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HOW AN EXPERT APPROACHES IT
Implementing Survivorship Care Plans
Within an Electronic Health Record
Deborah K. Mayer, PhD, RN, AOCN, FAAN1,4, Kinley Taylor, MSIE2,
Adrian Gerstel, BA1, Amy Coghill, MSN, RN, OCN2, Sarah A. Birken, PhD, MSPH3,4
Survivorship care is “a distinct phase of care for
cancer survivors that includes four components:
(1) prevention and detection of new cancer or recurrent cancer; (2) surveillance for cancer spread,
recurrence, or second cancers; (3) intervention
for consequences of cancer and its treatment; and
(4) coordination between specialists and primary
care providers to ensure that all of the survivor’s
health needs are met.”[1] To promote the fourth
requires its own unique care plan; volume of patients; and lack of systems to facilitate this process.
[3-6] In our large academic medical center, which
sees about 5,000 new cancer patients per year
within 11 disease groups, the Director of Cancer
Survivorship was charged with implementing a
process that would overcome these barriers and
fulfill the CoC requirement. We were provided
with an opportunity to develop and implement
Value stream mapping (VSM) was used to develop action plans
for the delivery of SCPs within each disease group. VSM provided
a simple diagram of every step in the patient and information
flow that was needed to complete each task in the process
1School
of Nursing, University
of North Carolina, Chapel Hill,
North Carolina
2University of North Carolina
Health Care System, Chapel Hill,
North Carolina
3School of Public Health, University of North Carolina, Chapel
Hill, North Carolina
4University of North Carolina
Lineberger Comprehensive
Cancer Center, Chapel Hill,
North Carolina
980
component, coordination between specialists and
primary care providers, the Institute of Medicine’s
seminal 2006 report, “From Cancer Patient to Cancer Survivor: Lost in Transition” recommended—
and the American College of Surgeons Commission on Cancer (CoC) requires—the development
and delivery of survivorship care plans (SCPs) for
all patients completing active treatment (Standard
3.3).[1,2] Standard 3.3 stipulates that “the cancer
care committee develops and implements a process
to disseminate a comprehensive care summary &
follow-up plan to patients with cancer completing
cancer treatment”.[2]
SCP development involves compiling a treatment summary and follow-up care plan; delivery
involves providing a copy of the SCP to the patient and his or her primary care provider. Barriers to implementation of these recommendations include lack of agreed-upon standards for
survivorship care; excessive time to prepare the
SCP; perceived and actual shortage of oncology
practitioners assigned to complete and deliver the
SCP; the number of tumor types, each of which
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SCPs for adults completing cancer treatment with
curative intent within our new electronic health
record, Epic@UNC, using a systematic Lean Six
Sigma approach.
This process improvement method provides
“a set of concepts, principles, and tools used to
create and deliver the most value from the customer’s perspective while consuming the fewest
resources”.[7,8] Express Workout is a Lean tool
used for intense team problem solving; it is a tool
that emphasizes speed, with the team identifying
countermeasures and creating action plans to address barriers to optimal performance in a short
period of time. Value stream mapping (VSM) was
used to develop action plans for the delivery of
SCPs within each disease group (Table). VSM provided a simple diagram of every step in the patient
and information flow that was needed to complete
each task in the process (eg, create the SCP). Specifically, VSM used visual representation to display the patient path and information flow from
the beginning to the end of the process (Figure).
It helped people understand how the process was
DECEMBER 2015
supposed to work, helped them reach agreement
on how well the process was actually working,
helped uncover inefficiencies and problems with
flow in the value stream, and helped people reach
agreement on what changes needed to be made to
effect improvements. We used VSM to define the
steps needed to develop and deliver SCPs for all
patients, since an SCP process did not exist.
We initially had Epic create the generic American Society of Clinical Oncology (ASCO) template
content, modifying the look and feel to meet the
specific needs of our institution (Epic@UNC). This
was occurring at the same time that the national
Epic organization was working with other users to
anticipate the CoC Standard 3.3 and making this
template available to other institutions.
We identified a physician in each disease group
to champion SCP development and delivery
within the group. This champion also appointed
a disease group team leader (nurse practitioner
or navigator) to be the point person who would
oversee communication between his or her group
and study staff for this project and who would help
identify multidisciplinary groups of physicians,
nurse practitioners, nurse navigators, and Patient
and Family Advisory Board members from that
disease group.
We met with each disease team to identify
which cancers had enough volume to warrant creation of a standardized SCP template, then create a
process for identifying eligible patients, track when
these patients would complete treatment with curative intent, identify who would develop the SCP,
and identify who would deliver the SCP to the patient and ensure that copies were also delivered to
the primary care provider of record. Two groups
(genitourinary and gynecology), actively led by
their disease group team leaders, volunteered to
be “early adopters” who would work with this process first. This was important, as they needed to
contribute in an iterative manner to help develop
the optimum way to create and deliver SCPs. We
then identified one cancer in each of the disease
groups (bladder and cervical, respectively) and
asked the disease group to create “smart phrases”
for each section of the template (including symptoms, surveillance, and possible late and long-term
effects) that could then be inserted into the generic
template. Smart phrases are created when the same
statement may be needed multiple times (eg, statement about common side effects or the delivery of
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Table. Disease-Specific Templates
Disease Group
SCP for Specific Cancers
Genitourinary
Bladder
Prostate
Renal
Testes
Gynecologic
Ovarian
Endometrial
Cervical
Vulvovaginal
Gastrointestinal
Colon
Rectal
Pancreatic
Gastric
Musculoskeletal/
Soft tissue
sarcoma
Osteo
Head & neck
Oropharyngeal
Thyroid
Laryngeal
General head & neck
Thoracic
NSCLC
Limited-stage SCLC
Esophageal
Breast
Melanoma
Hematologic
malignancies
Acute leukemia
Hodgkin and non-Hodgkin
lymphomas
Myeloma
Neuro-oncology
NSCLC = non–small-cell lung cancer; SCLC = small-cell lung
cancer; SCP = survivorship care plan.
the document); they can be pulled into a document
from an existing list.
Teams used Plan-Do-Check-Act (PDCA) cycles, an iterative process, to facilitate continuous
quality improvement, and to test the effectiveness of the SCPs for patients and providers, using
specifically designed evaluation surveys that included quantitative data as well as qualitative data
on patient and provider satisfaction. After a few
PDCA cycles, based on feedback from our early
adopters—and by observing them create SCPs—
we realized that using smart phrases in a generic
template was too time-consuming (taking about
We met with
each disease
team to
identify which
cancers had
enough volume
to warrant
creation of a
standardized
SCP template
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HOW AN EXPERT APPROACHES IT
Survivorship Care Plan (SCP) Process Map
Start: New patient diagnosis
End: Deliver SCP to patient and PCP; document delivery
New patient
diagnosed
Staging
entered into
Epic
1. Who completes and
enters Dx/
staging into
Epic?
Treatment
plan created
• Letter to patient
and PCP sent
• Projected end
of tx entered in
Epic
2. Who will
estimate projected approx.
end date and
enter in Epic?
Treatment
delivered
Treatment
completed
SCP
developed
• Alert to
oncologist
SCP is due
(via In-Basket)
• SCP delivered
to patient
• Document
that SCP was
delivered
• Schedule
first follow-up
appt
3a. Who receives
the alert?
4. Who will
develop the
SCP?
3b. What happens
with the alert?
3c. How does the
follow-up visit
get scheduled?
KEY
SCP delivered;
first follow-up
appt
5a. When is
first followup?
5b. Who does
first followup?
Notify
provider SCP
ready to be
delivered at
next visit.
5c. Who delivers/
shares/documents?
Process step
Process substep
Questions
Other Notes:
6. Who will develop smart phrases for different
patient populations?
7. Create Epic list to track newly diagnosed patient
being treated curatively.
Figure. ‘Value Stream Map’ of the Steps in the Patient and Information Flow Involved in Establishing a
Process for Creating, Delivering, and Documenting Delivery of SCPs. Dx = diagnosis; PCP = primary care
provider; tx = treatment.
20 minutes) and cumbersome (requiring at least
three smart phrases per disease). As a result, we
decided to create disease-specific care plans that
included all of this information for the highervolume cancers (see Table), and then use the generic ASCO template for others. This approach
would minimize the amount of content to add and
therefore take less time to complete. The process
evolved into the following:
1. The disease group was given an Epic@UNCformatted SCP draft template in a Microsoft Word
document to adapt for each specific cancer, reflecting the group’s standards. They also discussed the
processes for identifying patients, and then for
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tracking when patients would end treatment and
when SCPs had been delivered to eligible patients
ending curative treatment. Each group started by
developing an SCP template for one cancer; once
that went into production in Epic, other SCP templates were created, incorporating lessons learned
from the first template.
2. The SCP template was then submitted to the
Epic@UNC team for creation; a draft was validated
by the disease group team before going into production. Each SCP template was mapped to the
correct ICD-9/10 codes for that cancer, so that the
right template attached to the correct diagnosis.
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3. Once the SCP template became available in
Epic@UNC, it was piloted in a few patients to identify any changes needed from either the provider’s
or the patient’s perspective. If it was determined
that changes were needed, a change request was
submitted to Epic@UNC.
4. Once the changes were made, the SCP process was then presented to the entire tumor group
during a tumor board meeting at which the team
discussed their pilot experiences. At that time, the
disease group was then expected to begin SCP implementation as adopted by their group, with the
champion and project leader serving as contacts
for issues that might arise. The disease teams met
regularly after the SCP template was launched to
reevaluate and monitor its effectiveness and patient
satisfaction.
Increased autocompletion of the SCP decreased the time to completion from about 20
minutes to about 5 minutes. This time should
continue to decrease as more fields within the
SCP (eg, diagnosis, stage) are able to be autopopulated after future software updates. The steps
required to create an SCP dropped from nine
steps to four; access to the SCP from within a patient’s problem list (which is centrally located on
the home page of the patient’s medical record in
Epic@UNC) was also made easier—no longer requiring five clicks into the medical record to find
it. The “tip sheet” of instructions for Epic-based
SCP creation, which provided step-by-step directions for completing the creation of an SCP, went
from five pages to two. Additionally, we are working to have a report function created within Epic
that will give tumor groups feedback on the number of patients eligible for an SCP and the number
who have actually received the SCP.
Ongoing communication between the various
disease teams and the Epic developers has been
necessary to facilitate this process. The Director
of Survivorship provided updates at the Hospital’s
Committee on Cancer quarterly meeting. Our goal
is to increase SCP use for more patients as we address the CoC Standard 3.3 metrics. We need to
evaluate the effect that receipt of an SCP has on
outcomes such as adherence to surveillance recommendations. We are committed to using the SCP
process to support collaboration and communication with, and education of, our survivors and their
primary care providers, but we expect that we will
continually revise this process until it becomes a
standard of cancer care.[9-11] P
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KEY POINTS
Implementing Survivorship Care Plans
Within an Electronic Health Record
• Implementing a process for the development and delivery of survivorship care plans (SCPs)
requires multiple Plan-Do-Check-Act cycles involving key stakeholders.
• Creating the semi-automated SCP within an electronic health record is only one component
of this process.
• Other issues that need to be addressed include creating systems for identifying eligible
patients, knowing when the treatment ends, creating the SCP, determining when to deliver
the SCP to the patient and relevant providers, and creating reporting functions to track use.
Acknowledgments: This project was funded by the
University of North Carolina Institute for Healthcare
Quality Improvement. We would like to thank Dr. Michael Pignone and Laura Brown for their guidance and
support of this project. We would also like to thank
the genitourinary and gynecology teams for being
early adopters for this project.
Financial Disclosure: Dr. Mayer serves as an advisor
to CareVive Systems. The other authors have no significant financial interest in or other relationship with the
manufacturer of any product or provider of any service
mentioned in this article.
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