Gina McWhirter

Background

There is unequal access to subspecialty oncology expertise across the Veterans Affairs (VA) network. To address this need, the VA established National TeleOncology (NTO), which provides multiple virtual services (asynchronous [electronic consult] and synchronous [phone, video to home, video to facility]) to over 20 VA sites. Beyond these care modalities, a virtual tumor board was conceived to provide a forum for multidisciplinary review of patient cases. We describe the creation of the first NTO virtual tumor board, encompassing malignant hematology diagnoses.

Observations

Tumor boards are considered a standard of care. While challenging to quantify nationally, multiple single institution experiences have established the importance of tumor boards across different measures. A panel of stakeholders were convened to discuss the creation of a virtual tumor board. Best practices and standard operating procedures were created based on guidance from relevant literature and internal VA experience. Participants from specialties including medical oncology, surgical oncology, radiology, pathology, transplant, and palliative care were engaged from eight different VA medical centers across the nation. On March 2, 2022, the initial tumor board was held allowing for synchronous virtual review of patient pathology and imaging. Thus far 6 tumor boards have been convened, reviewing 11 patients originating from 6 different VA sites.

Results

A participant survey was conducted after 4 sessions, which indicated that all who completed the survey (n = 9) found the sessions beneficial or somewhat beneficial, and 55% found the sessions highly applicable to their practice. The most recent tumor board had 33 participants (physicians, nurses, advanced practice practitioners, and pharmacists).

Conclusions

The establishment of a national VA tumor board represents a novel approach to the review of oncology cases across the VA network. The goal of this tumor board is to leverage the diverse knowledge base that exists within the VA to deliver equitable care regardless of veteran location. Along with improving our general understanding of tumor board application, we believe that the NTO tumor board establishes a unique forum for additional tumor types, continued medical education opportunities, and the review of VA clinical trial opportunities.

Background

There is unequal access to subspecialty oncology expertise across the Veterans Affairs (VA) network. To address this need, the VA established National TeleOncology (NTO), which provides multiple virtual services (asynchronous [electronic consult] and synchronous [phone, video to home, video to facility]) to over 20 VA sites. Beyond these care modalities, a virtual tumor board was conceived to provide a forum for multidisciplinary review of patient cases. We describe the creation of the first NTO virtual tumor board, encompassing malignant hematology diagnoses.

Observations

Tumor boards are considered a standard of care. While challenging to quantify nationally, multiple single institution experiences have established the importance of tumor boards across different measures. A panel of stakeholders were convened to discuss the creation of a virtual tumor board. Best practices and standard operating procedures were created based on guidance from relevant literature and internal VA experience. Participants from specialties including medical oncology, surgical oncology, radiology, pathology, transplant, and palliative care were engaged from eight different VA medical centers across the nation. On March 2, 2022, the initial tumor board was held allowing for synchronous virtual review of patient pathology and imaging. Thus far 6 tumor boards have been convened, reviewing 11 patients originating from 6 different VA sites.

Results

A participant survey was conducted after 4 sessions, which indicated that all who completed the survey (n = 9) found the sessions beneficial or somewhat beneficial, and 55% found the sessions highly applicable to their practice. The most recent tumor board had 33 participants (physicians, nurses, advanced practice practitioners, and pharmacists).

Conclusions

The establishment of a national VA tumor board represents a novel approach to the review of oncology cases across the VA network. The goal of this tumor board is to leverage the diverse knowledge base that exists within the VA to deliver equitable care regardless of veteran location. Along with improving our general understanding of tumor board application, we believe that the NTO tumor board establishes a unique forum for additional tumor types, continued medical education opportunities, and the review of VA clinical trial opportunities.

Background

There is unequal access to subspecialty oncology expertise across the Veterans Affairs (VA) network. To address this need, the VA established National TeleOncology (NTO), which provides multiple virtual services (asynchronous [electronic consult] and synchronous [phone, video to home, video to facility]) to over 20 VA sites. Beyond these care modalities, a virtual tumor board was conceived to provide a forum for multidisciplinary review of patient cases. We describe the creation of the first NTO virtual tumor board, encompassing malignant hematology diagnoses.

Observations

Tumor boards are considered a standard of care. While challenging to quantify nationally, multiple single institution experiences have established the importance of tumor boards across different measures. A panel of stakeholders were convened to discuss the creation of a virtual tumor board. Best practices and standard operating procedures were created based on guidance from relevant literature and internal VA experience. Participants from specialties including medical oncology, surgical oncology, radiology, pathology, transplant, and palliative care were engaged from eight different VA medical centers across the nation. On March 2, 2022, the initial tumor board was held allowing for synchronous virtual review of patient pathology and imaging. Thus far 6 tumor boards have been convened, reviewing 11 patients originating from 6 different VA sites.

Results

A participant survey was conducted after 4 sessions, which indicated that all who completed the survey (n = 9) found the sessions beneficial or somewhat beneficial, and 55% found the sessions highly applicable to their practice. The most recent tumor board had 33 participants (physicians, nurses, advanced practice practitioners, and pharmacists).

Conclusions

The establishment of a national VA tumor board represents a novel approach to the review of oncology cases across the VA network. The goal of this tumor board is to leverage the diverse knowledge base that exists within the VA to deliver equitable care regardless of veteran location. Along with improving our general understanding of tumor board application, we believe that the NTO tumor board establishes a unique forum for additional tumor types, continued medical education opportunities, and the review of VA clinical trial opportunities.

Background

Since inception, the Veterans Affairs (VA) National TeleOncology (NTO) service has monitored clinical operations through data tools produced by the Veterans Health Administration Support Service Center (VSSC). Unfortunately, pertinent data are spread across multiple reports, making it difficult to continually harmonize needed information. Further, the VSSC does not account for NTO’s hub and spoke clinical model, leading to inaccuracies when attempting to analyze unique encounters. To address these challenges, NTO partnered with the VA Salt Lake City Health Care System Informatics, Decision-Enhancement, and Analytic Sciences Center (IDEAS) to develop an informatics architecture and frontend NTO Clinical Operations Dashboard (NCOD). Here, we summarize our dashboard development process and the finalized key reporting components of the NCOD.

Methods

The VA Corporate Data Warehouse (CDW) serves as the primary data source for the NCOD. SQL Server Integration Services was used to build the backend data architecture. Data from the CDW were isolated into a staging data mart for reporting purposes using an extract, transform, load (ETL) approach. The frontend user interface was developed using Power BI. We used a participatory approach1 in determining reporting requirements. Stakeholders included the IDEAS dashboard development team and potential end users from NTO, including leadership, program managers, support assistants, and telehealth coordinators.

Results

The NCOD ETL is scheduled to refresh the data nightly to provide end users with a near real-time experience. The NCOD is comprised of the following four data views: clinic availability, team productivity, patient summary, and encounter summary. The clinic availability view summarizes clinic capacity, no shows, overbookings, and percent utilization. Relative value unit- based productivity is summarized in the team productivity view. The patient summary view presents aggregated data for veterans served by NTO, including geographic distribution, with patient-level drill down displaying demographics, cancer characteristics, and treatment history. Lastly, the encounter view displays utilization trends by modality, while accurately accounting for the hub and spoke clinical model.

Conclusions

An informatics architecture and frontend information display that is capable of synthesizing EHR data into a consumable format has been pivotal in obtaining accurate and timely insight into the demand and capacity of services provided by NTO.

Background

Since inception, the Veterans Affairs (VA) National TeleOncology (NTO) service has monitored clinical operations through data tools produced by the Veterans Health Administration Support Service Center (VSSC). Unfortunately, pertinent data are spread across multiple reports, making it difficult to continually harmonize needed information. Further, the VSSC does not account for NTO’s hub and spoke clinical model, leading to inaccuracies when attempting to analyze unique encounters. To address these challenges, NTO partnered with the VA Salt Lake City Health Care System Informatics, Decision-Enhancement, and Analytic Sciences Center (IDEAS) to develop an informatics architecture and frontend NTO Clinical Operations Dashboard (NCOD). Here, we summarize our dashboard development process and the finalized key reporting components of the NCOD.

Methods

The VA Corporate Data Warehouse (CDW) serves as the primary data source for the NCOD. SQL Server Integration Services was used to build the backend data architecture. Data from the CDW were isolated into a staging data mart for reporting purposes using an extract, transform, load (ETL) approach. The frontend user interface was developed using Power BI. We used a participatory approach1 in determining reporting requirements. Stakeholders included the IDEAS dashboard development team and potential end users from NTO, including leadership, program managers, support assistants, and telehealth coordinators.

Results

The NCOD ETL is scheduled to refresh the data nightly to provide end users with a near real-time experience. The NCOD is comprised of the following four data views: clinic availability, team productivity, patient summary, and encounter summary. The clinic availability view summarizes clinic capacity, no shows, overbookings, and percent utilization. Relative value unit- based productivity is summarized in the team productivity view. The patient summary view presents aggregated data for veterans served by NTO, including geographic distribution, with patient-level drill down displaying demographics, cancer characteristics, and treatment history. Lastly, the encounter view displays utilization trends by modality, while accurately accounting for the hub and spoke clinical model.

Conclusions

An informatics architecture and frontend information display that is capable of synthesizing EHR data into a consumable format has been pivotal in obtaining accurate and timely insight into the demand and capacity of services provided by NTO.

Background

Since inception, the Veterans Affairs (VA) National TeleOncology (NTO) service has monitored clinical operations through data tools produced by the Veterans Health Administration Support Service Center (VSSC). Unfortunately, pertinent data are spread across multiple reports, making it difficult to continually harmonize needed information. Further, the VSSC does not account for NTO’s hub and spoke clinical model, leading to inaccuracies when attempting to analyze unique encounters. To address these challenges, NTO partnered with the VA Salt Lake City Health Care System Informatics, Decision-Enhancement, and Analytic Sciences Center (IDEAS) to develop an informatics architecture and frontend NTO Clinical Operations Dashboard (NCOD). Here, we summarize our dashboard development process and the finalized key reporting components of the NCOD.

Methods

The VA Corporate Data Warehouse (CDW) serves as the primary data source for the NCOD. SQL Server Integration Services was used to build the backend data architecture. Data from the CDW were isolated into a staging data mart for reporting purposes using an extract, transform, load (ETL) approach. The frontend user interface was developed using Power BI. We used a participatory approach1 in determining reporting requirements. Stakeholders included the IDEAS dashboard development team and potential end users from NTO, including leadership, program managers, support assistants, and telehealth coordinators.

Results

The NCOD ETL is scheduled to refresh the data nightly to provide end users with a near real-time experience. The NCOD is comprised of the following four data views: clinic availability, team productivity, patient summary, and encounter summary. The clinic availability view summarizes clinic capacity, no shows, overbookings, and percent utilization. Relative value unit- based productivity is summarized in the team productivity view. The patient summary view presents aggregated data for veterans served by NTO, including geographic distribution, with patient-level drill down displaying demographics, cancer characteristics, and treatment history. Lastly, the encounter view displays utilization trends by modality, while accurately accounting for the hub and spoke clinical model.

Conclusions

An informatics architecture and frontend information display that is capable of synthesizing EHR data into a consumable format has been pivotal in obtaining accurate and timely insight into the demand and capacity of services provided by NTO.

Purpose

The PCMTP was developed to provide standardized decision support for molecular testing for veterans with prostate cancer.

Background

Prior to the precision medicine era, molecular tumor testing in prostate cancer was not standard of care. Field practitioners were unfamiliar with the role of molecular testing in clinical care. The PCMTP provides direction for germline and tumor testing in appropriate patients with prostate cancer. The expectation is that at least 80% of veterans will be pathway adherent. The PCMTP is an Oncology Clinical Pathway (OCP) that supports evidence-based practice providing highquality, safe, and cost-effective care for veterans reducing variability of care in the VHA.

Methods

The National Oncology Program Office assembled a Prostate Cancer Team (PCT) to develop OCPs. The pathways were incorporated into note templates that record clinical decisions using text and metadata (Health Factors [HF]), and record pathway adherence for the 4 key nodes of the PCMTP. The templates were pilot-tested and improved using an iterative process over a 3-month period. Further evaluation was conducted by the Office of Human Factors Engineering and the National Clinical Template Workgroup, utilizing a heuristic evaluation to ensure standardization, interoperability, and reduce duplication. HF data were retrieved from the Corporate Data Warehouse using a custom-built dashboard. Descriptive statistics of PCMTP use are presented.

Results

Between 4/1/2021 and 6/22/2022, 6276 health factors were generated from 1707 unique veterans in whom this clinical pathway was accessed. 328 distinct providers participated at 61 sites. Average veteran age was 73 years. (range 45-100) including 42% Black and 56% White. Of 1243 veterans considered for germline testing, 96.6% had germline testing ordered and for 1102 veterans considered for tumor testing, 93.3% had tumor testing ordered.

Conclusions

Pathway adherence exceeded the 80% benchmark. Race representation was diverse and reflective of the VA prostate cancer population. About 46% of VA oncology practices have used the PCMTP for ~11% of the estimated 15,000 veterans with metastatic prostate cancer in VHA. Increased use of this pathway is expected to improve outcomes for veterans with prostate cancer

Purpose

The PCMTP was developed to provide standardized decision support for molecular testing for veterans with prostate cancer.

Background

Prior to the precision medicine era, molecular tumor testing in prostate cancer was not standard of care. Field practitioners were unfamiliar with the role of molecular testing in clinical care. The PCMTP provides direction for germline and tumor testing in appropriate patients with prostate cancer. The expectation is that at least 80% of veterans will be pathway adherent. The PCMTP is an Oncology Clinical Pathway (OCP) that supports evidence-based practice providing highquality, safe, and cost-effective care for veterans reducing variability of care in the VHA.

Methods

The National Oncology Program Office assembled a Prostate Cancer Team (PCT) to develop OCPs. The pathways were incorporated into note templates that record clinical decisions using text and metadata (Health Factors [HF]), and record pathway adherence for the 4 key nodes of the PCMTP. The templates were pilot-tested and improved using an iterative process over a 3-month period. Further evaluation was conducted by the Office of Human Factors Engineering and the National Clinical Template Workgroup, utilizing a heuristic evaluation to ensure standardization, interoperability, and reduce duplication. HF data were retrieved from the Corporate Data Warehouse using a custom-built dashboard. Descriptive statistics of PCMTP use are presented.

Results

Between 4/1/2021 and 6/22/2022, 6276 health factors were generated from 1707 unique veterans in whom this clinical pathway was accessed. 328 distinct providers participated at 61 sites. Average veteran age was 73 years. (range 45-100) including 42% Black and 56% White. Of 1243 veterans considered for germline testing, 96.6% had germline testing ordered and for 1102 veterans considered for tumor testing, 93.3% had tumor testing ordered.

Conclusions

Pathway adherence exceeded the 80% benchmark. Race representation was diverse and reflective of the VA prostate cancer population. About 46% of VA oncology practices have used the PCMTP for ~11% of the estimated 15,000 veterans with metastatic prostate cancer in VHA. Increased use of this pathway is expected to improve outcomes for veterans with prostate cancer

Purpose

The PCMTP was developed to provide standardized decision support for molecular testing for veterans with prostate cancer.

Background

Prior to the precision medicine era, molecular tumor testing in prostate cancer was not standard of care. Field practitioners were unfamiliar with the role of molecular testing in clinical care. The PCMTP provides direction for germline and tumor testing in appropriate patients with prostate cancer. The expectation is that at least 80% of veterans will be pathway adherent. The PCMTP is an Oncology Clinical Pathway (OCP) that supports evidence-based practice providing highquality, safe, and cost-effective care for veterans reducing variability of care in the VHA.

Methods

The National Oncology Program Office assembled a Prostate Cancer Team (PCT) to develop OCPs. The pathways were incorporated into note templates that record clinical decisions using text and metadata (Health Factors [HF]), and record pathway adherence for the 4 key nodes of the PCMTP. The templates were pilot-tested and improved using an iterative process over a 3-month period. Further evaluation was conducted by the Office of Human Factors Engineering and the National Clinical Template Workgroup, utilizing a heuristic evaluation to ensure standardization, interoperability, and reduce duplication. HF data were retrieved from the Corporate Data Warehouse using a custom-built dashboard. Descriptive statistics of PCMTP use are presented.

Results

Between 4/1/2021 and 6/22/2022, 6276 health factors were generated from 1707 unique veterans in whom this clinical pathway was accessed. 328 distinct providers participated at 61 sites. Average veteran age was 73 years. (range 45-100) including 42% Black and 56% White. Of 1243 veterans considered for germline testing, 96.6% had germline testing ordered and for 1102 veterans considered for tumor testing, 93.3% had tumor testing ordered.

Conclusions

Pathway adherence exceeded the 80% benchmark. Race representation was diverse and reflective of the VA prostate cancer population. About 46% of VA oncology practices have used the PCMTP for ~11% of the estimated 15,000 veterans with metastatic prostate cancer in VHA. Increased use of this pathway is expected to improve outcomes for veterans with prostate cancer