State-of-the-art technology is as valuable in oncology as it is everywhere else. However, new technology is not always available to providers, and when it is, it may not be used to its fullest potential. Older technology may be surprisingly adequate. In this month’s issue of 

, we look at these matters through the eyes of providers who wanted to get more out of old and new technology and who succeeded in doing so.

When researchers at Dana-Farber Cancer Institute wanted good quality biopsy samples for their DNA analysis project with Brigham and Women’s Hospital, they discovered that samples preserved in formaldehyde, embedded in para n wax, and stored in pathology labs were perfectly adequate for the large-panel genomic assays they were doing. When samples were rejected, it wasn’t because of the long-used storage method. More likely, it was because the available sample was too small or the tissue was cancer-free. Of the tumor samples that were useable, 73% were found to be clinically actionable.

Patient portals have been a key element of CMS’ Meaningful Use guidelines for the integration of electronic health records with patient-centered care. However, adoption of these systems for communicating important health information to patients has lagged; in some cases, patient portals are created but not supported by a commitment to use them to their fullest potential. Our story this month by Emily Brill explains that although patient portals can be used in many ways to improve patient engagement and achieve valuable results, the information they provide must be intelligible and useful, and physicians need to embrace these tools.

Brill unearthed an interesting fact during her investigation: the average user age on My Care Plus, the patient portal launched by McKesson Specialty Health, is 67. This belies the notion that older individuals, who make up the majority of patients with cancer, would not make good use of patient portals if they were provided and if they were truly engaging.

There’s a wealth of other coverage in this month’s 

. Our stories from the Community Oncology Alliance annual meeting held in April include articles about the debate over pharmacy benefit managers, lessons from the first year of the Oncology Care Model, and tips for ensuring oral drug adherence. We also present coverage from the World Congress conference in Philadelphia, held in March, including whether modern pathways are patient- or payer-centered and the direction in which accountable care organizations are heading.

In this month’s issue, as always, you’ll find valuable information and guidance on running your practice, compelling journalism, and inspiring success stories. Don’t miss a word of it!

Articles

State-of-the-art technology is as valuable in oncology as it is everywhere else. However, new technology is not always available to providers, and when it is, it may not be used to its fullest potential.

Medical Tech Is a Marriage of Something Old, Something New

Large panel gene assays come with so much information that oncologists may have difficulty putting all of the data to practical use, Barrett Rollins, MD, PhD, chief scientific officer at Dana-Farber Cancer Institute, said. “I think the practitioner understands very well that for certain diseases, there are genetic biomarkers that are very important, and he or she understands how to use that, but when confronted with a report on 400 different mutations at different locations in the genome, it’s not clear to me that people know how to make sense of that,” Rollins said.

Dana-Farber and Brigham and Women’s Hospital have been working on a large scale DNA analysis project that could one day put much more useable information into the hands of oncologists. Known as Profile, it involves the collection and analysis of thousands of tumor samples from cancer clinics. “That’s the next big frontier,” Rollins said. “We—the American oncology community, the research centers, and the cancer centers&mdash;need to work harder on translating all of this data into useable, understandable data for the practitioner, and I don’t think we’re there yet.”

One advantage of Profile, begun in 2011, is that it uses preserved samples from pathology labs rather than requiring patients to undergo fresh biopsies. A surprising fact has emerged from the analysis: researchers have found that most of the samples indicate that patients’ cancers are candidates for treatment with FDA-approved or experimental agents. For example, Profile researchers were expecting just 15% of the useable tumor samples would provide clinically actionable information. Seventy-three percent of useable samples have provided actionable information, Rollins said.

“It has become one of the arguments we use with third-party payers that this kind of test really ought to be reimbursed,” Rollins said. As a result, Dana-Farber is working with Massachusetts General Hospital and Blue Cross Blue Shield of Massachusetts to pilot a form of coverage for the Pro le testing. “The big question we’re trying to answer, and this is going to take a couple of years, is: does this change clinical outcomes?” He expects that efforts will show that it does, “and once we do that, I think this will become standard of care reimbursed by insurers.”

OncoPanel is the Profile test, and it reads the codes of hundreds of genes. Rollins said the per-patient cost ranges from $800 to $1000. The tests are conducted using tumor tissue from patients who have been examined at Dana-Farber, Brigham and Women’s, and Boston Children’s Hospital.

Although there are many genetic assays on the market, what sets OncoPanel apart is that it can be modified to examine specific genes that researchers feel confident about, Rollins said. “We like our homegrown test because every couple of months we can swap in tests. It gives us some flexibility that dealing with a [gene assay] company we may not have.” Clinical samples are preserved in formaldehyde and embedded in paraffin wax before they arrive in the laboratory. Rollins explained that researchers wanted to find a way to test without requiring patients to undergo additional biopsies. In addition, soliciting frozen samples from clinics would have entailed a rush and a risk of decay.

Although Profile researchers wanted to spare patients from discomfort and inconvenience, they were concerned that the quality of the preserved samples would not be high enough for use in genetic testing. They were happily proved wrong on that point, Rollins explained. “It really is feasible to get high-grade sequencing information from clinically acquired specimens. Our technology is so robust that routine fixation of tissues for pathology is perfectly fine for our test to be done.”

Half of the samples they received from pathology labs were not useable, but for reasons the researchers hadn’t anticipated. Much of the time, the tissue sample was too small, such as that collected via needle biopsies; there wasn’t any cancer in the sample collected; or the samples were preserved incorrectly. However, among the samples that were acceptable, 90% could be sequenced, Rollins said.

In the search for actionable mutations and other cancer-related DNA abnormalities, the Profile project has created 15,000 genetic profiles of patients’ tumors. These data are made available to researchers through an ambitious data sharing project known as the Project Genomics Evidence Neoplasia Information Exchange, or Project GENIE, which is overseen by the American Association of Cancer Research. The registry collects sample data from multiple institutions and makes it available for outside analysis, hoping that this will contribute to the success of translational research, validate suspected biomarkers of cancer, suggest new uses for approved drugs, and support the argument that payers should broaden their coverage for genomic testing.

Rollins said all of the GENIE data temporarily remain proprietary but are later released for public use, in the interests of keeping science in the public domain. “We’ve done this with the commitment that after a year of exclusivity, this data could be released to the public so that anyone with an interest in looking at cancer genomics could get into this database and ask questions,” Rollins said. “This has been so successful that there are cancer institutions from around the world who are basically petitioning us to join. We just sent out a request for applications for the next round of institutions to join the GENIE consortium.”

So far, biomarkers have proved most useful in targeted therapy, but the potential of the Profile and GENIE projects could extend this utility to immunotherapy, Rollins said, noting that too little is known about how cancers are going to respond to immunotherapies. “We don’t yet have the kind of biomarkers for immunotherapy that we have in targeted therapy. We don’t know for sure what characteristic it is about somebody’s lung cancer that makes them respond to a PD-L1 blocker, but we need to know that, so the next big phase of Profile and these other tumor profiling projects is to incorporate immunologic measurements as well.”

Researchers at Dana-Farber Cancer Institute and Brigham and Women’s Hospital are attempting to improve personalized medicine by analyzing DNA samples for known cancer biomarkers. 

Hunting for Biomarkers in Paraffin Wax

Clinical pathways were originally created to standardize cancer care and ensure patients receive the best evidence-based treatment for their disease. A divide has developed, however, between pathways that primarily serve physicians and those that cater to payers that are trying to rein in costs. Among those on the side of physicians and practices is Via Oncology, a Pittsburgh-based pathway development company whose pathways emphasize drug efficacy and toxicity rather than price, said Gordon Kuntz, Via’s senior director of strategy.

In theory, oncology pathways always consider efficacy first in guiding a drug choice, followed by toxicity. Cost is only to be used as a kind of tie-breaker between 2 or more similarly effective treatments. But some payers require doctors to use pathways that put more weight on cost or that steer them toward certain less expensive drugs and make it difficult to go off-pathway when needed.

When doctors in Via’s network create pathways, they are aware of drug costs, but Kuntz said those prices rarely contribute to their decisions. “About 5% of the time, we actually look at cost as a driver. Some payers want cost to be a more important factor, and that’s not how we operate,” he said at the World Congress 4th Annual Oncology Market Access Summit in March. Kuntz said his company has passed on opportunities to do business with payers because of their greater focus on cost. “Because it’s our philosophy—it’s in our DNA&mdash;it would be just wrong for us to develop a specific pathway for a payer,” he said.

Practices become paying members of Via’s network because they want to improve their patient outcomes through standardization of treatment, Kuntz said. Pathway programs also provide data that demonstrate a practice’s value by showing how physicians made treatment choices, he said.

This can help attract referrals, which is important for community practices and academic centers that are not part of large hospital systems. Pathways can make it easier to participate in new payment models, such as medical homes. For large practice networks, pathways can help ensure consistency of quality across many locations, he said.

Via originated at the University of Pittsburgh Medical Center and was spun off as a company in 2009. The number of physicians in its network of clients is approaching 1500 at 38 providers, including 10 academic centers, 13 hospitals, and 15 community-based practices in 27 states, Kuntz said. The clinical pathways are developed by 31 disease committees made up of physicians in the network. Most of the committees meet quarterly to review the latest research and update drug recommendations; after a meeting, it takes 4 to 6 weeks for the company to integrate any pathway changes into its software.

Unlike some other companies, Via always has a single best drug option at the end of each pathway, although it also provides an alternative treatment plan for patients who have neuropathy, in case of a drug shortage, or for other special situations, Kuntz said. As is standard in the industry, 80% of patients are expected to be treated on pathway, a quarter of whom may be assigned to the alternative scenario. Up to 20% may be off-pathway, with physicians required to explain their reasoning through Via’s software.

Kuntz said Via is unique in that it supports all 3 major oncological treatment approaches. Its pathways cover 95% of its members’ medical and radiation oncology cases and about 60% of surgical oncology. However, as with other companies, individual pathways do not integrate the 3 methods. “Today, they live a little bit independently,” he said. “We’ve talked about, how do we create a true multidisciplinary scenario?”

Part of Via’s mission is to promote clinical trials. With its pathways software, a physician enters a patient’s data and proceeds to a recommendation page that first presents relevant trials available at that practice. “The physician can’t get past that, to the standard of care, without saying either, ‘Yes, please screen this patient for trials’ or ‘No, the patient doesn’t want to be on a trial’ or ‘No, I don’t think this trial is applicable to this patient.’ And you have to say why,” Kuntz said. Patients aren’t automatically enrolled in trials, but the system can send an e-mail to a trial screener who can quickly meet with the patient. Adopting the software has helped practices increase their clinical trial accrual rates, he said.

Via’s competitors include McKesson Specialty Heath/US Oncology Network, which also sells clinical pathways to practices. Payer-side pathway developers include Cardinal Health, eviCore, Eviti, New Century Health, and Anthem’s AIM Specialty Health. Kuntz said the companies differ in the ways they develop their pathways, how transparent their processes are, the number of diseases they cover, the pathways’ levels of detail, how well they support practices, and the number of choices at the end of each pathway.

Kuntz said he knows of a few practices that are large enough to develop their own pathways, such as Moffitt Cancer Center in Tampa, Florida, but he cautioned that the work “is not for the faint of heart.” “While the building (of pathways) is very, very challenging, the maintenance is worse,” he said. “We have 1 very large practice that uses our software to develop their own pathways, and frankly, it’s been very challenging.” Although Via does not sell pathways to payers, it does regularly work with them. Aetna and some Blue Cross Blue Shield plans allow physicians to use clinical pathways from multiple developers, and Kuntz said his work involves facilitating those kinds of relationships. “Our job is to be transparent with payers, to show them what we do and how we do it, so that they can get comfortable with the pathways that our clients are using,” he said.

In theory, clinical pathways software also enables automation of the prior authorization process, providing practices with much-desired relief from an onerous and expensive administrative burden. But Kuntz said getting payers to accept authorization requests electronically has proved challenging. “That’s incredibly difficult. Prior authorizations have resisted automation forever.” Via already collects the data needed for prior authorization, such as disease stage and biomarkers, but only a small fraction of payers are set up to accept the information through e-mail or a digital feed, rather than fax or phone, he added.

Increased coordination with payers will be part of the future of pathways, Kuntz said. For example, insurance claims data can be combined with patient data to guide the development of payment bundles for accountable care organizations. Pathways will also continue to expand to cover the full continuum of care, he predicted, noting that Via’s software has features related to diagnostic workup, discontinuation of therapy, hospice, and survivorship. He said the company also recently launched Via Triage, which guides nurses as they handle patient phone calls and respond to adverse events of drugs.

Other changes that will affect clinical pathways in the coming years include the arrival of personalized medicine, which will have to be handled differently than standard chemotherapy, and the development of pathway certification programs by ASCO and potentially other organizations, Kuntz said. He said Via is in “pretty good shape” to satisfy the criteria ASCO is developing, although meeting the organization’s call for patient input as part of pathway decision making is a challenge.

An audience member asked Kuntz about the prospect of building clinical pathways that further promote value-based care by considering the total cost of care. Kuntz said Via’s physician committees consider toxicity when building pathways, but not at the level of empirical, numerical detail the questioner suggested.

A divide has developed between pathways that primarily serve physicians and those that cater to payers that are trying to rein in costs.

Keeping the Pathway Focus on Treatment Instead of Cost Will Ensure the Best Care

Genomics, proteomics, precision analytics, Big Data analysis, and artificial intelligence now in use or in late phases of development can help healthcare providers to achieve the promises of the Triple Aim of medicine: improve clinical outcomes for all, reduce total cost of care for the populations served, and improve patient experiences.

For quite some time, oncology has been at the forefront of using genomic information to target therapy against genetically driven molecular mutations, leading to improvements in overall survival. Proteomics is now the leading edge of the sword in improving outcomes because it prevents the synthesis, or translation, of damaging proteins. Applied immunology is another breakthrough technology that can dramatically improve outcomes when used properly and with good timing.

As medical data accumulate, physicians are losing the ability to acquire, process, and utilize this information in real time to help their patients. Many physicians are not keeping up with the rapidly evolving knowledge base, and patients are not achieving optimal outcomes in all cases due to adverse variance in care (too much or too little care). Adverse variance leads to increased costs of care and lessens the return on investment for companies that develop new therapies and devices. This is because the marketplace is slow to accept innovations it doesn’t understand well enough.

Enter precision analytics, Big Data, and artificial intelligence. The dream is to provide the current world’s medical knowledge at the point of care along with real-world evidence and precise patient stratification, thereby enabling optimal care choices and outcomes. Indeed, this issue is of particular importance to researchers at Dana-Farber Cancer Institute and Brigham and Women’s Hospital. They are among those making strides for personalized medicine by analyzing patient DNA data for actionable DNA mutations. We write about this effort on page 34.

Physicians have a moral duty to do what is in the best interest of their patients and, based on their knowledge and experience, they clearly are capable of doing so when provided with the information needed to make the best decisions. However, the fundamental question remains: what about patients? How much baseline knowledge is required by a patient to use medical information resources effectively and without distress? I use Uber all the time, and I know very little about how a satellite is launched or how a GPS works on a technical level. Despite this, I am very comfortable in my knowledge that after the input of my current and desired locations, I will arrive via the most direct route at a set price. Can we do the same in healthcare? This is a fundamental issue that holds the greatest promise to transform healthcare transparency and, hopefully, quality and affordability.

If every patient knew precisely where they were starting and what route of care would get them to their desired outcome at the lowest possible cost, we would have an Uber version of healthcare. Is this practicable? Will patients find this useful or frightening? Only time will tell.

Genomics, proteomics, precision analytics, Big Data analysis, and artificial intelligence now in use or in late phases of development can help healthcare providers to achieve the promises of the Triple Aim of medicine: improve clinical outcomes for all, reduce total cost of care for the populations served, and improve patient experiences

Is Healthcare Ready for an Uber-Type Patient Application?

Tennessee Oncology was a relatively small practice until 1992, which is when F. Anthony Greco, MD, left Vanderbilt University Medical Center to become its fourth partner. Greco came with the then-radical idea that he could perform more trial work at a private practice than he could at a larger institution, such as an academic hospital. His vision not only made Tennessee Oncology a key player in many oncology studies, but also precipitated its 25 years of rapid growth.

By 1996, Tennessee Oncology had hired its 15th physician, current CEO Jeffrey Patton, MD. Today, after a trio of mergers and sustained organic growth, the practice has 81 physicians who provide care in 30 locations in central and east Tennessee. This growth has made Tennessee Oncology the dominant provider of cancer care across its service footprint. It has also fulfilled Greco’s original vision: Tennessee Oncology does significantly more work on clinical trials than the only big competitor it still faces, Vanderbilt Ingram Cancer Center.

“We have more patients in clinical trials than any other private practice in the country, and when you look specifically at phase I trials, we’re the second busiest drug development unit anywhere in the world. We have been the venue for more than 100 first-inman trials,” said Patton. “We are very proud of this trial work, both because it gives our patients options that they could not get elsewhere and because it advances the state of cancer care for patients all around the world.”

Tennessee Oncology conducts this work across an extremely varied service area. It is based in Nashville, a middle-income state capital of just over 650,000 people that lies at the heart of a booming metropolitan region with 1.8 million inhabitants. The practice’s footprint spreads far beyond that region, however, across more than a dozen rural counties, all the way to Chattanooga, a middle-income city of 175,000 just north of the Georgia border. Cancer incidence rates exceed the national average throughout most of this region.

 State officials report that Tennessee ranks 19th nationally in per capita cancer incidence and third in per capita cancer deaths.

Many factors contribute to this problem, especially tobacco use. About 22% of Tennesseans

 ) smoke cigarettes, according to the Centers for Disease Control and Prevention. As a result, Tennessee’s annual lung cancer death rate of 56 per 100,000 individuals far exceeds the national average of 43 per 100,000.

 The exact size of the problem varies greatly across Tennessee Oncology’s service area. In the wealthy suburbs of Williamson County, the lung cancer death rate is just 41 per 100,000, but many other health metrics exceed national averages. In rural Polk County, the annual lung cancer death rate of 103 per 100,000

 is just one of many serious public health problems.

“Different parts of our service area differ in just about every way you can imagine, but our operations are the same pretty much everywhere, except that offices are smaller in less populous areas and some of them operate fewer days per week,” said CFO Ron Horowitz. “Despite the overall demographics of a particular area, you get all sorts of patients at every office, so you have to be able to deal with different cancers and different financial situations and different everything at every office.”

The real challenge in covering Tennessee Oncology’s service area isn’t so much the differences from place to place as it is managing the growth of the practice. “When you’re growing from a local to a regional practice, you have to be careful not to outrun your support,” Horowitz said. “It’s easy for technology to give the impression you can open an office anywhere you can get an Internet connection, but oncology requires physical support. If you have an office that’s 200 miles away from any other office, you can’t get staff there to cover unexpected absences or medicine when your refrigerator breaks. Offices need to be close enough to support each other when the need arises. Otherwise, you don’t get the benefit of running a network rather than a series of independent offices.”

Although primary care providers, public health officials, and others probably have more ability to reduce the state’s elevated cancer incidence rates and get patients with cancer diagnosed earlier, Tennessee Oncology is continuously testing new strategies for improving outcomes once patients are diagnosed. The practice’s ongoing participation in clinical trials is an example, but the group has also spent the past few years testing new care delivery models and gradually implementing them across its practice.

Tennessee Oncology now uses Via Oncology’s treatment pathways software to help determine how to treat most of its patients. This technology ensures that its oncologists know the accepted standard of care for patients with a particular diagnosis and that the overwhelming majority of patients with that diagnosis receive the specified treatment regimen. Some oncologists at the practice have resented the loss of autonomy, but Patton says there’s more than enough evidence to support pathway adherence in about 80% of all cases (with usual factors justifying deviations in the remaining 20%).

“We all have a very natural and understandable tendency to want to treat patients on a truly individual basis, based upon each patient’s unique attributes and our own unique experience of what has and hasn’t worked in the past,” Patton said. “Unfortunately, there’s a mountain of evidence showing that a standardized template outperforms individual discretion for a large majority of patients. Medicine, it turns out, is a lot more like manufacturing than many of us like to think. If you do something exactly the same every time, you produce better outcomes and make fewer mistakes than someone who does it differently every time.”

Tennessee Oncology has also tested an oncology medical home (OMH) model of service delivery. The goal of all such models is to improve patient outcomes while simultaneously reducing the total cost of their care, mostly by offering patients so much extra access to oncology care that little problems never get big enough to send them to the hospital. Typical provisions include 24/7 telephone triage to encourage same-day appointments when problems arise.

The pilot program provided Tennessee Oncology more than a year to work its way through all the issues associated with the transition from a standard care model to the OMH in order to develop new workflows and work out any kinks that arose. The practice was therefore ready last summer to roll out the new service model to all patients covered by CMS when that organization launched its Oncology Care Model (OCM). CMS has been collecting data on costs and outcomes for more than 6 months now, but the agency has yet to report back to Tennessee Oncology on whether its OMH model is reducing hospital usage. (Tennessee Oncology has no access to hospital records and thus could not evaluate the OMH program’s efficacy during the pilot.)

The practice also provides OMH care to patients insured by Aetna, which has embraced the model. BlueCross Blue Shield, by far the largest private payer in central Tennessee, and Cigna, the second largest private payer, have not yet expressed any interest in covering OMH services or experimenting with any sort of outcome-based payment plan. The gradual rollout of OMH care and the need to use the new system for some payers while maintaining the old system for others has created a significant amount of work for everyone at the practice, but Tennessee Oncology has leaned heavily on consultants who have eased the transition.

“This model is new enough that it continues to evolve. New studies provide new evidence about best practices and require you to change a workflow shortly after you put it into place,” Horowitz said. “But OMHs aren’t such a new concept that practices need to implement them by pure trial-and-error or even on their own. There is outside help available, consultants who have put the model in place before and can help ease the transition at your practice. I can’t speak for others, obviously, but they sure have been helpful to us.”

National Cancer Institute; Centers for Disease Control and Prevention. Incidence rates table. State Cancer Profiles website. statecancerprofiles.cancer.gov/incidencerates/index.php?stateFIPS=47&cancer=001&race=00&sex=0&age=001&type=incd&sortVariableName=rate&sortOrder=default#results. Accessed April 21, 2017.

Tennessee Cancer Coalition. State of Tennessee cancer plan 2013- 2017. State of Tennessee website. www.tn.gov/assets/entities/health/ attachments/TN_Cancer_Coalition_State_Plan_2013-2017.pdf. Accessed April 21, 2017.

Centers for Disease Control and Prevention. Map of current cigarette use among adults. CDC website. www.cdc.gov/statesystem/cigaretteuseadult. html. Updated September 16, 2016. Accessed April 21, 2017.

Centers for Disease Control and Prevention. Current cigarette smoking among adults in the United States. CDC website. www.cdc.gov/tobacco/ data_statistics/fact_sheets/adult_data/cig_smoking/. Updated December 1, 2016. Accessed April 21, 2017.

National Cancer Institute; Centers for Disease Control and Prevention. Death rate report for Tennessee by county: lung & bronchus, 2013. State Cancer Profiles website. statecancerprofiles.cancer.gov/cgi-bin/deathrates/deathrates.pl?47&047&00&0&001&1&1&1&1#results. Accessed April 21, 2017.

National Cancer Institute; Centers for Disease Control and Prevention. Death rate report for Tennessee by county: lung & bronchus, 2009-2013. State Cancer Profiles website. statecancerprofiles.cancer.gov/cgi-bin/ deathrates/deathrates.pl?47&047&00&0&001&0&1&1&1#results. Accessed April 21, 2017.

After a trio of mergers and sustained organic growth, Tennessee Oncology has 81 physicians who provide care in 30 locations in central and east Tennessee.

Tennessee Oncology Group Finds Growth Bonanza in Clinical Trials

For about a decade, patient portals have been hailed as the wave of the future. However, many still require some work before they reach peak functionality, partly because many patients are reluctant to use them. Although a CMS incentive program has driven patient portal adoption, it has not provided a direct incentive to make the portals user-friendly, University of Pittsburgh researchers say.

Patients with cancer stand to benefit greatly from portal access. Such patients often see many specialists and submit to frequent blood tests. Having 24-hour access to a portal, which consolidates patients’ lab results and their other medical records, can relieve tension and increase their sense of involvement in their healthcare, proponents say.

Adopted by a handful of large healthcare organizations in the late 1990s, patient portals entered widespread use around 2006. Since then, these secure websites have been a familiar element of oncology practice. Supporters say the technology can increase a practice’s efficiency and give it an edge over the competition while simultaneously improving patient satisfaction and meeting the Meaningful Use criteria of the CMS electronic health records (EHRs) incentive program.

Barriers to successful implementation persist, however, and implementing a portal is not a panacea for problems with patient engagement, said University of Pittsburgh researcher Taya Irizarry, BSN, MSN, who conducted a 2015 state-of-the-science review on patient portals with 2 colleagues.

Launching and maintaining the technology can strain a small practice’s finances, said Alex Seleny, senior director of portal and patient services for McKesson Specialty Health. Patient portals are often tied to EHRs, which HealthIT.gov estimates cost between $15,000 and $70,000 to purchase and install. Many portals are run by outside vendors, some of which charge a fee per patient or per physician. A physician at a small family medicine practice in Delaware was alarmed to learn, in 2014, that a portal vendor she was considering would charge $5000 per physician, plus training costs and a per-use fee. Posting about her quandary on the American Academy of Family Physicians website, Rebecca Jaffe, MD, wondered if satisfying Meaningful Use criteria was worth what could be an “unfathomable” expense.

Whether patient portals prove useful depends largely on patients’ comfort with them and doctors’ willingness to encourage their use, Irizarry said (Table). It helps when the medical records available on a portal are accurate, clearly explained, and laid out in a way that makes sense to a patient with a low degree of health literacy.

Table. How Practices Achieve Higher Patient Portal Use

If the information isn’t meaningful to the patient or the information is outdated or not right, it becomes a source of frustration and anxiety, which is the opposite of what we want people to feel when they’re engaged in their healthcare with this kind of information tool,” Irizarry said.

On the other hand, if information is intelligible, accurate, and complete, and physicians embrace the portal (thus encouraging patients to do the same), the tool’s benefits to a practice can be enormous, Seleny said. Portal features allowing patients to securely message doctors and access helpful information about symptoms can even keep patients out of the emergency department (ED).

“Patient engagement has become much more important,” Seleny said. “Now that we’re moving toward value-based care, it becomes a financial requirement for the practice to do everything it can to help ensure that a patient does not go to the ED, that they have as positive an outcome as possible.”

In 2013, the US Oncology Network’s partner organization, McKesson Specialty Health, began marketing My Care Plus, a portal that runs in conjunction with the EHR system iKnowMed. Used by the US Oncology Network’s group of independent physicians, the portal is designed specifically for oncology and hematology patients. It includes several features common to all portals: a secure messaging service, medical records, lab results, and educational resources. Several of these features are mandated by CMS’ Meaningful Use criteria, which constituted the most significant driver of patient portal adoption in the United States, Irizarry said. The program, launched in 2011, makes up to $44,000 in incentive payments available to eligible providers whose EHRs and patient portals meet certain criteria.

However, the criteria do not require providers to make their health records easy to understand, Irizarry said. Nor are the portals required to be easy to use. “At the majority of healthcare organizations of the larger variety, their patient portals are more like a checkbox. They’re meeting a requirement, but it’s not necessarily ‘meaningful,’” she said. “At this point, there’s not a clear value on designing patient portals for people to truly use them.”

Irizarry added that making medical information as easy to understand as possible is key to creating a user-friendly patient portal experience. She recommended placing records in chronological order so patients can get a sense of how their health has changed as their disease has progressed. She likes when portals include space for doctors to upload their notes or type a message next to medical records to explain them. My Care Plus contains this feature, Seleny said.

“One of the areas of biggest confusion in our specific world is lab results. If you take the number in a white (blood cell) count to Google and ask, ‘Is this normal?’ odds are it’s going to say, ‘No,’” Seleny said. “So, any time a lab result is released to a patient, the physician has the opportunity to add a comment to it. Right next to the lab result, there’s a comment from the physician saying, ‘Don’t panic. I know this is a little high, but as we talked about, it’s going to be a little high, and it’s less high than we expected, so don’t worry. Breathe. Relax.’”

When patients log into My Care Plus, they are presented with a dashboard that contains content specific to their disease. “If someone logs in and has lung cancer, they’re not going to see information about a sarcoma,” Seleny said. By digging a little deeper, patients can access more information about their disease and their care plan.

The portal tells patients what form of chemotherapy they’ve been put on and what the chemotherapy does. It gives them resources from the practice, cancer foundations, and the drugmakers. It also includes what Seleny calls “pragmatic info”—how to talk to your family about cancer, how to explain the disease to small children, and how diet, exercise, massage, drinking enough fluids, and yoga might help. These are “tools that anyone can have access to, to make the journey easier,” Seleny said.

Smaller practices may wonder if implementing a patient portal is worth it. The tool, after all, can confound patients who have low technological literacy. Irizarry recently conducted a study in which she asked focus groups questions about their level of comfort with patient portals. The study determined that the biggest predictor of patient involvement with a portal was their comfort level with technology.

“People with higher health literacy and people who have more ability to navigate an online world were the people who could prioritize and make sense of those data fields or go onto the Web and find out what they are,” Irizarry said. On the flip side, those with lower health literacy and less comfort with technology were more wary of the portal despite still being interested in it, she noted.

Physicians can coax patients to use portals if they enthusiastically adopt the tool themselves, Irizarry and Seleny said. Patients can sense when a portal is an afterthought for a physician rather than a true commitment, Irizarry added. A patient is likely to become more engaged if a physician endorses portal use, answers questions about it, and incorporates the portal into the workflow. Some physicians tell patients to view their lab results online, Seleny said. “You’d be surprised how much not printing out the lab results leads to portal adoption,” Seleny said.

To the question of whether a patient portal would be worth it for a small practice, Seleny said he thought practices should conduct a “very, very rigorous cost-benefit analysis” before deciding. He said that he considers portals a valuable tool for patients who want more access to healthcare information and practices that want to save time.

Many portals offer a feature allowing patients to fill out paperwork at home, which saves time during office visits and sometimes even leads to more accurate paperwork, he said. “More often than not, patients will have better recall of their issues if they’re at home. It’s easier to get paperwork about what medicines you take filled out if you’re by your medicine cabinet,” Seleny said.

“The whole intent behind a patient portal is to increase value for our patients, but also help the practices increase efficiency.” He recommended that smaller practices buy portals from a company that offers different pricing options based on the amount of features a portal provides. An inexpensive, simple portal might be all a small practice needs, he said. However, he recommended that all practices purchase portals that can be accessed on smartphones. “We have seen mobile use increase faster than any other metric we have,” Seleny said. “A lot of people may say, ‘OK, but we only serve an older population.’ Well, the average age of a user on our portal is 67.”

Top performing practices are aggressive about registering patients for portal use, according to Josh Gray, vice president of athenahealth’s Athena Research.

 These practices make sure that portals have functions that patients will find useful and that the interaction component of portals is 2-way, meaning that providers respond to patients’ messages. In addition, staff members need to be trained on techniques for getting patients involved with portals; otherwise, patients may never access these tools for expanding their healthcare experience. It is better to tell patients that they have an obligation to use their portals rather than merely invite them to do so, according to Gray.

Irizarry T, DeVito Dabbs A, Curran CR. Patient portals and patient engagement: a state of the science review. 

 2015;17(6):e148. doi: 10.2196/jmir.4255.

Jaffe R. Patient portals: useful resource but expensive mandate. AAFP Leader Voices Blog. blogs.aafp.org/cfr/leadervoices/entry/patient_portals_useful_resource_or. Published May 28, 2014. Accessed April 24, 2017.

Landi H. The business case for increasing patient portal adoption. Healthcare Informatics. www.healthcare-informatics.com/article/business-case-increasing-patient-portal-adoption?page=2. Published January 7, 2016. Accessed May 9, 2017.

For about a decade, patient portals have been hailed as the wave of the future. However, many still require some work before they reach peak functionality, partly because many patients are reluctant to use them.

Experts Say Current Patient Portals Leave Much Room for Improvement

The number of accountable care organizations (ACOs) across the country has grown rapidly in the last 5 years, creating opportunities and challenges for oncology practices as they seek to benefit from the organizations’ referral networks, shared-savings programs, and care-improvement efforts, said Lisa Samerdyke, senior national market manager for oncology at Eli Lilly.

ACOs are organizations of providers that accept joint responsibility for the cost and quality of care for a defined patient population. ACOs tend to focus on improving primary care while also linking patients with specialty care. A few are designed to enroll oncology patients exclusively. They also receive shared-savings payments if they meet a set of benchmarks. CMS created ACO regulations after passage of the Affordable Care Act (ACA); most ACOs cover Medicare patients, but commercial ACOs and Medicaid ACOs are also becoming more common.

The number of ACOs has grown steadily from fewer than 200 in 2012 to more than 800 at present, Samerdyke said during a presentation at the World Congress 4th Annual Oncology Market Access Summit held in Philadelphia in March. As of May 2016, 433 of these ACOs were part of the Medicare Shared Savings Program (MSSP), 9 were Pioneer ACOs, and 18 were the newer Next-Generation ACOs, which take on more risk and can yield greater financial rewards. The total number of Medicare ACOs increased to more than 560 this year, including 121 in risk-bearing tracks.

Samerdyke said there are at least 290 commercial ACOs in 29 states, and 64 Medicaid ACOs in 14 states. Commercial efforts include the first ACO specifically for cancer care, formed in 2011 by Florida Blue (Blue Cross and Blue Shield of Florida), Baptist Health South Florida, and Advanced Medical Specialties, a physician group. The ACO reported per-patient spending decreases in each of its first 4 years, according to an Advisory Board report.

 Florida Blue also set up a second oncology-specific ACO with Moffitt Cancer Center in Tampa.

ACOs designed primarily around oncology are rare, but Samerdyke pointed out that some of the 34 quality measures by which Medicare ACOs are evaluated require them to provide cancer care and collaborate with oncologists. “These ACOs have to make sure they have access to specialists,” she said. For example, patients must be screened for breast and colorectal cancer. Thus, joining an ACO can help an oncology practice establish relationships with primary care doctors and other providers who will refer patients, she said.

Samerdyke said boosting referrals this way may be particularly important for practices that are part of CMS’ Oncology Care Model (OCM) and are looking to recoup the costs of new technology and staff they are adding to meet the program’s requirements. “They’re making a massive investment in dollars to deliver on the OCM,” she said.

Many OCM practices, especially larger ones, are hiring care managers and creating phone triage systems. An ACO is a vehicle for advertising those assets to referring providers and to patients’ employers, Samerdyke said. “If you’re an OCM practice, that [may be] an opportunity to deliver a message back to primary care to say, ‘Hey, look, we’ve got 24/7 access. We’ve got care managers that are engaging with your patients,’” she said. “How are you delivering those messages back to the marketplace?”

Samerdyke noted that a few years ago, care managers worked primarily at insurance companies, but thanks to medical homes, the OCM, and other programs that incentivize care management, they are moving to providers. Payers support the shift because they realize practices are better at working directly with patients. “The insurance companies know, if I’m a complex diabetic and I’m getting a call from my care manager at the insurance company, I’m probably not going to be as honest because I’m really worried about my premium rates. If I’ve got a care manager sitting in my physician’s practice, I can have a much more fluid conversation,” she said.

As in other innovative payment and care delivery efforts, such as patientcentered medical homes, bundled payments, and Medicare alternative payment models (APMs), ACO practices focus on improving the treatment of costly conditions such as diabetes and heart disease. Those providers are creating new kinds of partnerships to address high-profile disease states, Samerdyke said. “In some very developed networks, you’ll have an oncology practice where they will now have an endocrinologist as someone that they can consult with,” she said. “So they’re actually developing these relationships.”

Those relationships can help ACOs manage the risks they take on as part of their agreements with CMS or other payers, but the results so far suggest that much more innovation is needed. Samerdyke said Medicare ACOs have only achieved what she called “modest results” in meeting their cost and quality goals. In 2014, of 353 Medicare ACOs, 55% achieved savings and just 27% received shared-savings payments, she noted. In 2015, there were 392 Medicare ACOs, of which 31% shared in savings.

 In both 2014 and 2015, physician-led and physician-hospital partnership ACOs were more likely to achieve shared savings than hospital system ACOs.

For a number of reasons, hospitals are particularly motivated to use ACOs to cut costs in specialty fields, Samerdyke said. Under the ACA, hospitals are major financial contributors to federal healthcare reform (eg, reduced Medicare payments); in some cases, they are experiencing higher levels of bad debt. They are also seeing lower revenue due to new CMS programs like the Comprehensive Care for Joint Replacement Model, which sets ceilings on payments for hip and knee procedures.

“If your ortho service line has been hit pretty hard, you’ve got to make that up somewhere,” Samerdyke said. “You see this pressure being put on the oncology service line or the neurology service line or those additional lines in the hospital.” For the oncologist, whether at a hospital or group practice, membership in an ACO brings not only an opportunity for shared savings, but also an additional overseer pushing for efficiency, she added.

“If our cancer centers or our community oncology practices are now joining with a broader entity, who else is looking at the costs? And what are those pressures to shift those costs, not from the oncologist necessarily, but from an administrator of the ACO?” Samerdyke asked.

Looking to the future, she noted that CMS is working to attract more practices to higher-risk, higher-reward payment models, such as its Next-Generation ACO. Participants in the OCM’s 2-sided risk track and in MSSP tracks 2 and 3 are among those eligible for Advanced APM incentive payments. Another change is the introduction of regional spending trends in benchmarks for MSSP ACOs, which Samerdyke said will make the benchmarks more “realistic.”

She said CMS is also trying to remedy its failure to factor Medicare Part D drug costs into its benchmarks. Many critics consider that exclusion a major flaw in the agency’s effort to promote value-driven care, considering the extent to which pharmaceutical spending increases treatment costs in oncology and other specialties. CMS has said that a number of technical issues make integrating Part D into its payment models a complex project. “CMS is clearly interested in taking a look at that,” Samerdyke said.

She also briefly addressed the prospect of a repeal of the ACA. A repeal could eliminate CMS’ Center for Medicare & Medicaid Innovation, affecting ACOs and other payment models the agency oversees. Whatever happens legislatively, the broader healthcare system has gone too far down the reform path for that progress to be reversed, Samerdyke said. “So many of your commercial payers have bought in and engaged in this space. Think about the dollars that your health systems have invested in this space. My opinion is, we’d be pretty hard-pressed to go backwards because there’s been so much monetary investment in these models.”

Miller B. How the first oncology ACO achieves savings every year. Advisory Board website. www.advisory.com/research/oncology-roundtable/oncologyrounds/2016/03/miami-cancer-institute. Published March 1, 2016. Accessed April 25, 2017.

Muhlestein D, Saunders R, McClellan M. Medicare accountable care organization results for 2015: the journey to better quality and lower costs continues. 

 blog. healthaffairs.org/blog/2016/09/09/medicare-accountable-careorganization-results-for-2015-the-journey-to-better-quality-and-lower-costscontinues. Published September 9, 2016. Accessed April 25, 2017.

The number of accountable care organizations across the country has grown rapidly in the last 5 years, creating opportunities and challenges for oncology practices as they seek to benefit from the organizations’ referral networks, shared-savings programs, and care-improvement efforts.

ACOs Rapidly Expand, But Cost and Quality Improvements Lag Behind

Addressing the Challenges of Prior Authorization

Several provider challenges and opportunities were highlighted during the 2017 State Oncology Society Forum, hosted by the National Comprehensive Cancer Network (NCCN) at its annual conference, held in March in Orlando. Presenters and attendees discussed how the application of technology can drive significant near- and long-term benefits by easing prior authorizations (PAs), increasing information exchange, and balancing the roles between technology and human interaction in patient care.

PA requirements continue to increase as higher cost treatments, including oral and injectable therapies, are used in the treatment of cancer. Although payers initially developed the process to verify that a treatment is appropriate for a specific patient’s condition before the start of therapy, recent trends have led many providers to conclude that PAs are primarily a subterfuge intended to reduce costs and risk for payers; they have little regard for provider challenges or the burdens they place on patients.

Many oncology practices indicate that the PA workflow and process continue to be frustrating, time consuming, and expensive. Billing staff commonly initiate the process of gathering information and communicating with payers or their intermediaries to confirm that therapies or imaging tests are evidence based. However, the increasingly finegrained inquiries of payers often require the involvement of expert clinical staff and physicians. The labor time and disruptions in workflow can increase costs and delay patient care. Commentary from the podium and audience at recent oncology meetings has suggested these delays can stretch to 2 weeks or longer.

The slowdowns are visibly frustrating for patients and their families who already feel anxious about their diagnoses and impending treatments and are not commonly aware of the behind-the-scenes hurdles their care teams face. These feelings compound with each additional day, as patients wait for scheduling and more information and look to their providers for guidance and affirmation that they’re clear to begin or continue the battle against their disease.

PA difficulties are only growing worse as payers view this process as an acceptable means of data collection and verification; however, this is where technology can improve the situation for patients and their providers. A best practice to help streamline the PA process involves use of decision-support technology that integrates with an electronic health record (EHR) system to give physicians direct visibility of evidence-based treatment options at the point of care. With further clarity on which treatments are recognized by clinical guidelines and pathways, a physician can make recommendations that are likely to meet thresholds for compliance for PA and payment. Access to this information at the point-of-care leads to a quicker turnaround time for PAs and means patient delays and anxiety are minimized.

These tools also can ensure all necessary clinical data have been considered and captured, streamlining the workflow of the business office and clinical staff by easing the burden of paperwork, number of clicks, and other time spent on PAs. Integrating a decision-support system with Web-based PA portals can help to initiate cases and eliminate manual re-entry of patient details, further reducing delays and staff burden.

When choosing technology, a practice should find a solution that offers point-of-care access to the library of NCCN Guidelines—the most widely recognized clinical treatment recommendations in oncology. From their technology, providers should also expect narrower clinical pathways, visibility into treatment cost, and the ability to highlight payer-specific preferences (or coverage) for patients. The ability to directly transmit required information for PA submissions and to provide real-time reporting and physician feedback will ensure that the challenges of PA can be minimized. This will enable physicians to focus on practicing medicine, not negotiating with payers.

In the consumer world, we quickly become irritated if we are repeatedly asked to provide the same information to complete a transaction. Yet in healthcare, we are only now moving to an era in which the same information or data can be repurposed to complete multiple tasks.

From the EHR to billing and practice management, inventory management, decision support tools, and patient portals, providers rely on multiple tools to collect and manage data related to patient care. When these systems are not working together or sharing data, it becomes necessary to manually enter that data into multiple systems. Not only is this tremendously inefficient, but the risk of error increases. For many providers, their health information technology (HIT) remains in an awkward adolescence. Oncology is further challenged by the rapidly increasing depth of clinical content, terminology, and values that are required to deliver appropriate patient care.

The current push by payers toward value-based payment makes interoperability more important than ever. Practices face new requirements to merge clinical and financial data, and successful performance requires fast and accurate understanding of costs, quality, use, and other outcomes.

Significant strides have been made in the realm of interoperability. Static standards have given way to extensible toolkits, like Fast Healthcare Interoperability Resources. Savvy HIT vendors now offer not just closed-off tools, but open platforms and suites of solutions that share information and work together to lower costs, increase access, and improve the quality of care. A practice looking to implement any type of HIT system should partner with a vendor that will consider the interoperability of all of applicable systems.

Looking to the future, it’s beginning to appear that one day, a computer will be able to simulate how the human brain works. In just the last 6 months, learning systems have outperformed humans in everything from driving cars to playing high-stakes poker. The promises of Big Data and cognitive computing in healthcare have yet to become a reality, but as these advancements make their way from pilot programs to everyday practices, providers are asking when it is best to still have human interactions and decision making.

Large amounts of information can be overwhelming at best and counterproductive or dangerous at worst—everyone in the industry is familiar with this challenge. But technology is excellent at applying logic and capturing, managing, and storing data. Our reliance on modern search engines and smartphones is an example of the value of being able to organize mountains of information to gain insight from it.

In a similar sense, Big Data, clinical algorithms, and cognitive computing—properly coupled with an understanding of workflow and operations&mdash;have the potential to enhance care. Early pilots of cognitive computing systems and the wide customer footprint and quantitative benefit of clinical pathways highlight the opportunities here.

Even so, physicians and their supporting care teams have access to far more information than is captured in systems, and there are many aspects of care that technology cannot replace. For example, every patient has different values and priorities when it comes to care. There are cultural differences and emotional reactions to consider when discussing diagnoses, and the best treatment option or end-of-life care decision is not always identifiable from structured data and algorithms. In these situations, nothing can replace the human aspect of care and the need for providers to stay closely connected with their patients.

Leading HIT systems are fine tuned to clinical workflows and offer the flexibility to incorporate future advancements in cognitive computing. However, all will face the challenge to balance the use of these sophisticated capabilities to complement human caregivers, not distract them or attempt to replace them.

HIT presents boundless opportunity to address many of the challenges practices face in the rapidly evolving marketplace. But significant risks persist, and having a well thought out strategy and capable partners are essential for optimizing practice operations and payment, as well as for allowing a focus on quality patient care. Comprehensive workflow and billing support, managed clinical content, and user- and IT staff— friendly cloud-based systems are no longer enough. Winning providers need to organically extend systems with decision support and tools that minimize the burden of PA, adopt interoperability to enable modular applications that support value-based care, and have the foresight to enable integration to benefit from advancements in data processing and cognitive computing.

Several provider challenges and opportunities were highlighted during the 2017 State Oncology Society Forum, hosted by the National Comprehensive Cancer Network at its annual conference, held in March in Orlando.

June 2017 | Oncology Business News®