Tumor board workflow challenges in preparation, presentation and documentation

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1 Tumor board workflow challenges in preparation, presentation and documentation Executive summary Worldwide, tumor boards share the goal of improving patient care and achieving optimal treatment outcomes. Those objectives have been a driving force for multidisciplinary oncology care team meetings since the early tumor board meetings reported by John C. O Brien, MD, in the late 1960s at Baylor Hospital, as well as the regular breast tumor conferences at MD Anderson Hospital and Tumor Institute in the 1970s. 1 However, many tumor boards also share a series of inefficiencies related to workflow challenges, and many practitioners are investigating the role and efficacy of tumor boards in medical systems. 2 In addition to overall inefficiency, workflow challenges can lead to inconsistencies and hinder the ability to deliver optimal benefits of multidisciplinary collaboration. For example, collecting and organizing patient information is a time-consuming task for each participant, one that is often not standardized among specialists and among various tumor boards within the same institution, resulting in inefficiency and/or inconsistency at the point of preparation. Manual processes for planning and managing tumor boards can negatively affect information-sharing during the meetings and lead to treatment decisions that are not fully informed and/or documented. Subsequent group communication and post-meeting next steps can lack clarity where these common workflow challenges are present, increasing the risk that treatment decisions might not be fully implemented in practice. For those reasons, a well-defined, standardized process for preparation, presentation and documentation is necessary for tumor boards to realize their full potential for multidisciplinary decision-making, patient care and patient outcomes. This white paper explores common tumor board workflow challenges and tumor board experiences before, during and after meetings. Other papers in this series from Roche Diagnostics Information Solutions provide analyses of tumor board benefits and current practices.

2 The impact of inefficient workflow on cancer care Described in simple terms, a tumor board is a meeting of physicians and other care providers across various disciplines related to individual cancer cases a platform for specialists to come together to review each patient cancer case and reach consensus on proper diagnosis and treatment plan. Attendees typically include oncologists (medical, surgical and radiation), radiologists, pathologists and nurse navigators; at times, other specialists, primary care physicians and social workers are present as well. This multidisciplinary approach supports evidence-based decision-making and facilitates care coordination to ultimately optimize patient care and treatment outcomes. Tumor boards are commonplace but vary in size, area of focus and meeting frequency depending on the institution. Most tumor boards follow a similar workflow (see Figure 1). Given the complexity of gathering patient data from disparate sources and the fact that there are multiple touch points in play before, during and after each meeting it is easy to see how workflow inefficiencies can overwhelm participants and hinder the group s ability to make and follow through on treatment decisions. Typical tumor board workflow Collect Patient Data Coordinate Logistics Prepare for Meeting Conduct Tumor Board Each participant works individually to gather all patient information while focusing on the most relevant data related to his or her specialty to address patient-specific concerns. A cancer center coordinator plans the logistics of the meetings for the year, scheduling a time, date and place for each meeting, and inviting the appropriate specialists. A nurse navigator organizes the agenda and provides the list of patients to be discussed at each meeting. The specialist who requested convening on the case presents the patient-specific issues, allowing each participant to present his or her findings with related artifacts previously collected. Once all relevant data have been presented and treatment options have been discussed, the lead oncologist of the meeting summarizes the patient case and voices the agreed-upon, evidence-based treatment decision. Document Decisions A nurse navigator or other delegate in attendance (such as a resident or medical student on rotation) captures meeting notes, treatment decisions and next steps in patient care. In many cases, this individual enters all notes related to tumor board discussion into the patient s electronic medical record as well. Figure 1: The five overarching steps in typical tumor board workflow processes include data collection, logistical coordination, meeting preparation, meeting presentations and collaboration, and decision documentation.

3 We need to look at all the different reports and integrate the information. It s very time-consuming, and it s a complex process. - Dr. Clara Montagut, Medical Oncologist, Hospital del Mar in Barcelona, Spain Time-consuming preparation: The first step in preparing for a tumor board is collecting all relevant clinical and diagnostic information to be presented at the meeting. Such data may include a patient s medical history (including demographics, allergies and medications), radiology images, test results, pathology reports, tumor information, biomarkers and notes from the patient s electronic medical record, as well as applicable findings of comparable, evidence-based cases from the larger patient population. The higher the quality and relevance of the data being gathered, aggregated and presented and then assessed in conjunction with evidence-based guidelines to ensure adherence to standards the more effective the tumor board can be in making decisions collectively aimed at achieving the best possible treatment outcome for every patient. However, physicians and other members of oncology care teams, already pressed for time with their clinical responsibilities, often have little time to fully prepare for tumor boards. In fact, in a survey of British oncology surgeons involved in breast tumor boards in the United Kingdom (UK), nearly one-third (29%) of survey respondents indicated time to prepare for meetings was an area for improvement. 3 With information stored in numerous sources presentation slides, handwritten notes, a hospital s picture archiving and communication system (PACS), and more collecting and entering the data into a central location is a cumbersome task, and often a significant challenge, particularly where the processes are manual and subject to variation from one specialist to the next. Furthermore, manual entry of disparate inputs from numerous sources can increase the risk of errors. According to a growing body of evidence, when the processes for preparatory data collection are arduous and non-standardized among presenting specialists, it can negatively affect the group s ability to achieve consensus on treatment decisions. Interviews of 22 experts participating in urological and gastrointestinal tumor boards in the UK revealed one of the key factors that prevented a tumor board from reaching a decision was the lack of a holistic approach when discussing patients at the meeting. 4 Multidisciplinary oncology care teams require the ability to integrate clinically relevant patient data with evidence-based guidelines to inform clinical decisions and impact quality of care, which underscores the universal need for clinical decision support software tailored for tumor board workflow optimization. Standardization at the point of data collection can improve consistency while decreasing time spent on preparation among meeting participants. The UK study of urological and gastrointestinal tumor boards identified the use of a standard document or form as a way to improve tumor board preparation 4 ; to that end, cancer care organizations should assess and implement software technologies that enhance the ability to standardize processes in the tumor board workflow. Similarly, standardization across multiple tumor boards within the same organization is key, particularly when it comes to data management and the potential benefit decision support solutions can provide in collecting and populating patient information. A parallel is seen in the pharmaceutical industry, where companies rely on data from clinical research to develop new drug therapies. In a 2012 article explaining data management in clinical research, Krishnankutty and colleagues discussed the challenges of clinical data management (CDM): CDM should be evaluated by means of the systems and processes being implemented and the standards being followed. The biggest challenge from the regulatory perspective would be the standardization of data management process across organizations, and development of regulations to define the procedures to be followed and the data standards. 5

4 Inefficient meetings: Inadequate or incomplete preparation for a tumor board makes meeting management more difficult and less efficient an issue that is prevalent across multiple tumor boards at the same or different cancer care sites. For example, in an international survey by the American Society of Clinical Oncology (ASCO), members were asked to rank suggestions for improving efficiency during tumor board meetings. The two most highly ranked suggestions were a more effective moderator of discussions and better time management at meetings. Other highly ranked suggestions included creating criteria for selecting cases and providing attendees with written summaries of the cases before the meetings. 6 These responses suggest it is important to diligently prioritize and organize cases and, where possible, share written case summaries in advance to aid in more efficient time management of tumor board meetings. Likewise, in a Canadian study, Look Hong et al. conducted interviews with clinical specialists and administrators who had experience with implementing tumor boards at three hospital sites. The authors found that tumor boards can most effectively be implemented if administrators and health professionals see value in [them], despite the time and effort required. 7 Furthermore, the perceived value of the tumor board was influenced by how efficiently the meeting was managed. 7 The ability to convene around a centralized hub of well-structured diagnostic data and evidencebased treatment data improves perceived and actual value by enabling fully informed, highly collaborative decision-making for the goal of optimizing treatment outcomes. In some countries, time-strapped physicians are less likely to attend tumor boards if they are not optimally managed, which can negatively impact the treatment decisions made at the tumor board meetings. 8 In the aforementioned Canadian study, the authors noted that participants were more likely to attend and participate in [tumor boards] if there was a diversity of clinical specialists and patient case topics. They went on to describe the situation at one of the hospital sites, where the consistent absence of a radiation oncologist and gastroenterologist resulted in more disjointed discussion and fewer active treatment plans compared with the other two observed sites. 7 While tumor board participation is mandatory in the U.S. and numerous other nations, the benefits to be derived from solutions that optimize meeting workflow and information-sharing are evident everywhere. For tumor boards at institutions based in rural areas, attendance by specialists who work remotely can pose another workflow challenge. Under these circumstances, virtual tumor boards offer a way for offsite physicians to participate in multidisciplinary discussions and exchange input with other specialists. 9 However, to maximize information-sharing and the overall efficacy of long-distance collaboration, technological issues inherent in such a setup (e.g., availability of videoconferencing equipment, internet speed, etc.) must be fully addressed. The absence of a comprehensive system for connecting remote specialists can negatively affect the performance of the tumor board 4 presenting an additional set of workflow-related challenges unique to the virtual setting. Incomplete or inaccurate documentation: Capturing the discussion and resulting decisions is another challenge associated with tumor boards. Where robust software tools are not in place to assist with tumor board documentation, it is common practice for a nurse navigator or resident physician to handwrite or type notes during the discussion with little or no means to fully ensure accuracy and prevent human error. In some cases, there might be no recording of decisions at all, as noted in a 2011 review of published evidence titled, Cancer Multidisciplinary Team Meetings: Evidence, Challenges, and the Role of Clinical Decision Support Technology. In that study, Patkar et al. identified the consistent collection of crucial data such as cancer staging and related outcomes as a challenge that could prevent a tumor board from achieving its goals of improved decision-making and patient care. 10 Uncertain next steps: Workflow inefficiencies in the preparation and presentation stages of a tumor board can hamper the group s work long after the meeting, while insufficient documentation makes it difficult for participants to follow up on treatment decisions and exchange feedback. In a U.S. study of tumor boards in the Veterans Affairs (VA) health system, researchers observed little association of multidisciplinary tumor boards with measures of use, quality, or survival but noted that measuring only the existence of a tumor board is not enough to assess their impact on patient care or

5 treatment outcomes. 11 While researchers say those findings could suggest tumor boards do not affect quality of cancer care in the VA system, they also suggest that the influence of tumor boards on quality care may be subject to variation based on the structural and functional components [of the meeting] and the expertise of the participants. 11 The authors emphasize the need for further study to assess how the structure of a tumor board can be reformatted to create the ripple effect of improving quality of care. An accompanying editorial called for a feedback loop to enhance tumor board structure, process and outcomes. 12 Furthermore, research has shown that recommendations agreed upon during tumor boards might not actually be followed in practice and/or may not adhere to clinical practice guidelines; possible reasons for this include inadequate documentation and, in some nations, the absence of key specialists. 2,4,10 Participants in the UK study of urological and gastrointestinal tumor boards reported that approximately 91% of cancer patients discussed at a tumor board received a treatment plan as a result of that meeting; of those, only 90% were actually implemented. 4 Time is the most important factor in quality of care, and it is a scarce commodity in medicine. Time to test, time to review results, time to listen to the patients, time to consider the best therapeutic options. - Dr. Sergi Serrano, Pathologist, Hospital del Mar in Barcelona, Spain Conclusion When common challenges in tumor boards lead to suboptimal efficiency, it is possible such inefficiencies could have unintended effects on patient outcomes. Complex and scattered clinical data makes it difficult to collect all relevant information and provide a comprehensive view of the patient for presentation at the meeting. During the meeting, inefficient presentation impacts time management, which can delay or negatively affect treatment decisions. Errors or accidental omissions in the documentation of the discussion and decisions can create confusion and, in some cases, prevent the team from following up on decisions at the point of care. Using tools that streamline and standardize the entire workflow process, from preparation to presentation and documentation, can help tumor boards overcome these challenges and achieve the primary goal of choosing and implementing the best therapeutic options to improve patient outcomes.

6 References 1. O Brien JC. History of tumor site conferences at Baylor University Medical Center. Proc (Bayl Univ Med Cent). 2006;19(2): El Saghir, Nagi S., et al. Tumor Boards: Optimizing the Structure and Improving Efficiency of Multidisciplinary Management of Patients with Cancer Worldwide. Am Soc Clin Oncol Educ Book 34 (2014): e Macaskill, E. J., et al. Surgeons views on multi-disciplinary breast meetings. European Journal of Cancer 42.7 (2006): Jalil, Rozh, et al. Factors that can make an impact on decision-making and decision implementation in cancer multidisciplinary teams: an interview study of the provider perspective. International Journal of Surgery 11.5 (2013): Krishnankutty, Binny, et al. Data management in clinical research: an overview. Indian Journal of Pharmacology 44.2 (2012): El Saghir, Nagi S., et al. Global Practice and Efficiency of Multidisciplinary Tumor Boards: Results of an American Society of Clinical Oncology International Survey. Journal of Global Oncology 1.2 (2015): Look Hong, Nicole J., et al. Multidisciplinary Cancer Conferences: Exploring Obstacles and Facilitators to Their Implementation. Journal of Oncology Practice 6.2 (2010): Foster, Tianne J., et al. Effect of Multidisciplinary Case Conferences on Physician Decision Making: Breast Diagnostic Rounds. Cureus 8.11 (2016). 9. McEvoy C. Get on (Tumor) Board. Advance Healthcare Network Accessed August Patkar, Vivek, et al. Cancer Multidisciplinary Team Meetings: Evidence, Challenges, and the Role of Clinical Decision Support Technology. International Journal of Breast Cancer 2011 (2011). 11. Keating, Nancy L., et al. Tumor Boards and the Quality of Cancer Care. Journal of the National Cancer Institute (2013): Blayney, Douglas W. Tumor Boards (Team Huddles) Aren t Enough to Reach the Goal. J Natl Cancer Inst. (2013): Published by: Diagnostics Information Solutions Roche Molecular Systems, Inc Shoreway Road, Suite 300 Belmont, CA roche.com 2017 Roche Molecular Systems, Inc. All trademarks enjoy legal protection. 09/2017

The value of multidisciplinary tumor boards in cancer care

The value of multidisciplinary tumor boards in cancer care Executive summary Tumor boards provide a collaborative, multidisciplinary approach to cancer care, bringing together oncology, radiology and pathology