Closing the Care Coordination Gap Between Oncology, Primary Care
During a May 6 meeting hosted by the National Comprehensive Cancer Network (NCCN), stakeholders discussed hindrances to collaboration between oncology and primary care practices as well as opportunities for improvement.
The panelists began by explaining why close coordination is so important.
“We know that cancer doesn't happen by itself. Often people may have other co-morbidities,” said Linda Overholser, M.D., a general internist at the University of Colorado Cancer Center who sits on the NCCN survivorship guidelines panel. “If we're treating their cancer, their diabetes gets worse, their high blood pressure gets uncontrolled, or they develop new co-morbidities, there are missed opportunities there if care isn't coordinated to better control those co-morbidities. Now that patients are living longer after a cancer diagnosis, I think it's really important to think about health promotion and implementing strategies we know that can reduce future co-morbidities, addressing late effects. We know that health promotion and counseling is very important. That may not happen during treatment at the cancer center. If someone has survived cancer and they're doing well, they still need to make sure that they're getting immunizations, other cancer screenings and preventative health. If it's not coordinated well, then there's a gap there and primary care providers may not be able to implement good survivorship care.”
Lack of coordination can lead to delays in care, but also there can be redundancy, said Andrea Porpiglia, M.D., a surgical oncologist and clinical director for the survivorship program at Fox Chase Cancer Center in Philadelphia. “If a primary care physician is outside of the healthcare system and their oncologists have already done scans or colonoscopies or lab work, then the patient might be getting double the bill because the primary care may not be aware that this is already done. I also patients are frustrated. They don't think that their doctors are talking. They feel like they're being abandoned, and I think that's frustrating for them. At the end of your treatment, some oncologists will just send them right back to their primary care, and there's no good transition, so the patients feel like the oncologist has let them go with no continuity.”
There are questions of what are the primary care teams supposed to take on compared to the oncology team, Porpiglia said. “Is the primary care team going to get reimbursed for the time spent doing survivorship care? They often aren’t."
She described the challenges of trying to communicate across different electronic medical records and health systems.
“At Fox Chase Cancer Center, we’re a tertiary referral center, so we get a lot of patients. We have people coming from St Luke's or Geisinger, or even from New York City,” Porpiglia explained. “Trying to obtain those medical records, trying to communicate, especially if the PCP is out of state, trying to get ahold of them and communicate is difficult. My office sends notes to them, but if it's the wrong fax number or e-mail address or even mailing address, they'll never receive it. So I think as good as the electronic medical record is, it still has its faults.”
Skyler Taylor, M.D., a medical, hematology and oncology fellow at Mayo Clinic in Arizona gave an anecdotal example of the type of missed connections that happen between oncology and primary care.
He described a recent interaction with the Indian Health Services at Mayo in Arizona. “We have a dedicated social worker to help facilitate that interaction, and we had a patient who was admitted for a new diagnosis of aggressive lymphoma, and started her on treatment. Then we were trying to discharge her locally to be followed in between cycles,” he explained. “As part of that, you need to have follow-up labs twice a week after the chemotherapy regimen. And to do that with the health system, I can't order it locally. I have to give a paper referral. I can't follow up on those results. The primary care doctor has to put in the order, look at the results and send us the results. So by the time wen were acting on it, the patient already been admitted to the local emergency department. The emergency physician gave me a call and said, ‘Hey, why are the white blood cells 50,000? I said, Well, we just gave a medicine to increase the white blood cells. So that's expected, and there's nothing else to do. But all the discharge notes, all the planning that we had done apparently had been lost in the shuffle between the treatment for the patient and the follow-up locally with the primary care.”
Asked to describe some successful programs to address these issues, Porpiglia said Fox Chase implemented something called Care Connect. It was a way for primary care to become more involved with the oncology care treatment that was happening with their patients. “We have over 60 providers now, and it's for primary cares who are outside of our EMR, who are private practice,” she said. “This also can include OB/GYN. They get access to our electronic medical records. They don't have to have an Epic EMR. It's free to them. We give them a separate password, and they're able to access all the information that they need about their patients. Then it's easier for us as oncologists to provide updates to these primary care providers, because they're within the EMR now, and I'm able to send a direct message to them, versus having to try to fax or phone call."
Veronika Panagiotou, Ph.D., director of advocacy and programs for the National Coalition for Cancer Survivorship, said, “We’re super excited about the onco primary models that are emerging at the University of Cincinnati, at Duke and Kaiser Permanente in San Francisco — the idea that primary care is within the cancer center and the ability for primary care to see cancer patients solely and to be able to support their needs.”
Dorothy A. Rhoades, M.D., M.P.H., professor in the Department of Medicine and director of the Native American Center for Cancer Health Excellence at the Oklahoma Health Stephenson Cancer Center, described a navigator program working to improve care coordination and collaboration between the cancer center and the referring ITU systems — the Indian Health, Tribal Health and Urban Indian programs.
She said the referral process between ITU systems and the cancer center can be confusing to patients and providers. “A lack of understanding of how this process works does result in delays in care,” she said. “You’ve already got geographic access problems across the state, which get compounded. Imagine trying to come two and a half hours away to the cancer center and have something not be right in terms of that referral process.”
