporting on things we actually do in daily practice, which in turn, should reflect our quality of care.

For most of our oncologists, the reporting went smoothly, but we did encounter some serious complications. Under the oncology measures group, providers report on 20 qualified patients. This sounds simple enough, but it turned out to be a huge problem. Physicians coming out of training joined us late in the year and did not have time to fulfill the requirement. Additionally, a large group of providers merged with us in November, but they could not report on their prior patients because those patients were not seen under the provider’s current tax ID. Also, fee-for-service Medicare was required, and some of our sites had many patients with managed Medicare plans, making those patients ineligible.

In the end, about 50 physicians did not qualify under the oncology measures group. Our only option was to report them under the preventive care group, but it was still a struggle to get enough patients and quickly meet the requirements. For example, a specific depression screening questionnaire was required, and many physicians were scrambling at the end of the year trying to find patients to screen.

We also encountered problems reporting our more than 100 APPs, since they did not have chemotherapy charges under their National Provider Identifier (NPI). Consequently, they had to report under the preventive care group. Most APPs bill under the physician’s NPI for patient care services, so we had to quickly find qualified patients for each APP to bill under their own NPI.

Surgeons also had problems because the surgery reporting group required utilizing a specific risk-based calculator with patients. Most surgeons used other risk calculators, so we immediately had to transition them to the required process.

Our biggest challenge, by far, concerned the many urologists in our practice. They are essentially surgeons, but none of their surgeries qualified for the surgical measures group. They do not give chemotherapy or radiation, so that ruled out the oncology group, which led us, once again, back to the preventive care group. Preventive care services are not a standard part of urology care, and it was difficult for our urologists to meet this requirement. Some opted out. Unfortunately, these physicians will see an automatic 2% reduction in Medicare reimbursements in 2017 for not reporting through the PQRS program.

PQRS presents many challenges for multidisciplinary oncology practices that want to report on meaningful metrics. While the concept is valid, the program needs improvement, as it is difficult to execute and there are a lot of surprises along the way. Significant staff time was involved, and I personally spent countless hours on it, taking time away from patient care. Additionally, Medicare missed the boat for some providers by not offering a way for them to report meaningful measures.

We were fortunate to have the expertise and guidance we received from The US Oncology Network. They provided a PQRS expert whose support was invaluable. She spent countless hours walking us through the reporting process, driving deadlines, and counseling our providers. I am convinced we could not have completed the project without her assistance.

Thanks to her guidance and other innovative resources from The Network, we were able to meet critical CMS deadlines for 2015 PQRS reporting, avoiding roughly $12 to $15 million in penalties in 2017 Medicare reimbursements. This is not the first time The Network has helped us achieve success with complex challenges, and I am sure it will not be the last.

Throughout our association with The Network, we have come to rely on its collaborative expertise, knowledge, and resources to help us successfully navigate the ever-changing healthcare landscape.

In June, we must decide how we are going to report for 2016. Unfortunately, 2015 results will not be available until the fall, so we do not know whether individual reporting resulted in any financial rewards or penalties. We are strongly considering returning to group reporting, as our quality scores will likely remain adequate with no penalties. Given the time, effort and angst involved with individual reporting, the financial reward from this effort would have to be substantial to make it worthwhile. It is unfortunate that group-based reporting is probably our best choice, as it really does very little to advance the quality of our cancer care which is the ultimate goal.

Value in Practice is a regular feature of 

. Each month, a different oncology practice administrator discusses the challenges of bringing costs into line with value. To submit an item of your own, write to 

For most oncologists at Texas Oncology, healthcare quality reporting to the CMS went smoothly, but serious complications were encountered.

Lalan Wilfong, MD

Articles

Digital Health and Process Improvements Enhance Community-Based Patient Care

The US Oncology Network Highlights Success With Oncology Care Model

Patient Collaboration Can Help Solve "Crisis" in Cancer Care

Some Prefer Pay Cuts to Inflexible CMS Metrics