PROBLEM FACED: Broad use of oral chemotherapy poses safety challenges that are not manageable by systems designed for intravenous chemotherapy. Our institution, the University of Wisconsin Carbone Cancer Center, was experiencing challenges in safety and uniformity of processes for delivering oral chemotherapy and associated care.WHAT WE DID: ASCO and the Oncology Nursing Society jointly published safety standards for administering chemotherapy that offered a framework for improving oral chemotherapy practice. We used these standards to define gaps in the safety and uniformity of our oral chemotherapy practice and to develop recommendations for improving processes. Areas for improvement were addressed by multidisciplinary workgroups that focused on education, workflows, and information technology. Key changes included defining chemotherapy, standardizing patient and caregiver education, mandating the use of comprehensive electronic order sets, routing all oral chemotherapy prescriptions for review by an independent pharmacy before dispensing, and standardizing documentation of dose modification. In addition, drug-specific materials were developed to create uniformity in adherence and toxicity monitoring. Collectively, these processes enabled significant safety mechanisms for oral chemotherapy analogous to those in place for intravenous chemotherapy. Revised processes were implemented over a 5-month period.WHAT WE FOUND: Defining oral chemotherapy allowed creation of a list of oral chemotherapies that could be recognized and grouped in our electronic health record (EHR), which enabled EHR-facilitated solutions,includingconsent verification, prospectiveorderreview,education, and monitoring.Thefollowing are key performance indicators: 92.5% of oral chemotherapy orders (n = 1,216) were initiated within comprehensive electronic order sets (N = 1,315), 89.2% compliance with informed consent was achieved, 14.7% of orders (n = 193) required an average of 4.4 minutes review time by the pharmacist, and 100% compliance with first-cycle adherence and toxicity monitoring was achieved. We defined elements needed for complete patient education and provided staff education on this effort but did not build any EHR-based forcing functions. Subsequent assessment showed poor performance in documenting all elements of oral chemotherapy education (36%), which demonstrated the need for continued improvement. CONFOUNDING FACTORS, DRAWBACKS:We achieved demonstrable success in improving oral chemotherapy practice. Our approach relied heavily on the ability to electronically recognize oral chemotherapy prescriptions and apply all of the safety systems designed for intravenous chemotherapy. Our institution uses a well-established EHR and can dispense many oral chemotherapies because we have a specialty pharmacy. Potential limitations of our approach include EHR specificity, as well as ongoing time commitments by pharmacists for prospective order review. The capacity to fill many prescriptions mitigates the risk of pharmacy-related errors an...
56 Background: Accreditation guidelines require all breast cancer patients receive SCPs within 6 months of end of treatment (EOT) in 2016. SCPs require significant resources to provide, which EHR assistance might decrease. Our objective was to develop a standardized program for creating, providing, and tracking SCPs using an EHR. Methods: Clinicians and EHR analysts developed processes for implementing an EHR-based program, using our existing SCP to guide overall structure. We piloted this program 5/2015-6/2015 to identify barriers & facilitators to creating EHR-based SCPs, providing EHR-based visits and EHR-based tracking of both. Results: The pilot included 24 patients (2% of annual volume). Facilitators were: 1) pre-entry of cancer history, 2) clearly defined responsibilities for SCP & visit; barriers were: 3) no identified method to assess concerns or track referrals, 4) variability in EOT due to treatment heterogeneity, 5) limited time during routine follow up for SCP provision. The following changes were implemented: 1) SCP auto-population, requiring consensus on essential clinical data, 2) assigning staff roles (MD, NP/PA, RN) for all aspects of SCP creation & visit provision; 3) creating 1-page survey addressing NCCN recommended topics to pre-screen for concerns discussed at SCP visit and using a visit template to track topics covered plus information and referrals provided, 4) establishing processes and delivery dates for SCP & visit to newly diagnosed patients and 5) developing algorithms for referral for SCP & visit (4-8 weeks from EOT) including adding “SCP visits” to EHR-chemotherapy plans and other auto-reminders. Clinic-wide implementation began 7/2015; updated results will include: EHR-tracked, provision rate, type and frequency of survivor concerns and referral patterns and time for SCP creation and visits. Survivor/clinician satisfaction with EHR-based program will also be included. Conclusions: EHR-based SCP creation, provision and tracking is feasible. Future plans include assessing time and personnel resources required, and comparing the accuracy of EHR-tracking with cancer registry data or other standards used to address guideline compliance.
58 Background: Use of oral chemotherapy is expanding and offers advantages but introduces unique safety challenges. ASCO and ONS addressed these issues with inclusion of oral chemotherapy in published chemotherapy administration safety standards. Methods: The updated ASCO/ONS standards offered a framework for the University of Wisconsin Carbone Cancer Center to evaluate and improve our practice with the goal of full compliance with these standards. Gap analysis revealed noncompliance with five and partial compliance with eleven standards. We divided areas for improvement into three foci: patient education, workflow, and information technology. Multidisciplinary groups addressed each area generating twenty-five recommendations. Important changes included: defining chemotherapy, standardization of patient and caregiver education, mandated use of standardized electronic order sets incorporating safety checks, and standardizing dose modification documentation. The revised electronic process allows for prospective order review of all oral chemotherapy by pharmacists and supports automated processes for assessing adherence and toxicities utilizing a library of scripted drug specific materials. Results: Prior to implementation of new processes we estimated that only 39% of our oral chemotherapy was delivered with potential demonstrable compliance with ASCO/ONS standards. Audit of oral chemotherapy orders from February to July 2015 now shows compliance with use of electronic chemotherapy plans in 244/251 (97.5%) of cases. Prospective pharmacist order review resulted in one or more interventions in 24% of these cases.Identification of patients to receive adherence and toxicity monitoring calls is 100%. Conclusions: Closure of significant gaps between institutional practice and published standards was accomplished for our oral chemotherapy practice. Key elements of success included: multidisciplinary approach, defining chemotherapy, leveraging our electronic health record with mandated use of standardized order sets, and standardization of clinical and educational processes. We are disseminating this approach across our regional network and we believe our tools are broadly applicable.
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