NcXHF

MAYER ET AL
to enhance the quality of cancer care using the SCP could
include the addition of patient-reported outcomes (e.g., if a
symptom is reported, information about that symptom and
ways to manage it could be incorporated into the SCP). Other
opportunities to improve care would include data mining
and research. 13 However, we are still in the nascent period of
using EHRs to develop and deliver SCPs and have yet to realize
the full possibilities for improving the quality of survivorship
care. Many practices are currently working with
EHR vendors to implement SCPs, so we will be learning
many lessons about what works and what does not along
the way. One can use Donabedian’s conceptual framework,
as described in Table 1, using structure, process, and
outcomes to consider issues of EHRs implementation of
the SCP. 14
Structure
One must decide what elements to include in an SCP. There
are a number of free-standing, independent templates (e.g.,
Journey Forward, LIVESTRONG) that have been used, but
they have operability issues within EHRs. ASCO recently reviewed
and revised the essential elements to include in an
SCP. 15 These elements, endorsed and adopted by the CoC,
can be identifıed or created within a template to be autocompleted
or to provide standard options for completion
within any EHRs (Table 2). Where these documents will be
stored within EHRs, how they can be shared with intended
users (survivor, primary care provider, and other relevant
providers), and how they can be tracked and reported are
other structural issues that need to be resolved.
Process
A number of process issues need to be addressed (see sidebar).
These decisions need to be discussed, decided, tried,
and revised based on experience with the stakeholders of this
process. Furthermore, how these issues are addressed may
vary by type and size of oncology practices. 16,17 Effective
change management is needed and includes engaging key
stakeholders, standardizing terminology, clinical practices,
and processes. 16 Articulating and agreeing on key assumptions
help guide the approach and assure that this process,
and ultimately the document, is patient and primary care
centered. This process should be standardized as much as
possible but should allow for variations to reflect the complexity
of cancer care. It is helpful to have at least one champion
and to work with an interested and willing early-adopter
group to pilot this process. 18
Implementation of this process will take time and require
flexibility until the system for developing and delivering
SCPs becomes standardized and incorporated into practice.
For example, in a large academic medical center, there may
be a number of disease-specifıc groups with differing approaches
about who sees the patient and how often. Decisions
about who completes and delivers the SCP when all
three treatment modalities are delivered versus when one is
delivered could vary. For example, these decisions could fall
on the last person who treats the patient or the fırst person
SIDEBAR. Questions to Consider When
Implementing Survivorship Care Plans within an
Electronic Health Record
1. How will eligible patients be identified and tracked?
2. How will a provider know when an eligible patient is due to
receive a survivorship care plan (SCP)?
3. How will the SCP be created and by whom?
4. How will a provider know when to deliver the SCP?
5. How will the SCP be delivered to the patient and primary
care provider and be documented?
6. How will you bill for this service?
7. Where will it be stored within the electronic health record
for others to access?
8. How will you track the number of SCPs developed and
delivered?
9. How will you monitor and evaluate your effectiveness in
achieving the Commission on Cancer’s goals for your cancer
program?
10. How will this effort become a sustained standard of care?
11. Will you collect any patient/provider outcome measures
related to the SCP?
who sees the patient during the fırst follow-up visit. To say
that the devil is in the details is an understatement in trying to
delineate and implement a new process such as this. The
good news is that one is not trying to undo a previous way of
implementing the SCP—this is a new endeavor.
Another important questions about the process is how is it
delivered once it is completed. The SCP is a paper document
and it does not serve the original intent by merely handing it
to the patient and checking off that it was delivered. The SCP
is meant to serve as a communication tool to facilitate review
of the patient’s diagnosis and treatment, guide discussion of
planned surveillance and who will be responsible, and encourage
identifıcation and discussion of any current or future
concerns or issues the patient may face post-treatment. In
one study in patients with colon cancer, the delivery of the
SCP did not lengthen the usual surveillance visit, but it did
provide structure to what was discussed. 19 Nutritional concerns
and bowel management problems quickly became
identifıed as issues most of these patients raised, and these
topics were then incorporated routinely into the SCP and
visit.
There are many barriers to SCP implementation and these
need to be addressed as they are identifıed. Working closely
with the EHR vendor during the development and piloting
phase is critical. Receiving input from anticipated users and
having them try to use the SCP EHR system as intended will
identify many issues with implementation. Answering the
questions in the sidebar can be time consuming, and the approach
may need to change over time with experience. One
of the critical issues is reimbursement for SCP completion.
As of January 1, 2015, SCP preparation can be billed as a new
CPT code, 99490 (chronic care management services, at least
20 minutes of clinical staff time directed by a physician or
e586
2015 ASCO EDUCATIONAL BOOK | asco.org/edbook