Abstract
Introduction
Due to the increased utilization of oral anticancer agents, pharmacist-led oral anticancer programs have emerged to meet the needs of oral anticancer management. Currently, at Froedtert & MCW, there is a lack of established tools to collect metrics which demonstrate the value of a pharmacist-led oral anticancer program.
Methods
The purpose of this project is to establish metrics that reflect the interventions pharmacists are performing, and second, to develop a documentation tool which can reliably extract discrete data on the identified metrics.
Results
Eight of the 10 desired metrics were included in the documentation tool. Two questionnaires were created to allow for easy data retrieval of the metrics. The “initial” questionnaire focuses on interventions made at the time of starting an oral anticancer agent, while the “follow-up” questionnaire focuses on interventions made during the subsequent monitoring. The introduction of the questionnaire tool was well received by end users and did not add to the pharmacist’s overall workload.
Conclusions
By establishing metrics that reflect pharmacist interventions in a pharmacist-led oral anticancer program and creating a documentation tool to collect discrete data related to those metrics from the electronic health record, we at Froedtert & MCW are better able describe the workload of the ambulatory oncology pharmacists with regard to their interventions and monitoring of oral anticancer agents. This data will be used to establish differences in pharmacist workload between clinics, justify pharmacist resources, and provide a snapshot of the patient population served as part of the oral anticancer program.
Metrics and designing measurable outcomes in the electronic health record to evaluate pharmacist intervention in an oral chemotherapy program
Due to the increasing utilization of oral anticancer agents, pharmacist-led oral anticancer monitoring programs have emerged to meet the needs of oral anticancer management. 1 While both intravenous and oral anticancer agents require intensive laboratory monitoring and symptom management, frequent infusion appointments with intravenous chemotherapy regimens typically include laboratory monitoring and patient assessments by infusion staff as part of a single visit; whereas, oral anticancer agents rely on patients to adhere to a prescribed frequency of laboratory monitoring that can often misalign with routine appointments, and patients must often be relied upon to self-report adverse effects. Additional challenges with oral anticancer agents include ensuring patient understanding of complicated dosing regimens and maintaining safe administration and storage of medications. Because of these challenges, both the American Society of Clinical Oncology and the Hematology/Oncology Pharmacy Association have called for best practices specific to oral anticancer agents which require in-depth patient education and frequent engagement with a member of the healthcare team throughout therapy in order to identify and manage adverse effects and ensure adherence to laboratory monitoring.
There are numerous published reports of pharmacist-led oral anticancer management programs demonstrating improved adherence rates as a result of these services. 2 A pharmacist-led oral anticancer program consists of the pharmacy team assisting with the acquisition of the medication, followed by the pharmacist providing in-depth medication teaching regarding administration, side effect management, and required monitoring. Once the patient has started the medication the pharmacist follows up with the patient to monitor for side effects and provide supportive care recommendations. The pharmacist also monitors required labs at baseline and throughout therapy to assess the need for medication dose adjustments or holds. A review published by Mackler et al. in 2018 describes the value oncology pharmacists have within the healthcare team and identifies four key areas pharmacists demonstrate value: clinical care, patient education, informatics, and cost savings. 3 With these areas identified, the remaining challenge is identifying metrics to evaluate the performance of pharmacist-led oral anticancer programs. To address this, the Vizient Pharmacy Network Cancer Care Committee surveyed 38 Vizient member institutions regarding their current practices for collecting metrics in the following five domains: safety, effectiveness, adherence, financial, and value. 4
Previously at Froedtert & the Medical College of Wisconsin (F & MCW), ambulatory oncology pharmacists were limited in the ability to track time spent on direct patient care activities, a report within the electronic health record (EHR) was utilized to review patient care notes that contained a productivity dotphrase. The productivity level documented (1–5) is based on Medicare's Evaluation and Management Services Guide. While useful, this did not provide information on specific interventions completed or capture any time spent on nondirect patient care activities; therefore, it does not describe the complete picture of all the activities oncology pharmacists perform. The gap identified in ambulatory oncology pharmacy practice at F & MCW was a lack of established interventions and metrics, such as those described in the Vizient survey, which can ultimately demonstrate the value of a pharmacist-led oral anticancer program. Additionally, there is a need for a documentation tool which accurately captures pharmacist activities and interventions. The current evaluation of these interventions would require extensive manual chart review.
The purpose of this project was twofold, first to establish metrics that reflect the interventions pharmacists are performing, and second, to develop a documentation tool which can reliably extract discrete data on the identified metrics from the EHR. This information and tool can be applied throughout ambulatory oncology practices to demonstrate the value of the ambulatory oncology pharmacist and allow for discrete/trackable data.
Methodology
This was a quality improvement project conducted at Froedtert & MCW between June 2021 and May 2022. The project did not meet the definition of human subjects research, and institutional review board evaluation and approval were not required. The project included two distinct efforts, first, a survey was disseminated to ambulatory oncology pharmacist staff to identify valuable metrics and second, the implementation of a documentation tool within the EHR to populate discrete intervention data related to the aforementioned metrics into currently utilized progress notes.
Identifying metrics
A deidentified survey was disseminated to the ambulatory oncology pharmacists practicing at Froedtert & MCW to establish metrics specific to the oral anticancer program that was felt to be valuable and feasible to collect. Proposed metrics were generated from the Vizient study and were broken down into five categories which included safety, effectiveness, adherence, financial, and value outcomes.4 Survey respondents ranked each of the possible metrics on a scale of 1 to 5, with 5 being the most valuable metric to evaluate and 1 being the least valuable. Scores were then averaged and any metric meeting a threshold ranking of 3.5 or greater was to be included in the new documentation tool.
Documentation tool
The questionnaire functionality within the EHR was selected as the method for metric documentation. Questionnaires can be used to document discretely and consistently as each question within the questionnaire includes prespecified answers. The data contained within a questionnaire can be retrieved with reporting functions thus creating a tool that readily facilitates data analysis. Additionally, questionnaire responses can be pulled directly into documentation through the use of SmartLinks. Figure 1 provides an example of how these functionalities are used together. The question prompts were entirely customizable and selected based on metrics selected from the ambulatory oncology pharmacist survey. Responses could include dates, times, numeric entries, yes/no, custom lists and free text. For this project, most responses were designed as custom lists so as to keep response data to discrete values without compromising the varied nature of interventions being performed.
Section (1) highlights the questionnaire prompt “management of the following adverse effects were discussed with the patient” and (2) shows the custom list response type describing a number of common adverse effects with generalized statements meant to apply to a variety of oral anticancer agents. Section (3) shows the questionnaire entries pulling into the patient chart note as a result of the utilization of SmartLinks.
Objective
The primary objective was to create a documentation tool in the EHR that allows easy retrieval of discrete data related to safety, effectiveness, adherence, financial, and value outcomes. The primary outcome is the rate at which desired metrics, as determined from the ambulatory oncology pharmacist survey, were successfully incorporated as discrete data into the documentation tool. Secondary objectives include the dissemination of a survey to the ambulatory oncology pharmacists to establish metrics thought to be valuable and feasible to collect regarding safety, effectiveness, adherence, financial, and value outcomes in an oral anticancer agent program and to measure ambulatory oncology pharmacists satisfaction with changes in workflow that result from utilizing the documentation tool.
Results
A total of thirteen out of fourteen ambulatory oncology pharmacists at Froedtert & MCW responded to the survey establishing valuable metrics. The metrics selected by the pharmacist group in the survey mirrored that of the results of the National Vizient survey.4 The pharmacists surveyed represent a group of decentralized disease specialists that practice at the academic center in solid tumors, hematologic malignancies, and bone marrow transplants. The full survey is contained in Appendix 1. A total of 10 metrics met the prespecified threshold ranking of 3.5 (Table 1). These metrics were then further evaluated by the project team to determine the feasibility of being included in the documentation tool as discrete data. Eight of 10 metrics were ultimately included in the documentation tool, resulting in a primary outcome of 80% success rate of incorporation of metrics into the documentation tool as discrete data. Two questionnaires, an “initial” questionnaire (Figure 2) and a “follow-up” questionnaire (Figure 3), were created to allow for easy data retrieval of the eight aforementioned metrics. The “initial” questionnaire focuses on interventions made at the time of starting an oral anticancer agent, while the “follow-up” questionnaire focuses on interventions made during the subsequent monitoring of the oral anticancer agent.
“Initial” Questionnaire.
“Follow Up” Questionnaire.
Metrics identified through survey.
After the implementation of the questionnaire, we allowed a two-month time period for staff to become acclimated to the new method of documentation and to discuss as a group to develop consistency. After consistency was established we collected data for a 31 days period (from March 1, 2022 to March 31, 2022). A total of 479 unique questionnaires were utilized to document pharmacist interventions. One hundred and two were “initial” questionnaires and 377 were “follow-up” questionnaires. Table 2 shows the number of times each questionnaire answer was selected to describe an intervention along with the time spent on patient care activities. During encounters where the “initial” questionnaire was utilized, patients were counseled on 382 adverse effects; of note, multiple responses could be selected for this question as demonstrated in Figure 1. Oral anticancer agent dose adjustments were recommended by a pharmacist prior to beginning therapy 14 times, there were 18 instances of care coordination (e.g. recommending additional monitoring parameters beyond those built into the treatment plans) and 42 drug interactions were identified. There were 67 instances of medication access being pursued, including obtaining copay cards, manufacturer drug assistance, grant funding, or utilization of a repository supply of medication at a fixed cost.
Pharmacist questionnaire entries March 1st, 2022–March 31st, 2022.
Pharmacists were surveyed after the implementation of the documentation tool to evaluate value and questionnaire workload. All pharmacists surveyed agreed or strongly agreed that the questionnaire results “demonstrated the value of the ambulatory pharmacist.” Most pharmacists (87.5%) felt that the questions answered “sufficiently described the ambulatory pharmacist's workload.” The majority (67%) of pharmacists agreed or strongly agreed that the “questionnaire was easy to use,” 22% did not have a strong opinion on ease of use, and 11% of patients disagreed that it was easy to use. Finally, 87.5% of respondents did not feel the completion of the questionnaire “added time to current workload.”
Conclusions
The introduction of the questionnaire tool to standardize the collection of discrete data related to metrics of interest was well received by end users and did not add to the pharmacist’s overall workload. This data will aid in describing the workload of ambulatory oncology pharmacists with regard to their interventions and monitoring of oral anticancer agents. In the future, the anticipated value of the data will be to inform on differences in pharmacist workload between the various clinics, justify pharmacist resources, and provide a snapshot of the patient population served as part of the oral anticancer program. This project focused on the development of metrics and describing interventions made by ambulatory oncology pharmacists in the oral anticancer program. It was also found that it would be valuable to capture the time spent on activities outside of the purview of the oral anticancer program and describe other clinical interventions ambulatory oncology pharmacists make. Therefore, an additional questionnaire was created to quantify the time spent on activities, such as addressing questions on supportive care, treatment plan manipulation, drug interaction evaluation (for patients not on oral anticancer agents), drug information questions/literature searches, therapeutic drug monitoring, time spent on acquisition of medications, as well as several other categories. This is a future direction for tracking the value of the ambulatory oncology pharmacist.
One of the limitations of this tool is that it depends entirely on users inputting data, consequently, the data may be missing or invalid if not used consistently and accurately. Our team allowed two months for pharmacists to become accustomed to the tool prior to a formal data collection and held many meetings to drive consistency among answers to overcome this limitation. Ultimately, this project has resulted in the creation of a powerful tool that captures discrete data that is able to be readily analyzed and demonstrates meaningful interventions made by pharmacists related to the oral anticancer program.
Footnotes
Authors’ Contributions
MR conceived the study. SK researched the literature and explored options via the electronic medical record. SK, EW, NR, and EM were involved in the protocol development. KC designed the questionnaire tool. SK wrote the first draft of the manuscript. All authors reviewed and edited the manuscript and approved the final version of the manuscript.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Appendix 1.
“Preintervention survey”
*1. Which clinic will your responses apply to?
*2. Rank each of the following metrics related to safety on a scale of 1–5 (5 being the highest) for how valuable you find this metric in demonstrating pharmacist impact
Monitoring parameters addressed with patients
3. Specify “other” metric related to safety you review
*4. Rank each of the following metrics related to efficacy on a scale of 1–5 (5 being the highest) for how valuable you find this metric in demonstrating pharmacist impact
5. Specify “other” metric related to efficacy you review *6. Rank each of the following metrics related to adherence on a scale of 1–5 (5 being the highest) for how valuable you find this metric in demonstrating pharmacist impact
7. Specify “other” metric related to adherence you review
*8. Rank each of the following metrics related to finance on a scale of 1–5 (5 being the highest) for how valuable you find this metric in demonstrating pharmacist impact
9. Specify “other” metric related to finance you review
*10. Rank each of the following metrics related to value on a scale of 1–5 (5 being the highest) for how valuable you find this metric in demonstrating pharmacist impact
11. Specify “other” metric related to the value you review *12. Indicate how strongly you agree with the statement: it is important is it to avoid “double documentation”
Strongly disagree Disagree Neutral Agree Strongly agree *13. Indicate how strongly you agree with the statement: it is important to use free text in progress notes rather than preselected/populated values
Strongly disagree Disagree Neutral Agree Strongly agree *14. If free text in progress notes were to be replaced, rank the preferred method of displaying information
SmartLists (dot phrases that can be placed in progress notes, would not be editable)
Flowsheets (filled out in the flowsheet area then pulled into a progress note)
Questionnaire (filled out in a separate area in the EHR then pulled into a progress note)