Health Policy
Perspective
Treatment Summaries and Survivorship Care Plans: The Approach by the Commission on Cancer to Increase Use Commission on Cancer, Chicago, IL; Dana-Farber Cancer Institute, Boston, MA; Centura Health, Englewood, CO; University of Hawaii, Honolulu, HI; and Wayne HealthCare, Greenville, OH See accompanying article in J Oncol Pract 10:345-351, 2014 Since the release of the Institute of Medicine (IOM) report on cancer survivorship, “From Cancer Patient to Cancer Survivor: Lost in Transition,” there has been a broad-based call for the implementation of treatment summaries (TSs) and survivorship care plans (SCPs).1 Shortly after the IOM report, the American Society of Clinical Oncology (ASCO) created TSs and SCPs for a number of diseases. However, data suggest there has been limited uptake of TSs and SCPs by the oncology community.2-4 Logical, accessible, and timely creation of documents that support critical clinical information flow between health care providers has always been a staple of good medicine. No one questions the need for admission notes or discharge summaries at the beginning and conclusion of hospitalizations. A detailed and timely operative note is produced after every surgery. Clinic notes documenting care provided in a physician’s office are considered standard of care. These documents are required by the Joint Commission and other regulatory organizations. However, cancer care, which is often complex, spanning months to years, is not uniformly summarized in a concise and accessible manner for the benefit of the treating physician to refer to in the future, for other providers (primary care providers and other specialists) integral to the patient’s care, or for the patient or family members. The IOM report highlighted this as a significant deficiency in the care of patients with cancer. Numerous factors have been cited in the lack of uptake of TSs and SCPs. TS and SCP documents created by several groups have required extensive data to be manually entered by providers, often physicians or nurses, and in the context of the busy oncology practice, this is often time consuming and impractical. In addition, reimbursement does not correspond to the amount of time required to complete these documents. Even if the documents were easy to complete, they are best shared with the patient as part of an extensive discussion including the details of treatment and the plan for care going forward, requiring additional time, often not adequately reimbursed. Completion of these documents must also be viewed in the context of increasing documentation demands on health care providers. In addition, these documents have not been considered by the regulatory bodies to be essential components of medical documentation, as is the case with operative notes or discharge summaries, for example. 40
JOURNAL
OF
ONCOLOGY PRACTICE
•
There remains a lack of consensus as to whether the time and effort spent on TSs and SCPs is warranted based on clinical studies.5,6 Although it has been difficult to show a change in outcomes with the use of TSs and SCPs, it is well acknowledged that information gaps in transitions of care result in suboptimal outcomes. Increasing attention is being paid to transitions in care, particularly from inpatient to outpatient settings and from provider to provider in different health systems. Electronic sharing of data is a key focus to improve outcomes during transitions, but current systems often do not support this well. The Commission on Cancer (CoC) reviews and accredits hospital cancer programs. Participation in the accreditation program is voluntary, and currently, more than 1,500 hospitals in the United States are CoC accredited, where more than 70% of US patients with cancer are treated. The CoC accreditation program sets standards as the definition of quality cancer care, and assesses the quality of cancer care delivered at a hospital against those standards, with the goal of continually improving cancer care for patients in this country. In this spirit, the CoC has established patient-centered care standards, which include availability of patient navigation services, assessment of patient psychosocial distress, and provision of TSs and SCPs.7 CoC standard 3.3, requiring TSs and SCPs, is scheduled to take effect in January 2015. An informal survey of CoC-accredited hospitals suggested that many programs have not implemented use of these documents, and implementation is proving challenging. Therefore, the CoC has set a phase-in period for full implementation, as follows: 2015, implement a pilot SCP process involving 10% of eligible patients; 2016, provide SCPs for 25% of eligible patients; 2017, provide SCPs for 50% of eligible patients; 2018, provide SCPs for 75% of eligible patients; and 2019, fully implement the SCP process, providing SCPs to all eligible patients. In addition, although acknowledging that the definition of a cancer survivor can be broad, and some definitions span from the date of diagnosis to death for all patients diagnosed with cancer, the CoC has chosen to focus on patients treated with curative intent, who are likely to face many years managing the complications of their cancer and treatment. These patients will receive care from primary care physicians and many other health professionals, and access to critical cancer treatment data will be essential if they are to provide optimal care. The CoC hopes that by establishing this standard, there will be an in-
V O L . 11, I S S U E 1
Copyright © 2014 by American Society of Clinical Oncology
Information downloaded from jop.ascopubs.org and provided by at North Carolina State University Libraries on May 2, 2015 from 152.14.136.77 Copyright © 2015 American Society of Clinical Oncology. All rights reserved.
By Lawrence N. Shulman, MD, Linda Ferris, MA, PhD, Danny M. Takanishi, MD, and Daniel McKellar, MD
Treatment Summaries and Survivorship Care Plans
The CoC applauds this effort and has adopted the ASCO recommendations in its standards requirement. The establishment and implementation of CoC standard 3.3 represents a paradigm shift in the care of cancer survivors, with a strong statement that TSs and SCPs are important documents for patient care and should be required. Authors’ Disclosures of Potential Conflicts of Interest Disclosures provided by the authors are available with this article at jop.ascopubs.org.
Author Contributions Conception and design: All authors Administrative support: Lawrence N. Shulman Data analysis and interpretation: All authors Manuscript writing: All authors Final approval of manuscript: All authors Corresponding author: Lawrence N. Shulman, MD, Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA 02215; e-mail: [email protected].
DOI: 10.1200/JOP.2014.002329; published online ahead of print at jop.ascopubs.org on November 25, 2014.
References 1. Hewitt M, Greenfield S, Stovall E (eds): From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, DC, National Academies Press, 2005 2. Birken SA, Deal AM, Mayer DK, et al: Following through: The consistency of survivorship care plan use in United States cancer programs. J Cancer Educ 29:689-697, 2014
5. Grunfeld E, Julian JA, Pond G, et al: Evaluating survivorship care plans: Results of a randomized, clinical trial of patients with breast cancer. J Clin Oncol 29:47554762, 2011 6. Tompkins CT, Jacobs LA, Palmer SC: Survivorship care plans: An argument for evidence over common sense. J Clin Oncol 30:1392-1393, 2012
3. Birken S, Deal A, Mayer DK, et al: Survivorship care plans: Prevalence and barriers to use. J Cancer Educ 28:290-296, 2013
7. Commission on Cancer: Cancer Program Standards 2012: Ensuring PatientCentered Care. www.facs.org/cancer/coc/programstandards2012.pdf
4. Stricker CT, Jacobs LA, Risendal B, et al: Survivorship care planning after the Institute of Medicine recommendations: How are we faring? J Cancer Surviv 5:358-370, 2011
8. Mayer DK, Nekhyudov L, Snyder CF, et al: American Society of Clinical Oncology expert statement on cancer survivorship care planning. J Oncol Pract 10:345351, 2014
Copyright © 2014 by American Society of Clinical Oncology
J A N U A R Y 2015
•
jop.ascopubs.org
41
Information downloaded from jop.ascopubs.org and provided by at North Carolina State University Libraries on May 2, 2015 from 152.14.136.77 Copyright © 2015 American Society of Clinical Oncology. All rights reserved.
crease in the use of these documents at CoC-accredited hospitals and eventually an increase in use more broadly, benefiting both patients and their care providers. However, in its standard, the CoC emphasizes that production of these documents, although essential, does not take the place of a face-to-face conversation between the oncology provider and the patient. One difficulty with TSs and SCPs has been a lack of consensus on what data elements are required. Some of the templates created by health care organizations have required considerable data to be manually entered by health care providers, and this has been cited as a major obstacle to the use of these documents. With this in mind, ASCO sought to define the minimal data sets for TSs and SCPs, and the recommendations are published in Journal of Oncology Practice.8 The process of defining these elements was broad based, with many constituencies represented, including cancer survivors. The process analyzed each data point for necessity and feasibility, always keeping in mind that creation of a document that could be successfully used in busy oncology practices was the ultimate goal. Creation of an overly burdensome document populated with marginally useful, so-called nice-to-have data would only lead to continued low use rates. ASCO piloted the proposed TSs and SCPs in busy oncology practices and found them to be feasible.
Shulman et al
AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST Treatment Summaries and Survivorship Care Plans: The Approach by the Commission on Cancer to Increase Use
Lawrence N. Shulman No relationship to disclose
Danny M. Takanishi No relationship to disclose
Linda Ferris No relationship to disclose
Daniel McKellar No relationship to disclose
JOURNAL
OF
ONCOLOGY PRACTICE
•
V O L . 11, I S S U E 1
Copyright © 2014 by American Society of Clinical Oncology
Information downloaded from jop.ascopubs.org and provided by at North Carolina State University Libraries on May 2, 2015 from 152.14.136.77 Copyright © 2015 American Society of Clinical Oncology. All rights reserved.
The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated. Relationships are self-held unless noted. I ⫽ Immediate Family Member, Inst ⫽ My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO’s conflict of interest policy, please refer to www.asco.org/rwc or jop.ascopubs.org/site/misc/ifc.xhtml.
Perspective
Treatment Summaries and Survivorship Care Plans: The Approach by the Commission on Cancer to Increase Use Commission on Cancer, Chicago, IL; Dana-Farber Cancer Institute, Boston, MA; Centura Health, Englewood, CO; University of Hawaii, Honolulu, HI; and Wayne HealthCare, Greenville, OH See accompanying article in J Oncol Pract 10:345-351, 2014 Since the release of the Institute of Medicine (IOM) report on cancer survivorship, “From Cancer Patient to Cancer Survivor: Lost in Transition,” there has been a broad-based call for the implementation of treatment summaries (TSs) and survivorship care plans (SCPs).1 Shortly after the IOM report, the American Society of Clinical Oncology (ASCO) created TSs and SCPs for a number of diseases. However, data suggest there has been limited uptake of TSs and SCPs by the oncology community.2-4 Logical, accessible, and timely creation of documents that support critical clinical information flow between health care providers has always been a staple of good medicine. No one questions the need for admission notes or discharge summaries at the beginning and conclusion of hospitalizations. A detailed and timely operative note is produced after every surgery. Clinic notes documenting care provided in a physician’s office are considered standard of care. These documents are required by the Joint Commission and other regulatory organizations. However, cancer care, which is often complex, spanning months to years, is not uniformly summarized in a concise and accessible manner for the benefit of the treating physician to refer to in the future, for other providers (primary care providers and other specialists) integral to the patient’s care, or for the patient or family members. The IOM report highlighted this as a significant deficiency in the care of patients with cancer. Numerous factors have been cited in the lack of uptake of TSs and SCPs. TS and SCP documents created by several groups have required extensive data to be manually entered by providers, often physicians or nurses, and in the context of the busy oncology practice, this is often time consuming and impractical. In addition, reimbursement does not correspond to the amount of time required to complete these documents. Even if the documents were easy to complete, they are best shared with the patient as part of an extensive discussion including the details of treatment and the plan for care going forward, requiring additional time, often not adequately reimbursed. Completion of these documents must also be viewed in the context of increasing documentation demands on health care providers. In addition, these documents have not been considered by the regulatory bodies to be essential components of medical documentation, as is the case with operative notes or discharge summaries, for example. 40
JOURNAL
OF
ONCOLOGY PRACTICE
•
There remains a lack of consensus as to whether the time and effort spent on TSs and SCPs is warranted based on clinical studies.5,6 Although it has been difficult to show a change in outcomes with the use of TSs and SCPs, it is well acknowledged that information gaps in transitions of care result in suboptimal outcomes. Increasing attention is being paid to transitions in care, particularly from inpatient to outpatient settings and from provider to provider in different health systems. Electronic sharing of data is a key focus to improve outcomes during transitions, but current systems often do not support this well. The Commission on Cancer (CoC) reviews and accredits hospital cancer programs. Participation in the accreditation program is voluntary, and currently, more than 1,500 hospitals in the United States are CoC accredited, where more than 70% of US patients with cancer are treated. The CoC accreditation program sets standards as the definition of quality cancer care, and assesses the quality of cancer care delivered at a hospital against those standards, with the goal of continually improving cancer care for patients in this country. In this spirit, the CoC has established patient-centered care standards, which include availability of patient navigation services, assessment of patient psychosocial distress, and provision of TSs and SCPs.7 CoC standard 3.3, requiring TSs and SCPs, is scheduled to take effect in January 2015. An informal survey of CoC-accredited hospitals suggested that many programs have not implemented use of these documents, and implementation is proving challenging. Therefore, the CoC has set a phase-in period for full implementation, as follows: 2015, implement a pilot SCP process involving 10% of eligible patients; 2016, provide SCPs for 25% of eligible patients; 2017, provide SCPs for 50% of eligible patients; 2018, provide SCPs for 75% of eligible patients; and 2019, fully implement the SCP process, providing SCPs to all eligible patients. In addition, although acknowledging that the definition of a cancer survivor can be broad, and some definitions span from the date of diagnosis to death for all patients diagnosed with cancer, the CoC has chosen to focus on patients treated with curative intent, who are likely to face many years managing the complications of their cancer and treatment. These patients will receive care from primary care physicians and many other health professionals, and access to critical cancer treatment data will be essential if they are to provide optimal care. The CoC hopes that by establishing this standard, there will be an in-
V O L . 11, I S S U E 1
Copyright © 2014 by American Society of Clinical Oncology
Information downloaded from jop.ascopubs.org and provided by at North Carolina State University Libraries on May 2, 2015 from 152.14.136.77 Copyright © 2015 American Society of Clinical Oncology. All rights reserved.
By Lawrence N. Shulman, MD, Linda Ferris, MA, PhD, Danny M. Takanishi, MD, and Daniel McKellar, MD
Treatment Summaries and Survivorship Care Plans
The CoC applauds this effort and has adopted the ASCO recommendations in its standards requirement. The establishment and implementation of CoC standard 3.3 represents a paradigm shift in the care of cancer survivors, with a strong statement that TSs and SCPs are important documents for patient care and should be required. Authors’ Disclosures of Potential Conflicts of Interest Disclosures provided by the authors are available with this article at jop.ascopubs.org.
Author Contributions Conception and design: All authors Administrative support: Lawrence N. Shulman Data analysis and interpretation: All authors Manuscript writing: All authors Final approval of manuscript: All authors Corresponding author: Lawrence N. Shulman, MD, Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA 02215; e-mail: [email protected].
DOI: 10.1200/JOP.2014.002329; published online ahead of print at jop.ascopubs.org on November 25, 2014.
References 1. Hewitt M, Greenfield S, Stovall E (eds): From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, DC, National Academies Press, 2005 2. Birken SA, Deal AM, Mayer DK, et al: Following through: The consistency of survivorship care plan use in United States cancer programs. J Cancer Educ 29:689-697, 2014
5. Grunfeld E, Julian JA, Pond G, et al: Evaluating survivorship care plans: Results of a randomized, clinical trial of patients with breast cancer. J Clin Oncol 29:47554762, 2011 6. Tompkins CT, Jacobs LA, Palmer SC: Survivorship care plans: An argument for evidence over common sense. J Clin Oncol 30:1392-1393, 2012
3. Birken S, Deal A, Mayer DK, et al: Survivorship care plans: Prevalence and barriers to use. J Cancer Educ 28:290-296, 2013
7. Commission on Cancer: Cancer Program Standards 2012: Ensuring PatientCentered Care. www.facs.org/cancer/coc/programstandards2012.pdf
4. Stricker CT, Jacobs LA, Risendal B, et al: Survivorship care planning after the Institute of Medicine recommendations: How are we faring? J Cancer Surviv 5:358-370, 2011
8. Mayer DK, Nekhyudov L, Snyder CF, et al: American Society of Clinical Oncology expert statement on cancer survivorship care planning. J Oncol Pract 10:345351, 2014
Copyright © 2014 by American Society of Clinical Oncology
J A N U A R Y 2015
•
jop.ascopubs.org
41
Information downloaded from jop.ascopubs.org and provided by at North Carolina State University Libraries on May 2, 2015 from 152.14.136.77 Copyright © 2015 American Society of Clinical Oncology. All rights reserved.
crease in the use of these documents at CoC-accredited hospitals and eventually an increase in use more broadly, benefiting both patients and their care providers. However, in its standard, the CoC emphasizes that production of these documents, although essential, does not take the place of a face-to-face conversation between the oncology provider and the patient. One difficulty with TSs and SCPs has been a lack of consensus on what data elements are required. Some of the templates created by health care organizations have required considerable data to be manually entered by health care providers, and this has been cited as a major obstacle to the use of these documents. With this in mind, ASCO sought to define the minimal data sets for TSs and SCPs, and the recommendations are published in Journal of Oncology Practice.8 The process of defining these elements was broad based, with many constituencies represented, including cancer survivors. The process analyzed each data point for necessity and feasibility, always keeping in mind that creation of a document that could be successfully used in busy oncology practices was the ultimate goal. Creation of an overly burdensome document populated with marginally useful, so-called nice-to-have data would only lead to continued low use rates. ASCO piloted the proposed TSs and SCPs in busy oncology practices and found them to be feasible.
Shulman et al
AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST Treatment Summaries and Survivorship Care Plans: The Approach by the Commission on Cancer to Increase Use
Lawrence N. Shulman No relationship to disclose
Danny M. Takanishi No relationship to disclose
Linda Ferris No relationship to disclose
Daniel McKellar No relationship to disclose
JOURNAL
OF
ONCOLOGY PRACTICE
•
V O L . 11, I S S U E 1
Copyright © 2014 by American Society of Clinical Oncology
Information downloaded from jop.ascopubs.org and provided by at North Carolina State University Libraries on May 2, 2015 from 152.14.136.77 Copyright © 2015 American Society of Clinical Oncology. All rights reserved.
The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated. Relationships are self-held unless noted. I ⫽ Immediate Family Member, Inst ⫽ My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO’s conflict of interest policy, please refer to www.asco.org/rwc or jop.ascopubs.org/site/misc/ifc.xhtml.
