LGH Implements Symptom Assessment and Management for Patient Oncology Program

LGH implemented a texting-based outreach system to help manage patient reported outcomes (PROs) during cancer treatment called SAM (Symptom Assessment & Management). This was accomplished by further automating the SAM interactions and directly integrating into the clinical workflow. LGH offered SAM to all Ann B. Barshinger Cancer Institute (ABBCI) patients to comply with CMS Oncology Care First program requirements. As cancer treatments have become more advanced and complex, follow up and monitoring from the clinical team became more difficult and frequent. Yet at the same time with this added complexity, the expectation emerged for a greater degree of proactive follow-up between visits, placing a large burden on the oncology nursing workforce. SAM has proven to be an effective way of reducing the growing number of outbound calls required to stay on top of the needs of high-risk patients. SAM has also been helpful in prioritizing nursing time towards those patients’ reporting issues and only those that required follow up from human nurses.

The implementation included the development of a texting algorithm on the Way to Health platform. The development of this framework supported future phases and included a pilot, implementing texting outreach to new patients in two of the four clinics, while phasing in existing patients and new patients over time. A later phase included an alternate outreach model—such as email and automated phone calls. Patients were seen prior to each cycle of medical treatment, in addition to treatment specific appointments. This texting program was stood up in parallel with the practice moving to a triage model where the patient would self-manage lowlevel treatment side effects from home and have access to a nurse triage team for assistance in more complex symptom management or as self-determined.

Cancer patients have been known to fight to survive both their disease and the side effects of treating it. In the turmoil of such uncertainty and physical and emotional challenges, patients have often held back from disclosing significant treatment side effects for fear that clinicians will alter or stop their life sustaining therapy. When combined with clinicians underestimating symptom severity, these factors not only contributed to lower quality of life for patients, but they have also driven increased health care expenditure through potentially unnecessary emergency room visits and hospitalizations. The implementation of SAM in Oncology significantly improved the clinical team’s ability to communicate with patients, control symptoms, reduce hospitalizations, and improve quality of life. The SAM tool has helped the clinical team achieve its primary goal of significantly reducing patients from going to the emergency room. Additionally, patients have reported high levels of satisfaction with using an AI-driven tool as an alternative to calling a clinician with basic questions.

Information Services provided extensive workflow analysis and documentation with the team for the oral and IV treatment pathways. The cancer, outpatient and patient portal teams completed build, testing, and training to support the clinical pathway changes, in addition to supporting the phone texting campaigns. After implementation, the team also modified the ADT feed to turn off/on Way to Health messaging when a patient is admitted/discharged, and automation of the enrollment step eliminating many incomplete enrollments.

Lancaster Community Gains Local Penn Fertility Care Clinic

A reproductive endocrinology and in-vitro fertilization (IVF) facility now serves the Lancaster General Health Suburban Outpatient Pavilion. Ambulatory eHealth integration ensures smooth patient integration of scheduling, clinical documentation, testing, and billing. The practice’s cryotanks and incubators house embryos and other high liability materials which are alarmed for temperature and liquid nitrogen level monitoring. Penn Fertility Care Lancaster General Health is also using a third-party application, as an assisted reproductive technology management system to manage the fertility information for all patients of the practice. This new clinic brings the entire IVF process—which includes egg retrieval, implantation, and storage to the Lancaster community. Patients no longer need to travel beyond their general region for this treatment.

Brachytherapy Radiology Oncology Services Refreshed to Provide Improved Experience

Brachytherapy is a critical procedure used in the treatment of cancer, and it is important to provide patients with a seamless and efficient experience. To this end, a brand-new procedure room was created in the Perelman Center for Advanced Medicine to provide brachytherapy procedures. Previously, these services were being performed in multiple phases and various procedure rooms or locations, causing a more cumbersome workflow for providers and staff. Due to this development, the services are now consolidated to provide a better patient experience.

By leveraging an existing interface, a new workflow was designed to allow brachytherapy procedures to be scheduled and performed in the newly renovated procedure room with all the appropriate medical equipment in one location. A new billing workflow was designed to streamline and improve billing workflows for technical and professional charges being performed for the procedures.

Patients now receive all phases of the brachytherapy procedure within one case, inside a newly renovated space. The new space provides a single location to receive the procedure, along with enhanced scheduling tools, and efficient billing.

New Order Panel Guides Evidence Based Ordering, Clinical Decision Support, and Interpretation

Penn Medicine’s Center for Evidence-based Practice (CEP) collaborated with the Antimicrobial Subcommittee, Sepsis Alliance, Critical Care Collaborative, and Pathology and Laboratory Medicine to establish evidence-based guidelines for inpatient procalcitonin (PCT) testing. This testing has been used to guide antibiotic discontinuation for sepsis or lower respiratory tract infection (LRTI). The guidelines provide recommendations on patient selection, testing frequency and timing, and result interpretation for ordering providers.

To improve provider ordering in the EHR, the previous inpatient PCT order was redesigned. PCT results now contained detailed guidance for serial PCT testing and antibiotic discontinuation based on indication and results for inpatient PCT orders. One order panel was created for use throughout the entire health system, carrying the same consistent clinical guidance.

By implementing evidence-based guidelines and a standardized ordering process, Penn Medicine has improved the quality of care for patients with sepsis or LRTI. Clinicians can now make more informed decisions regarding antibiotic use, which may ultimately lead to better patient outcomes and reduced healthcare costs.

High Sensitivity Troponin Project Leads to Significant Patient Care Outcomes

American Heart Association and American College of Cardiology 2021 guidelines indicate that, “high-sensitivity cardiac troponins (hs-cTn) are the preferred standard for establishing a biomarker diagnosis of acute myocardial infarction, allowing for more accurate detection and exclusion of myocardial injury” in the evaluation and diagnosis of chest pain or its angina equivalents. Two UPHS hospitals (LGH and CCH) were already using this biomarker, and the remaining 5 hospitals (PAH, PPMC, HUP, HUP Cedar, MCP) needed to be implemented.

Transitioning from conventional cardiac troponin to hs-cTn allows for earlier rule out while reducing rates of missed myocardial infarction. However, it can also be elevated in patients without ischemic disease. So, instead of relying on a single value and a reference range, proper use requires evaluation within the clinical context and interpretation of temporal changes (deltas) at set intervals relative to presentation. Patients without active ischemic disease can now be appropriately discharged with elevated troponins. Some of these will require follow up and others will be “incidental” and, thus, potentially seen in a wide range of outpatient practice settings.

This paradigm shift, both in workflow and interpretation, presents a large educational, logistical, and implementation challenge. In benchmarking with peers such as Duke, Mass General Brigham, and University of Texas Southwest, Penn Medicine learned that there were significant risks of diagnostic errors, inappropriate admissions, significant rise in cardiology consultation and unnecessary imaging, delayed discharges from the ED, and/or delayed outpatient follow-up.

An additional challenge with the launch at Penn Medicine was the variation in infrastructure. Hs-cTn is run on large analyzers in the core laboratories and not all laboratories have the same equipment. Harmonization of equipment would involve prohibitive large capital purchases and construction. The UPHS launch required a combination of types of hs-cTn biomarkers (Troponin T and I), each with the need for distinct interpretive guidance for each hospital depending on the analyzer in use.

The project was highly collaborative- engaging multiple physician disciplines, informatics experts, nursing leaders and operations leaders. It required interplay of clinical, laboratory, and informatics expertise. The physicians researched the existing algorithms, considering the different clinical workflows within the system. The team then worked with informatics experts to build the care path (the first one deployed at UPHS) and vetted the proposed workflow with different user groups, including every ED and many inpatient and outpatient users. Every potential user received targeted education on the impact to their area.

High sensitivity troponin is, by definition, a marker of early cardiac leak; it is expected to be elevated in disorders that elevate cardiac risk (cancer, diabetes, hypertension), which touches most providers in the system as potential impact (approximately 8000 individuals). Penn Medicine took the following implementation approach:

• Formed an interdisciplinary, enterprise-wide governance, eventually including 89 participants

• Designed algorithms for both I and T isoforms based upon research, embedded these in PennChart Care Path logic optimized for individual workflows through user collaboration as well as to the website for reference and links

• Coordinated the launch with all affected labs and analyzers

• Facilitated educational efforts:

• Provided five learning modules for users

• Created educational material such as tip sheets and eLearning

• Created a project hub (website) for FAQs and additional material links

• Numerous meetings with stakeholder groups to ensure education needs were met

• Coordinated communication plan for impacted groups, including newsletters, CMO office, the PM report, in addition to local messaging

• Supported a multidisciplinary command center for questions

• Created analytics dashboard for continuous monitoring

The initiative successfully went live on June 3rd, 2022 with an exceptionally smooth transition from the old assay to new high sensitivity troponin. Penn Medicine did not experience any reporting of diagnostic error, inappropriate admission, delaying discharge or increase in cardiology consultation. Patients with a chief complaint of CHEST PAIN have a 26% decrease in median percentage of observation dispositions. Of the patients with a chief complaint of CHEST PAIN or SHORTNESS of BREATH, 13% had an increase in median percentage of discharge disposition while there was a 17% decrease in median percentage of observation dispositions. Diagnosis of NSTEMI and STEMI increased for patients presenting with chief complaint of chest pain. Stable ED length of stay for patients presenting with chief complaint of chest pain despite unusually high boarding times.

Improving Sepsis Detection in Newborns Using EHR Neonatal Sepsis Risk Calculator

Early onset sepsis in neonates has long been established in the U.S. as a life-threatening condition. As a result, newborns have been screened for this risk after birth to take precautionary measures for detection. In the past, providers calculated a neonate’s risk of sepsis by manually entering data into a web calculator and copying the score back into the EHR. Caregivers sought a more automated tool, which appeared conveniently in workflows, to capture related data directly in our EHR. The hope was to leverage clinical documentation by generating an accurate score as soon as possible and begin therapy if it were needed.

The EHR application team developed a customized sepsis enhancement from a baseline feature in our EHR to meet our goals for more rapid scoring and automatic score recalculation. The team also designed the clinical decision follow-up recommendations to appear dynamically, depending on the reported values and the newborn presentation. The project team performed multiple proof of concept trials, enabling consistent calculation even when tested toward the event of less common, real-world scenarios. Additional performance adjustments were also applied to the design and testing, which improved run time.

Since the initial implementation in July 2021 through March 2023, the tool has auto calculated the sepsis risk score for 20,237 newborns. Patients and clinicians benefited from accurate scores and quick access, helping to expedite vital patient care. The benefits to clinical detection outcomes were so significant that our EHR partner decided to update their base application to match our new design so that all organizations could use a more featured, highly performant, research current calculator.

Clinical Trial Shows Effect of EHR Nudges to Increase Statin Prescribing

Statins reduce the risk of major adverse cardiovascular events, but less than half of Americans that meet guideline criteria for a statin are prescribed one. Effective statin therapy requires prescribing, acceptance, and adherence from patients and encouragement from clinicians. Barriers exist at both points, revealing opportunities to improve effective statin use.

A study team conducted a cluster randomized trial to evaluate the effect of nudges to clinicians, patients, or both on the initiation of statin prescriptions during primary care visits. These interventions were automated through the EHR, representing a scalable approach to nudge behavior. The clinician nudge included two components. First, clinicians received an active choice prompt by BPA (best practice advisory) which triggered when a clinician entered the order in the EHR. Second, clinicians received monthly peer comparison in the form of a 3-month rolling average of the percent of their eligible patients prescribed a statin and how that compared to peer clinicians at Penn Medicine.

Patient nudges were sent by text messages starting 4 days prior to their appointment, reminding patients of the upcoming appointment, and informing them of an important message about their heart health. Patients confirming their willingness to communicate by text were told: “Guidelines indicate you should be taking a statin to reduce the chance of a heart attack.” Patients were told “At Penn Medicine, it is standard of care to prescribe a statin to patients like you.” Patients were asked to reply “Y” if they were interested in taking a statin or reply “?” if they were unsure or had questions for the doctor. Patients replying “Y” were told to remember to discuss the statin during their visit and sent a link to a shared decision-making tool on statins. Patients replying were told to write down their questions or concerns and share them with their doctor at the visit. Patients were sent an additional message 15 minutes before their appointment time: “As a reminder, speak with your doctor about taking a statin medication to reduce your risk of a heart attack.”

The trial included 158 primary care clinicians from 28 primary care practice sites. During the intervention period, the sample included 4131 patients with a mean (SD) age of 65.5 years (10.5); 51.3% were male, 66.1% were white, 29.3% were Black, and 22.6% had Atherosclerotic cardiovascular disease. The primary outcome was initiation of a statin prescription by the end of the day of the primary care visit. A secondary outcome was whether a statin was dispensed by a pharmacy within 30 days of the visit.

In this pragmatic, cluster randomized trial, a clinician nudge alone, and when combined with a patient nudge significantly increased initiation of a statin prescription during primary care visits. Sending nudges to patients alone was not effective. These findings demonstrate the potential benefit and scalability of using nudges to change prescribing behavior through automated processes within the EHR.