Jivesh Sharma, M.D.

Published Oncology Net Guide August 2008 

Call it the latest take on the independent practice association (IPA), or perhaps the evolution of the group purchasing
organization (GPO). Rather than building coalitions for management efficiencies or purchasing power, Cancer Clinics of Excellence, a year-old organization that bills itself as an oncology service company, brings together physician practices around common clinical practice guidelines, with a heavy dose of information technology.  “We’re at the end of the arms race in terms of squeezing out efficiencies,” says J. Ike Nicoll, named in June as president and CEO of Cancer Centers for Excellence (CCE).  “Now, IPAs have to stand for something.” In this case, the goal is to make CCE stand for guiding care based on standards. “The GPO strategy has run its course,” agrees Oncology Net Guide editorial board member Jivesh Sharma, MD, CEO of Texas Cancer Associates, Dallas and Plano, TX. “The oncology drug business has basically become commoditized,” says Sharma, whose practice is not affiliated with CCE. He believes there is little value for a practice to switch from one of the two major oncology GPOs to the other:

OTN, formerly Oncology Therapeutics Network, a unit of McKesson; and International Oncology Network, or ION, which is part of Amerisource Bergen Specialty Group. The seeds of CCE were planted nearly three years ago, when some OTN-affiliated physicians decided that they needed to start working more closely together to help advance care in their field. The privately fi nanced company formally started in April 2007. Since that time, they have been developing treatment protocols and working with practices and software vendors to build the electronic infrastructure to facilitate collaboration.

CCE is set up as individual, physician-owned practices under the umbrella of a holding company, with no real headquarters location.  “We’re the classic virtual company,” Nicoll says. The practices own a majority of CCE, and McKesson Specialty is a corporate partner; its McKesson Specialty division has two seats on the seven-member CCE board. McKesson, the $102 billion drug distribution giant that also has an information technology unit, serves CCE with drug distribution, technology, consulting, and specialty pharmacy services.  Th e specialty pharmacy market in particular has been changing rapidly, thanks to longer survivability of cancer patients and expensive biologics. “For the fi rst time, insurance companies are starting to recognize oncology as a chronic disease,” Nicoll explains.  Sharma sees two drivers of the shift in strategy among oncology practices: the advent of pay-for-performance and the desire for more consistent treatment guidelines. “Th e main thing that attracted us was that we saw oncology changing with the [2003] Medicare Modernization Act,” says Cathy Beaker, CEO of Hematology-Oncology Centers of the Northern Rockies in Montana and Wyoming. That law changed how Medicare reimbursed for physician-delivered cancer drugs and in-offi ce oncology services. 

Hematology-Oncology Centers had been part of OTN, purely to obtain better prices on expensive chemotherapy drugs, but jumped at the chance to be a charter member of CCE. “We felt that the vision they had was our vision,” Beaker says. That vision includes the application of evidence-based treatment protocols (ETPs) among several like-minded practices that want to provide the highestquality care possible. Beaker was in on the initial planning meetings, where practice leaders discussed such collaborative eff orts as group purchasing for pricey biologic drugs and information technology. “More than anything, we really wanted to start doing evidence-based treatment protocols,” she recalls. “We want to have a forum to go to payers and say, ‘We’re doing things the right way,’” Beaker adds.  “It’s a psychographic, not a demographic,” Nicoll says of the type of practice that fi ts the CCE model. Instead of picking physicians based solely on geography or even EMR vendor, the doctors have to buy into the organizational philosophy. “This is a big commitment to step up to,” Nicoll says.

It also is geographic, to a point. CCE is starting by focusing on certain regions, including Southern California, Massachusetts, Georgia, and Florida, though it currently has operations in 14 states. Th ere has to be a critical mass in each market it plays in to provide leverage in contract negotiations with payers.  Employers that purchase insurance are increasingly looking for accountability for their substantial healthcare dollars, and guidelines have a way of holding healthcare providers accountable. “Insurance companies have very little granularity,” Nicoll says. CCE hopes to fill that void.

“Before CCE, we were using a care plan, but we weren’t doing any reporting and didn’t have any way of monitoring compliance,” Beaker says.

“The biggest thing is to be able to have the impact of several people looking at the same thing,” says Maureen Middlebrook, director of communications for Redwood Regional Medical Group, a Santa Rosa, CA-based oncology and radiology practice with locations in four Northern California counties. “It can only benefi t our patients [for our doctors] to see how others with the same conditions are being treated.”

The ETPs help practitioners know they are providing the most appropriate care for each patient, says Middlebrook, of Redwood Regional Medical Group, which has 43 physicians and nearly 400 employees, and joined CCE in June 2007. CCE has created or adopted best practices in a variety of care scenarios, including a logic tree to help determine if a patient is eligible to participate in certain protocols, Nicoll says. A clinical council and clinical quality committee create and review the ETPs. By midyear, CCE had developed 49 treatment protocols, including complete sets for ovarian and prostate cancers. In the coming months, they will bring online protocols for certain forms of breast and lung cancers. “We have to help educate doctors and practices on the guidelines,” says Nicoll. To deliver the protocols and support best practices, McKesson Lynx Mobile clinical informatics software, including inventory management and charge-capture functions, is in place or is being installed at all CCE clinics, according to Mike Kelly, chief information officer for McKesson Specialty.  Th e ETPs are on a Web-based common technology platform run by McKesson, regardless of where the EMR is hosted. Practices that do not have an EMR yet—and only 20% of CCE members currently do—still can access the ETPs via the Internet. “We work with each CCE member practice to get them implemented on the protocols,” Kelly says.

“We plan for evolving the technology based largely on user feedback,” Kelly adds. “We are working very closely with our customer base to provide the most pragmatic technological solutions on a daily basis.”

Many of the practices’ websites have a common look and feel, including physician portals to access the EMR and ETPs remotely.  According to Kelly, the practices are mostly ready for the switch, without major workfl ow changes. “We haven’t seen radical deviations from one site to another,” he says.  CCE requires its practices to use or at least make progress toward implementing EMRs but allows each member to choose a suitable system and timetable. “One-size-fits-all doesn’t really work,” Nicoll says. With one in five CCE practices using EMRs now, the organization actually is more technologically advanced than the medical profession as a whole. Harvard Medical School researchers reported in the July 3 edition of the New England Journal of Medicine that a mere 4% of US physicians in ambulatory care had “fully functional” EMRs and another 13% had basic systems.  Redwood Regional Medical Group is among the 80% of CCE practices that does not have an EMR yet. In fact, the practice is not done installing a new MedInformatix practice management system. Although MedInformatix off ers an integrated EMR and practice management system, Redwood has not yet chosen its clinical records vendor. About two-thirds of the practice—everybody but the radiology department—is up on the Informatix system. Once that rollout is complete, the practice will move toward EMR selection and planning, Middlebrook says.

It is a long process for sure, but oncology practices have only a few specialty-specific EMRs to choose from. Impac Medical Systems, a unit of Swedish medical technology firm Elekta, has interfaced its medical oncology EMR with OTN’s Lynx Mobile software. Hematology-Oncology Centers of the Northern Rockies have had an Impac EMR since April 2005, helping to tie together far-fl ung clinics in Billings and Butte, MT, and Sheridan and Cody, WY, with a patient base covering 150 miles east, 235 miles west, 150 miles southwest, and 150 miles southeast of the Billings headquarters. “We use technology to do that,” says Beaker. Telemedicine and physician assistants also help the eight medical oncologists, and two radiation oncologists serve this vast geographic footprint.

McKesson also has a partnership with Los Altos, CA-based Altos Solutions, producer of OncoEMR, a Web-based EMR and management system for oncology practices, Nicoll says.

Another system popular among cancer specialists is the ARIA oncology information system from Varian Medical Systems, Palo Alto, CA. Th is is the EMR that Sharma uses in his own practice and is bringing to another organization, NexGen Oncology, which is following a similar strategy as CCE. “It’s an oncology company with an emphasis on technology as an enabler,” Sharma says.

Nicoll says CCE is working with vendors to put clinical guidelines for cancer treatment into the EMRs, regardless of whether the records system is designed specifi cally for oncology. Sharma says his organization wants to do the same, though NexGen Oncology—no relation to EMR vendor NextGen Healthcare Information Systems primarily is focusing on the ARIA system. “We are embedding algorithm-driven care into the EMR,” Sharma says. Personalized medicine is a big part of the future plans for NexGen. “It’s all about mass customization,” Sharma adds.  All of NexGen’s systems follow Health Level Seven messaging standards for transferring clinical data between the oncology practices, primary care physicians, and hospitals, Sharma says. “We are moving to extend our platform for surgeons, medical oncologists, and radiation oncologists so the cancer patient’s journey is on a single EMR.”

Sharma is working to consolidate practices into a single medical group and expects to have the fi rst mergers done by the end of 2008. In that sense, NexGen will be less like CCE and more like US Oncology, but there are commonalities in the reasons for doctors banding together. “Care in the last century was about fi nding the great clinicians. Care in this century will be about great clinicians enabled by great systems,” Sharma says. On that point, Nicoll heartily agrees.

Neil Versel is a freelance healthcare journalist.

As the concept of healthcare consumerism gains currency, patients will expect (and be expected) to play an even greater role in their care. Patients’ awareness of treatment options and level of involvement in determining treatment plans is increasing. Payors are also starting to shift more payment responsibilities to patients. More than ever, patients are at the center of cancer care. The cancer patient’s journey is more complex and emotionally demanding than in almost any other area of medicine.

Unfortunately, much of the care they receive is still very disjointed and geographically dispersed. Many providers are in separate entities that do not have business-to-business IT tools for exchanging information with other providers; multi-specialty care is the standard today.  From initial screening and diagnosis through the long path of surgery, radiation, and chemotherapy—enormous amounts of information are generated. All of this information needs to be shared in a coordinated fashion so that optimal decisions can be made on behalf of patients. Th e “focused factories” model holds the promise of taking the care of individual cancers such as breast cancer, lung cancer, colon cancer, and prostate cancer to the next level. We must build the support infrastructure to pull the care together.

The core focus in building this infrastructure should be engaging the patient (customer). Wal-Mart’s view of healthcare is to provide healthcare customers with more control, enabling them to own their healthcare data much like they control their finances today. Their initial focus is to drive down the cost to drive up value. In the longer term, the goal is to provide both cost and quality data as a justification for value provided.  Wal-Mart has already dramatically lowered the cost of many generic drugs to less than $10 for a three-month supply.  They plan to add convenient care clinics that will be driven by EHRs that will provide data for a personal health record (PHR) that will be available across all the Wal-Mart stores. As the patient finishes a clinical visit, an e-prescription will be filled and ready at the pharmacy. All the clinical events will be recorded and accessible in some form by the patients. Google Health and Microsoft’s HealthVault online projects are also placing an emphasis on health information being owned and controlled in the future by patients. These organizations have developed a core model that involves a hard aggressive push to engage the customers (patients).

Who are our patients? What do they want? Where are they going? Are our organizations falling behind our customers?  Perhaps in the future the patient will truly drive the healthcare experience and we as providers will help them navigate. Expert providers enabled by systems that support navigation will be key for providing value to our customers. How will we demonstrate value to our customers? How good is the cancer care that we provide? How does it compare to care provided elsewhere? What are the tools we will use to engage patients?

As we evolve our organizations, the above models are excellent case studies for helping us build our vision for the future. I believe EHR adoption and measuring outcomes are essential activities for cancer care organizations today. Measuring outcomes is essential for improving patient safety and the quality of cancer care. Some fi nancing for EHR adoption is emerging. In the professional sector, provider organizations like ASCO are starting to certify IT products in the marketplace. In the public sector, CMS has funded the EHR demo project with $150 million bonus payments in 12 regions for adopting, measuring, and performing with certifi ed products. A Stark exception for donation of up to 85% of the cost of certifi ed EHRs has been created. In the private sector in some regions, up to 9% of payers off er EHR adoption incentives and physician liability insurance premium discounts of 3–5% are available for implementation of certifi ed EHRs.  The online banking industry has clearly demonstrated that the lay public can do very complex things when given the right tools. Healthcare will be no exception. In oncology, the need for the proper tools is even greater because consumers believe that participating in decisions about their own care will not only improve their chances of doing well but may actually save their life.

Jivesh Sharma, MD, is CEO of Texas Cancer Associates, a midsize oncology practice based in Dallas/Fort Worth, TX. He is also CEO of HealthIT, an Internet services company that supports the patient/ provider network with technology solutions, and founder of NextGen Oncology, which works to provide next-generation solutions for the diagnosis, management, and treatment of cancer. E-mail Dr. Sharma at JSharma@MyCancerCenter.com.

Cancer care is rapidly evolving. Over the last decade we have seen the advent of new chemotherapy drugs and novel classes of agents such as targeted therapies that aff ect signal transduction pathways; angiogenesis inhibitors and vaccines are becoming routine components of care; radiation therapy technologies continue to improve with the arrival of IGRT and other modalities; and minimally invasive surgical techniques are making rapid progress.

Unfortunately, these advances in the science of oncology have been accompanied by a variety of challenges to the fi nancial health of many oncology practices. As reimbursements have steadily declined and tighter restrictions have been placed on the use of many of these novel tools, some smaller practices have been pushed to the brink of insolvency. Th is is in part because oncology practice is increasingly marked by a curious dichotomy, wherein physicians are receptive of the latest advances in clinical science and technology, but resistant to (or unaware of) new developments in information technology that are just as essential to their practices. Commentators in the media have often provided one-sided, inadequate explanations for the causes of this, in many cases lacking the experience and depth of knowledge necessary to truly understand the challenges faced by oncology practices. What many observers (and oncology professionals, as well) fail to understand is that as the treatments we provide for our patients have grown in complexity, so too have the business processes and tools that must be employed to ensure the continued health of our practices. In order to operate efficiently, practices must improve productivity, doing more with fewer people while maintaining or enhancing the services provided to patients.

Oncologists must also come to grips with the fact that healthcare is becoming increasingly service-oriented and consumer-centric. As new decision-support tools emerge in oncology, we will also see more algorithm-driven care with embedded predictive modeling. Some of these tools will be incorporated into EMR systems, adding to the challenges of product selection and implementation many practices are currently facing. Th ese new technologies will not only support the patient journey but also capture information as a byproduct of workfl ow. Mining this information will allow us to optimize operational effi ciencies and clinical outcomes in the pay-for-performance environment required by payers and the changing expectations of oncology patients and their families. Newer patient tools, such as gene expression assays, will not only make risk assessment and cancer care more personalized, but also aff ect how patients utilize our services, requiring us to adjust our business practices. Clearly, the clinical, IT, and business domains will be integrated more tightly than ever before.

The pursuit of next-generation cancer care will always be the correct path. The challenge is to define what that means for oncology professionals and their patients, identify the tools we need to produce the desired outcomes, and find pragmatic ways to pursue our goals. Due to several attractive tax incentives for hardware and software purchases, this year is a particularly important year for making IT investment decisions. How are you building your strategic vision? How will you defi ne the path forward and the priorities that you will pursue? How will you pay for it? Over the next few months, this column will focus on new health IT tools and processes and the ways in which they can benefi t oncology care and the fi nancial health of your practice. I will cover decision-support tools, economic optimization through operational effi ciencies, breast cancer IT systems, utilization of improved clinical pathways, support for the patient cancer care journey, and other topics, reviewing key technology options and providing examples of successful best practices. I welcome your feedback and suggestions, and I look forward to engaging in a discussion about the challenges facing our profession as we move to make next-generation cancer care a reality.

Published: June 17, 2008
Oncology Net Guide
http://www.mdnglive.com/articles/Oncology_Outlook_Next-generation_Cancer_Care