Enhancing Cancer Care Coordination for Vulnerable Populations
Explore how the ACHIEVe initiative led by Dr. Ahmed Hassoon at Johns Hopkins aims to eliminate cancer care disparities through the Transition of Care Plus tool for lung cancer patients. The project focuses on survivorship care plans, EHR optimization, and integrating evidence-based guidelines into patient care plans for high-risk populations.
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ACHIEVe Academic & Community Health Systems Initiative to Eliminate Cancer Care Disparities in Vulnerable Populations Transition of Care Plus: An Epic tool for care coordination for lung cancer patients Ahmed Hassoon,MD, MPH, PMP Assistant Scientist | Department of Epidemiology Johns Hopkins Bloomberg School of Public Health Departmentof Neurology| Johns HopkinsMedicine 2022
Disclosuresfor Ahmed Hassoon, MD MPH PMP Grant support Cigarette Restitution Fund,Seed Fund,Stateof Qatar ,Ernest &Young Gordon &Betty Moore Foundation,MERCK Foundation Research devices Amazon Echo(fully purchased) Fitbit (fully purchased) GPU (Donatedby Nvidia) Related Roles Scientific Manager , Johns Hopkins Armstrong Institute Center for Diagnostic Excellence (salarysupportfor effort) 1. 2. 3. 2
3 Care Coordination and Transition of Care Enhancement through EHR Optimization TEAM: Ahmed Hassoon, MD,MPH (ToCPI YasminBaig, BS (Coordinator) Leftthe team AdrianDobs,MD, MHS (ACHIEVPI) JoyFeliciano,MD Clinical Review Dan Hill, BS Epic Analyst 3
4 Project Goal Create a comprehensive Survivorship Care Plan in EPIC, using a rules-based system and to be delivered to the patient at the time of transition of care Oncology --------- primary care Use standards developed by National Comprehensive Cancer Network (NCCN) Survivorship Guidelines, American Society of Clinical Oncology (ASCO), American College of Surgeons Committee on Cancer (ACOS CoC), and CoC Standard 3.0 4
5 Project Goal Aim: Develop and implement EHR-based tools to integrate evidence-based guidelines into patient care plans and facilitate its translation and use among authorized providers involved in cancer patient's care. Targetpopulation : AA, or in a high-risk zip code, >60 y,and with a diagnosis of lung, prostate, breast or colorectal cancer How: we will utilize our existing in-house engineering developers to use Epic CER Rules application, Best Practices Advisories & Patient Scoring Systems, and MyChart/Epic machinery to enhance cancer care coordination post-active treatment in the form of Transition of Care Plus. Provider version and patient friendly version on mychart 5
6 Development of Transition of Care Plus Intervention Conduct Multidisciplinary Sessions toAssess Current Weakness, Opportunities, Solution Design, Guidelines Updates, and Ownership & Responsibility Assess PracticeCurrent Processes and Readiness by Cancertype Select and Upgrade Existing EPICMachineryforTransition Of CareFunctions Plan Our Approach With EPIC Technology Group Continuous Quality Improvement Conduct Testing, Refinement, and Training ScaletoOtherCenters AchieveMeaningful Use 6
7 Indicators Proportion of providers who provide a summary of care record using Epic Transition of Care Plus for more than 50% of their patients who transition from active treatment to survivorship setting. Proportion of cancer patients in the intervention who receive MyChart Transition to Primary Care checklist following conclusion of active cancer therapy. Proportion of cancer patients in the intervention who accessed the MyChart Transition to Primary Care checklist after active therapy. In addition, we will be able to monitor Utilization Rates through admissions and out-patient visits, as well as adherence to evidence-based guidelines for preventative services. 7
8 NCCN Guidelines: Prevention of new and recurrent cancers and other late effects Surveillance for cancer spread, recurrence, or second cancers Assessment of late psychosocial and physical effects Intervention for consequences of cancer and treatment (eg, medical problems, symptoms, psychologic distress, financial and social concerns) Coordination of care between primary care providers and specialists to ensure that all the survivor's health needs are met Survivorship care planning 8
9 The Analytic Flow Operationalize toaction(s) Transform Structure Unstructured Turningdatainto insight Forthepurpose ofgenerating insight Usinginsightto informaction Ingestand digest Visualization 9
10 Setting the Stage/Context Beacon EPIC @Hopkins Ambulatory MyChart 10
11 Cancers* 2017-2018 Addressed Started Completed Given Currentuse: 1273 9(0.7%) 4(0.3%) 0 0 Lung 3762 292(7.8%) 186(5%) 137(3.6%) 134(3.6%) Breast 3921 94(2.4%) 94(2.4%) 49(1.3%) 38(1%) Prostate 457 14(3.1%) 8(1.8%) 4(0.9%) 4(0.9%) Colon *Onlyincluded serialencountersand notsinglevisitfor treatment.
12 Build on Existing Modules OncologyHistory EpicTools: BeaconinEpic OncologyHistory Labmodule TreatmentSummary Survivorshipchecklist Mychart Oncology Treatment Summary
13 Addingnew knowledge Predictivedecisionmodel
14 Demo Actual demonstrationof the toolin Epic https://epic.webex.com/recordingservice/sites/epic/recording /playback/e1e6d44742f74cb4961aafb21e6a3e40 MzyUCDH5
