"The Rapid Autopsy Program" and "Ambulatory Oncology Transformation: Care Delivery Workflow"

Transcript

• 00:00Welcome everyone to grand Rams.
• 00:06We have two sets of speakers today
• 00:09with two quite different topics,
• 00:13so our first presentation is going to
• 00:17be focused on tissue donation and the
• 00:21rapid autopsy program that's developing
• 00:24and and we welcome Harry Sanchez,
• 00:27who's an assistant professor of pathology.
• 00:31And and as well as Marcella Destasio,
• 00:35who is an instructor in pathology.
• 00:39Doctor Sanchez is currently
• 00:41developing the Yale or Doctor Sanchez
• 00:45and and doctor this size there.
• 00:47Currently developing the Yale
• 00:49Tissue Donation Program,
• 00:50which we hope will enhance.
• 00:53Both basic and translational research
• 00:56at at the school.
• 00:57When fully launched,
• 00:59the program will enable patients
• 01:01with late stage cancer to consent
• 01:03to donate tissue for research,
• 01:05as well as the component that
• 01:09is about rather rapid autopsy,
• 01:11where patients will be will be able
• 01:14to donate tissue in the context
• 01:17of a rapid autopsy program or a
• 01:20warm autopsy program so the tissue
• 01:24can be can can be taken and used
• 01:27for a variety of different.
• 01:29Purposes in.
• 01:30In my experience,
• 01:32many,
• 01:33many different labs and it's one
• 01:36of the big advantages of this this
• 01:40somewhat difficult to approach.
• 01:42So without further ado,
• 01:44I'm gonna ask Harry this morning
• 01:46and we'll go from there.
• 01:49OK, I'm gonna share my screen.
• 01:52And hopefully you can see that OK.
• 01:56Yeah, you just need to
• 01:57be in presentation mode
• 01:58that you go.
• 01:59OK, well thank you. Thank you very much.
• 02:01Doctor Weiner for the introduction
• 02:03and thank you very much for having us.
• 02:05As you said, we'd like to talk to
• 02:07you about the rapid autopsy program,
• 02:09which is really, there's nothing
• 02:11technologically new about the approach,
• 02:13but it is a it's a way to get patients
• 02:16I think involved in the basic
• 02:18science aspect of clinical research,
• 02:20and it's way to coordinate our existing
• 02:23resources of so that we can get.
• 02:26You know, sort of address the
• 02:28problem of getting high quality and
• 02:31and sufficient quantity of tissue.
• 02:33And so our objective said today are
• 02:34to talk to you a little bit about
• 02:36this approach and its advantages for
• 02:38patients and and clinical researchers.
• 02:40And we do feel they were advantages for both.
• 02:42To talk to you a little bit about rapid
• 02:46autopsy programs that already exist.
• 02:48And finally,
• 02:49to ask for your input and to
• 02:51and your participation,
• 02:53so that we're still putting this together.
• 02:55Those of you with thoughts on
• 02:56how we could do this better.
• 02:57We'd love to hear them,
• 03:00and so sorry to do that.
• 03:02And we'll just. We'll go with that.
• 03:04The outline I'd like to put
• 03:06the problem sort of in context,
• 03:09and talk about the problem of sort
• 03:11of human tissue for research from the
• 03:14patient and research scientist perspective,
• 03:17and then talk to a little bit about
• 03:19how I think the rapid autopsy approach
• 03:21addresses some of those things.
• 03:23It's it's not a solution for everything,
• 03:24but I think it is a very useful
• 03:27addition to to what's already in place.
• 03:32So problems for patients in the
• 03:35general public or, you know,
• 03:36sort of the subheading why you might
• 03:38not want if you are a patient to
• 03:40participate in clinical research.
• 03:42And I think this goes back
• 03:44to the problem that has been
• 03:46since the beginning of sort of.
• 03:48Sort of formal medical research
• 03:50once people realized physicians in
• 03:52the 1300s that it was hard to study
• 03:56function without understanding form,
• 03:58people started studying anatomy,
• 03:59and at the very beginning it was a
• 04:02small enough enterprise that only
• 04:04the most marginal people executed.
• 04:06Criminals were what was needed
• 04:08and that was enough,
• 04:09but as interest spread success became,
• 04:12you know,
• 04:13sort of more universal and the
• 04:15approach became adopted.
• 04:17The supply of of bodies for a study
• 04:22was far short of the legitimate demand,
• 04:25and so it created this sort of
• 04:28underground network of supply and
• 04:29people resorted to grave robbery,
• 04:32and when that wasn't enough,
• 04:33eventually in in Edinburgh murder to
• 04:37come by tissue and that led to the
• 04:39Anatomy Act of 1832 and the reason
• 04:41that I include this is that I think
• 04:44the Anatomy Act which addressed this
• 04:46problem beautifully states the problem.
• 04:47Basically,
• 04:48you can't know the causes and nature
• 04:51of disease without studying tissue,
• 04:53but the supply of tissue is
• 04:55insufficient and that can drive
• 04:57people to do very ill advised things,
• 05:00and that's not a problem that
• 05:02went away in the 1800s.
• 05:04So on the left here you can see
• 05:06this is an image from the Tuskegee
• 05:08syphilis experiments,
• 05:08which are rather the study that started
• 05:11in 1932 and went on for the next 40 years,
• 05:15400 unwitting.
• 05:17Volunteers for this program and on
• 05:21the right is the front cover from
• 05:23the immortal life of Henrietta, Lex.
• 05:26She was a woman in her early 30s
• 05:28who developed cervical cancer,
• 05:31went to Johns Hopkins for treatment
• 05:33and tissue from her cervical cancer,
• 05:36was used to create a very successful
• 05:39cell line.
• 05:39The heel of cells,
• 05:41but that was done completely without
• 05:43her knowledge or her consent.
• 05:45And so while all of these things
• 05:47may have had.
• 05:48Good intentions behind them
• 05:50and developed some results.
• 05:52The result is that human.
• 05:56Sort of tissue for use of medical
• 05:58research has this sort of checkered
• 06:00and sort of fraud.
• 06:01Past that,
• 06:02I think generates the sort of
• 06:04suspicion that still with us today.
• 06:05Even when we try to do things as a as
• 06:07a profession that are for the public good.
• 06:11No, there are still
• 06:13plenty of people who want to participate
• 06:15in research and and and do and and and.
• 06:17I'd like to say that I'm going to talk
• 06:19mostly about participating in the earliest
• 06:21phases of sort of basic science research,
• 06:24and that is something that's very
• 06:27difficult to do as as a patient or
• 06:29just a member of the general public.
• 06:32Research is extraordinarily expensive.
• 06:35I think you know the average NIH award is
• 06:38something on the order of half $1,000,000.
• 06:40And it's not the sort of thing that most
• 06:43of us can put a dent in individually,
• 06:45and you can do work that helps you know
• 06:48with sort of organizations and things,
• 06:50but you can't really foster.
• 06:52You can't advance basic science
• 06:54work as an untrained person.
• 06:55You can, however, donate tissue.
• 06:58The problem with tissue donation
• 07:00as it currently exists is one of
• 07:02coordination so that people do
• 07:04occasionally come to us and say that
• 07:06their next of kin would like to donate
• 07:09their body to the medical school.
• 07:11Or for research,
• 07:12and the problem is that it's
• 07:14sometimes hard on short notice to
• 07:16put together somebody who will
• 07:17receive that really generous gift.
• 07:21And I'm going to turn this over here
• 07:24to Marco, or, rather to Marcello.
• 07:26So yeah, I'm I'm just going to point out
• 07:29a couple of issues for researchers when
• 07:31it comes to performing effective research
• 07:33into the pathobiology of human disease.
• 07:36We can do next slide.
• 07:39So you know if you wanna study human disease,
• 07:42you have a few few options.
• 07:44You need cells of some kind and you need
• 07:47tools to study them with and so there
• 07:50there are a few model systems out there.
• 07:53Actually, I shouldn't say a few.
• 07:54There are many many model systems out there,
• 07:56including cell culture and models,
• 07:59surgical specimens and
• 08:00standard hospital autopsies,
• 08:01all of which are are fairly readily
• 08:04available but have their own
• 08:06limitations next slide so you know with.
• 08:10Certain tissue sources,
• 08:11like cell culture, you know cell
• 08:12culture is an incomplete system.
• 08:13The tissue is not intact and the
• 08:17cells are grown in media that may.
• 08:20Have, you know,
• 08:21may have a lot of factors in it,
• 08:23but they are not embedded in
• 08:26their natural environment,
• 08:28so it makes it difficult to model.
• 08:29You know non solar cell autonomous functions.
• 08:32Animal models of course have have contributed
• 08:36tremendously to our understanding of biology,
• 08:38but there are cross species.
• 08:40Differences and I'll just
• 08:41highlight a couple of them here.
• 08:42RB Newton Mice developed pituitary
• 08:45adenomas as opposed to retinoblastoma.
• 08:48P53, essentially a lead from any
• 08:51type of mutation in a mouse,
• 08:53produces sarcomas as opposed
• 08:54to the the often you know,
• 08:56mucosal carcinoma is typical of,
• 08:59you know, the human patient would leave
• 09:01from any and in terms of metastasis,
• 09:04you know there are models that
• 09:07that do you know,
• 09:09produce metastases?
• 09:10In in miles,
• 09:13but spontaneous metastases are much more
• 09:16rare in mice than they are in human.
• 09:19So if you want to study human,
• 09:21it's best to actually look at human tissue.
• 09:24Ohh yeah, next slide.
• 09:25So with human tissue we have a few options.
• 09:28There are surgical specimens,
• 09:29but there is limited availability
• 09:32of certain tissues,
• 09:33and the tissue that is available
• 09:36must be retained and examined by a
• 09:39pathologist for diagnostic purposes
• 09:41before it can be released for research.
• 09:46I'm a neuropathologist my my research
• 09:48interested is in central nervous system
• 09:51diseases and of course brain tissue
• 09:54is extremely precious and surgically.
• 09:56Surgical removal is is minimal as
• 09:59possible to minimize morbidity.
• 10:01So we have very limited access
• 10:03to that kind of tissue.
• 10:05And then there are standard
• 10:07hospital autopsies which,
• 10:08while there is ample tissue
• 10:11available and often,
• 10:13you know,
• 10:13consent is given the the.
• 10:16Status of the tissue is
• 10:19often the problem here,
• 10:21so with longer postmortem intervals
• 10:24there's degradation that occurs and
• 10:26also you know the the standard autopsy
• 10:29service on the hospital you know accepts.
• 10:33Patients from a wide variety of sources,
• 10:35some of which are better
• 10:37documented than others,
• 10:38and so you know one thing that the rapid
• 10:41autopsy program aims to do is to recruit.
• 10:44You know donors who are well known to
• 10:48clinical services and their you know,
• 10:51clinical researchers here at Yale.
• 10:54So just to quickly highlight a couple
• 10:57of effects of postmortem interval,
• 10:59if you look at these Histology
• 11:00images here on the right side,
• 11:02this was a nice study where they they
• 11:04used surgical specimens and then
• 11:06basically just let them sit around
• 11:08for a few hours and see what happened
• 11:10to the tissue and you can see that
• 11:13as the postmortem interval changes.
• 11:16I just I really,
• 11:17I just want you to appreciate that
• 11:19there are changes from a an immediately
• 11:22resected specimen on the far left to the.
• 11:2424 hour interval on the on the far right
• 11:28and and essentially what's happening there.
• 11:29There's breakdown of membrane integrity.
• 11:32Proteins are denaturing, and you're.
• 11:35You're basically losing the
• 11:38the histologic structure.
• 11:40The histone morphology of the tissue
• 11:43which which can be limiting for for our
• 11:46understanding of of microscopic anatomy.
• 11:48In that case there's also
• 11:50molecular changes that occur.
• 11:52There's a lot of rhetoric around RNA.
• 11:56And post mortem interval is related to RNA.
• 11:58I can attest to the fact that grant reviewers
• 12:01get very very touchy when it comes to RNA.
• 12:04I think it's actually a little bit overblown.
• 12:06The total quantity of RNA actually
• 12:08doesn't decrease that much,
• 12:10but there's actually more insidious
• 12:12problem when it comes to setting
• 12:13RNA and postmortem tissue,
• 12:15which is that certain RNA's
• 12:17actually decrease or increase right?
• 12:20Because transcription,
• 12:21you know your your tissues don't necessarily
• 12:23know that your brain is stopped function.
• 12:25Functioning or that your heart
• 12:27has stopped beating immediately,
• 12:29so certain transcripts
• 12:31actually increase after death,
• 12:34and certain transcripts decrease after death,
• 12:36and so that can lead to substantial
• 12:39unquantifiable bias in your study,
• 12:41which I think is actually a more significant
• 12:44problem than total RNA integrity.
• 12:46And then for the next slide there
• 12:48are also effects on proteins.
• 12:49This was a nice study that was done
• 12:52on cerebral spinal fluid and looking
• 12:55at the effect of protein aggregation.
• 12:58Actually in the CSF.
• 13:01Overtime after death.
• 13:02And so again,
• 13:04these are basically deviations
• 13:06from the normal Physiology of life
• 13:08that are occurring and therefore
• 13:11less representative of the state
• 13:13of your system during life.
• 13:15So these are all effects that
• 13:16we would like to minimize.
• 13:17With the rapid autopsy program.
• 13:20Another limitation.
• 13:24With currently available tissue is
• 13:26just in sampling surgical specimens.
• 13:28For example, you know we have to.
• 13:30As I mentioned,
• 13:30we have to minimize morbidity.
• 13:32So in the central nervous system,
• 13:33you know that you you can only take so much.
• 13:35So this picture just shows a composite
• 13:38fMRI image of eloquent cortex.
• 13:40In other words,
• 13:41brain that you still need in your head,
• 13:44and so therefore is inaccessible
• 13:47to interested researchers, and so.
• 13:50Of course this stuff is
• 13:52is is extremely valuable.
• 13:54For understanding the tumor environment,
• 13:57but we are unable to study it
• 13:59using standard surgical specimens.
• 14:03And that's important.
• 14:05It's important to have a wide breadth of of
• 14:09tissue to study both in space and in time,
• 14:12because we need to understand tumor
• 14:15tumors both in space and time, we need to
• 14:19understand heterogeneity within the tumor.
• 14:21There are multiple clones within a tumor,
• 14:23some of which give rise to metastasis.
• 14:25There's evolution we see molecular evolution.
• 14:27We see phenotypic evolution in tumors.
• 14:30Within the primary tumor and
• 14:33we also see a selection for for
• 14:37certain features in metastasis,
• 14:39so access to all of this
• 14:41tissue from multiple sites.
• 14:43Multiple regions of the tumors.
• 14:46Is all essential for understanding
• 14:48the the complete,
• 14:49you know pathobiology of tumor
• 14:52Genesis and metastasis formation.
• 14:56So so thank you. So what
• 14:58I'd like to talk to you
• 15:00about next is just some of the mechanics
• 15:02of of what rapid autopsies actually are.
• 15:05And how they differ from a standard autopsy
• 15:08and then the short answer is that rapid
• 15:11autopsies are not technically autopsies.
• 15:13They are anatomic gifts,
• 15:15so an autopsy is a diagnostic
• 15:18procedure performed on the remains of,
• 15:21you know, a decedent and and.
• 15:23Permission can only be
• 15:25given by the next of kin.
• 15:26The legal next of kin.
• 15:28I cannot legally give permission
• 15:29in life for my own autopsy.
• 15:32That permission doesn't survive my death,
• 15:34however.
• 15:35I can give and this is by virtue of
• 15:39some universal anatomic gift act
• 15:42legislation that's been adopted
• 15:43by most states in this country.
• 15:46I can in life give permission for an
• 15:49anatomical gift of part or all of my
• 15:51body for the purposes of transplantation,
• 15:53therapy or research,
• 15:54and this is from the Connecticut statute
• 15:57and the important thing about this
• 16:00statute which governs organ donation,
• 16:02is that this permission survives my death.
• 16:06And cannot be.
• 16:09Sort of rescinded or modified
• 16:10by my next of Kent,
• 16:12so it's it's a durable gift and it
• 16:14can be made not only for as I said,
• 16:17transplantation,
• 16:17but to a hospital or a medical school
• 16:20dental school or university specifically
• 16:23for research and education purposes.
• 16:25So this is what covers these things.
• 16:27As Marcelo pointed out,
• 16:29the delay in standard autopsies
• 16:31is the thing that you know,
• 16:33renders the tissue less useful.
• 16:35And we've looked at our own
• 16:38postmortem intervals over.
• 16:392/3 of our cases are longer than
• 16:4324 hours between time of death
• 16:44and start of what typsy and most
• 16:47of that delay is due to consent
• 16:49delays and and family discussions,
• 16:51which are important but take place after
• 16:54death and and sort of slow things down.
• 16:57So how does the actual process work?
• 17:01So what we propose is that research
• 17:05investigators contact us when
• 17:07they have sort of Yale approved
• 17:10Yale IRB approved protocols,
• 17:13file them with us and and talk
• 17:15to us about the requirements for
• 17:18tissue collection and storage.
• 17:19The clinicians and researchers are identify
• 17:22patients and you already have research,
• 17:25you know,
• 17:25sort of relationships with them,
• 17:26so that makes that easier
• 17:28that might be interested,
• 17:29and if they are interested,
• 17:32walk through this very transparent
• 17:35and very thorough consent process.
• 17:38If the consent is is given,
• 17:40we retain a copy of that at our program and
• 17:44provide contact information with the family.
• 17:48When the donor dies,
• 17:50we were contacted either by
• 17:52the family or the facility.
• 17:55The permission you know we contact next
• 17:57of kin and then we assemble our staff
• 17:59as quickly as possible within an hour,
• 18:02certainly.
• 18:03And and we hope that we'll be able
• 18:06to get to the actual you know,
• 18:08process within a few hours,
• 18:11hopefully no more than six
• 18:12and and hopefully less.
• 18:14The idea is that we collect
• 18:16this according to protocol,
• 18:17save it in the appropriate way,
• 18:19and then hand it off at the
• 18:22first possible chance to the
• 18:24research lab who recruited.
• 18:25This patient, and so we're not a tissue bank.
• 18:28We are just sort of there to
• 18:30you know, smooth things over.
• 18:32I'll turn this back over to Marcella.
• 18:34Yeah, I won't be labor this but
• 18:36actually go right to the next slide.
• 18:39There are a whole host of
• 18:43modern technologies that have
• 18:45really come into their own.
• 18:46A lot of them driven by
• 18:49next generation sequencing,
• 18:50but also by new techniques and
• 18:53microfluidics and other other.
• 18:56High throughput.
• 18:59Platforms that allow us to just
• 19:01gather a huge amount of data from,
• 19:04you know, relatively small but
• 19:06high quality fragments of tissue,
• 19:09and so all of these highlighted
• 19:12here are certainly on the table
• 19:15they've been performed in human
• 19:18tissue and and validated there are.
• 19:21Yeah there. There are too many
• 19:23technologies to sort of enumerate,
• 19:25but a large number of them.
• 19:28Really yield the highest quality of data.
• 19:34And and by by quality I mean high
• 19:38reliability information which which is
• 19:41basically it's important to combat these
• 19:44issues of of bias and and and being
• 19:48misled by artifactual changes in the tissue,
• 19:51which with with these huge data sets is
• 19:53very easy to get sort of LED down the
• 19:56garden path by those kinds of artifacts.
• 19:58And so the quality of what you put in
• 20:01are really influences the value of the
• 20:04information that you get out of these these.
• 20:06High throughput, big data, new technologies,
• 20:10and so the rapid autopsy, again, will we?
• 20:12We aim for that to be sort of the input
• 20:16to many different types of experiments.
• 20:18My ability, yes.
• 20:19So these are the limitations.
• 20:20Again, the things that we talked
• 20:21about you know post mortem,
• 20:22interval, time, temperature,
• 20:24all these things can affect
• 20:26quality of tissue.
• 20:27And of course clinical factors.
• 20:29Again just contribute to the value
• 20:32in that the information about the
• 20:35patient having having a basically a
• 20:38pipeline in good communication between
• 20:41the the sort of basic science labs,
• 20:45the clinical researchers and the
• 20:48clinical teams treating the patients.
• 20:50You know closing that loop,
• 20:52ideally through the rapid autopsy program,
• 20:54where we can disseminate all this
• 20:56information, will will again,
• 20:57you get the most out of the out
• 21:01of the the the these precious
• 21:03gifts that the patients donate.
• 21:06So just very very quickly
• 21:07a couple of results.
• 21:09A couple of results from similar
• 21:11programs around the country.
• 21:13Johns Hopkins has a pretty mature program.
• 21:15They've had a a segment of it,
• 21:17very much focused on prostate cancer,
• 21:19and they've shown a lot of
• 21:21really interesting things about,
• 21:22you know,
• 21:23clonal evolution and prostate cancer,
• 21:25and how that contributes to metastasis
• 21:27in in different forms and the androgen
• 21:30insensitive and the androgen sensitive forms.
• 21:33Dana Farber has a very.
• 21:36It advanced program.
• 21:38This is just one example of of a breast.
• 21:43First carcinoma study that showed
• 21:47you know the the amount of diversity
• 21:49in breast tumor metastasis.
• 21:52But there's there's a lot of other
• 21:53research that's come out of that program.
• 21:55If we go to the next slide just a
• 21:58couple more of the NIH actually runs a
• 22:00program out of their clinical center.
• 22:03And this you know again they have.
• 22:05They had excellent records.
• 22:07This was a really exceptional case study
• 22:10and that they had tissue collected
• 22:12surgically during the patient's life,
• 22:15both of primary tumor and
• 22:17of lymph node metastasis.
• 22:18But also then they had the rapid autopsy
• 22:20at the end of the patient's life,
• 22:23which you know together comprise
• 22:25just a tremendously valuable data
• 22:27set. And finally the the
• 22:28live on New York. That's it.
• 22:30That's actually a a transplant.
• 22:33Service and Columbia has partnered
• 22:35with the transplant service to sort
• 22:38of simultaneously perform warm
• 22:40autopsy on consented patients,
• 22:42and that's enabled them to do all kinds
• 22:44of really innovative immunological studies.
• 22:46And this is just one example,
• 22:48looking at natural killer
• 22:50cell interactions and in their
• 22:52development in different tissues.
• 22:56So just quickly to go through
• 22:58some of the programs that exist.
• 23:00There's this is not a complete list,
• 23:02but there's somewhere I
• 23:03think between you know,
• 23:04a dozen and 15 of these programs,
• 23:06and I list them here in sort
• 23:08of order of proximity to us.
• 23:10And and I point out that what these
• 23:13programs all have in common is that
• 23:14they are in areas that are metropolitan,
• 23:16have large patient populations,
• 23:18and they're all based at academic
• 23:20hospitals with national reputations,
• 23:22and they all have a critical mass of NIH
• 23:24funded clinical research scientists.
• 23:26And I think we have all of those.
• 23:29All of those factors in place.
• 23:30And I think we are in a position to
• 23:32set up a successful program here.
• 23:35And I'll just turn that over
• 23:36to Marcelo to finish up.
• 23:38So finally, yeah, just just to summarize,
• 23:40you know the the the patients are offered an
• 23:44opportunity to to make a very meaningful.
• 23:48Contribution to medical research that really
• 23:51could not be replaced by anything else.
• 23:54This kind of program promotes transparency
• 23:57and preserves autonomy of the donor and
• 24:00really puts the the the donor at the
• 24:04center of of a very important line of
• 24:08research into their into their disease.
• 24:11Researchers I, you know,
• 24:12I spent a bunch of time on telling you
• 24:15about different factors and tissue quality.
• 24:17Essentially, that's the core good quality,
• 24:19good quality tissue that's well documented
• 24:23and and part of a sort of coordinated
• 24:28research team that includes the clinicians,
• 24:32the patient, the researcher and and the.
• 24:35The rapid autopsy program.
• 24:40So we I don't know Harry.
• 24:42Do you want to maybe take this one
• 24:44so so in trying to put this together, we've?
• 24:47We've looked for input from a bunch of
• 24:49different sources and we've had long
• 24:51talks with the the folks at MSK and
• 24:54Johns Hopkins about their program,
• 24:55and we've had some really great
• 24:58conversations with the Yale Cancer
• 25:00Centers patient and Family Advocacy
• 25:02council and Community Advisory Board.
• 25:05So we've had, you know,
• 25:06patient input and sort of existing.
• 25:10RAP input what we're looking for.
• 25:12Hopefully today is the input of some of
• 25:14our own clinical research community.
• 25:19And you know, we'd like to invite
• 25:21you to weigh in and ask questions
• 25:23and and hopefully participate.
• 25:24And and this is, you know,
• 25:26where we can reach where you can reach us.
• 25:28We have the beginnings of a website
• 25:31and and here our emails and be happy
• 25:33to take any questions you might have.
• 25:38That's great, thank you very much.
• 25:41Let's just see if there in the chat.
• 25:45So a question that was asked how do you
• 25:49recruit connect with patients and families?
• 25:52I know that body donation is a
• 25:54very meaningful gift and legacy for
• 25:56many patients and their families.
• 25:58How can frontline clinical
• 25:59colleagues help support your work?
• 26:01And I'll I'll just add to
• 26:03that a bit which is, you know,
• 26:05you talked about the fact that there
• 26:07was not a bank but that you would be
• 26:10essentially delivering tissue to a lab.
• 26:11I think it's often going to be a program.
• 26:14Or an individual clinician who
• 26:17can do the recruiting,
• 26:19and I don't think it's going to be
• 26:22a lab per se that that does that.
• 26:26Maybe your issues?
• 26:28Yeah, no, you're absolutely right.
• 26:30So the different hospitals
• 26:32use different models.
• 26:33So MSK, I think their program takes consent.
• 26:36Johns Hopkins, the clinicians take consent
• 26:39and the ideal situation is to have a
• 26:41clinician who is also doing research.
• 26:43But you're absolutely right.
• 26:44I think it's really the clinical
• 26:46the clinical carotene that has
• 26:48to approach the the patient,
• 26:49and they have a you know and and they
• 26:51have to identify people who they
• 26:53think you know might be interested
• 26:54and and might be willing to.
• 26:56To broach the subject.
• 27:01If a second question, if a patient
• 27:04dies at home, how is it that the
• 27:07the patients body reaches Yale?
• 27:11What in those cases what we have are?
• 27:14We have a contract with an area
• 27:17Funeral Home that has agreed,
• 27:20obviously for a fee, you know to
• 27:22make you know that transport to you.
• 27:27And finally, would you prioritize
• 27:29certain disease areas for for
• 27:32patient recruitment in the initial
• 27:34rollout or would be up to each and
• 27:37every clinical research group?
• 27:39And again, I'll add to that and say I
• 27:42think it would be really helpful if
• 27:45we could pilot this in a few areas.
• 27:48Getting those that you know,
• 27:50the clinic clinical people in
• 27:52those areas interested in invested.
• 27:54Do you have thoughts about that though?
• 27:56Yeah, more chill. Do you want to take that?
• 27:58Sure, so I think we have a lot
• 28:01of interest from neurology.
• 28:03Obviously, you know this is one
• 28:05of the main avenues for for
• 28:07central nervous system tissue,
• 28:09and so we we have a number of
• 28:12clinicians and research labs,
• 28:14sort of already sort of preparing,
• 28:18particularly in neurodegeneration,
• 28:21but also stroke.
• 28:22And I think we you know. Again,
• 28:25part of our purpose talking to to this group.
• 28:28Is we, you know,
• 28:29we think that the Cancer Center you
• 28:32know would be would be an excellent.
• 28:35Basically plays for us to connect,
• 28:37you know,
• 28:38with all the the the the research
• 28:40that's happening in the labs you know,
• 28:42run by Cancer Center,
• 28:43Pi and and the clinical teams here.
• 28:46So I I think essentially these two areas
• 28:48are probably our first two rollouts.
• 28:52I can tell you that our lead neuro
• 28:55oncologist has already jumped in
• 28:58to say that he is happy to pilot.
• 29:01Right, that's wonderful.
• 29:03Thank you, thank you Antonia.
• 29:06So with that I'll thank you and we'll
• 29:10move on to something entirely different.
• 29:14Monica, do you have a presentation yourself
• 29:16or you're going to use other people?
• 29:17You do OK, so we're going to hear 3
• 29:22presentations from Monica Fredkin
• 29:25and from Christina Matusek and from
• 29:29Mandeep Smith that will be presented
• 29:33at the Oncology Nursing Society and.
• 29:38With that I welcome them all.
• 29:41Thank you Doctor Weiner.
• 29:43I'm Monica Fredkin and I'm here
• 29:45sharing a presentation that we did
• 29:48in oncology Nursing Society Congress
• 29:50last week and I'm going to spend
• 29:52a few minutes talking about the
• 29:56ambulatory oncology transformation,
• 29:59specifically around one
• 30:00working group and I'm here.
• 30:02There were multiple people that were involved
• 30:04in this work and Chang Jeremy Corbyn,
• 30:07Mansky and Connie Angle King is a
• 30:10consultant and then I will hand.
• 30:11Give a high level of the work
• 30:13that we've done, and then I'll.
• 30:16Handed over to Christina Matusik
• 30:18and Mandeep Smith were the leads of
• 30:20one of the work groups that have
• 30:22patient visit readiness to kind of
• 30:24show how we took this ambulatory work
• 30:26and and put it into real practice.
• 30:29So with that,
• 30:30how did we get started at all this work and.
• 30:35Back in March of 2020 and April of 2020,
• 30:38we really had to.
• 30:42Change everything we did about
• 30:44how we provided ambulatory care.
• 30:46We consolidated clinics.
• 30:47We moved all of the New Haven teams
• 30:51and clinics out to the network
• 30:54to different sites.
• 30:55To provide additional capacity for inpatient,
• 30:58and with that what we learned is that.
• 31:01While we had, we were forced to do this.
• 31:03There was an opportunity to relook
• 31:05at how we provided ambulatory care,
• 31:08and so we Kim's luster,
• 31:10Lori Pickens, Kevin Billingsley.
• 31:15At the time said,
• 31:16how can we create a new normal and make
• 31:19one smile and really make this a two point?
• 31:22You know,
• 31:23version 2.0,
• 31:23so there was an ambulatory
• 31:25transformation steering group that
• 31:27was started and it really looked at
• 31:29the ambulatory flows from before the
• 31:31patient arrived all the way through.
• 31:33So when they left and there was
• 31:34a steering committee and within
• 31:36that steering committee there
• 31:38were six different subgroups.
• 31:40The subgroups were around facility and
• 31:44environment patient access technology.
• 31:46Staff and staffing and then communication
• 31:48and the final one in Orange is really
• 31:51the care delivery workflow subgroup
• 31:52that we're going to talk a little bit
• 31:54about today to share what we've done,
• 31:56but each one of these groups are,
• 31:58as you know,
• 31:59we're all interconnected.
• 32:00So how we do this really had to be done,
• 32:06thoughtful and coordinated.
• 32:08So the approach to this is that we had
• 32:10to do have a multiple steps in order
• 32:13to even understand where we were,
• 32:16and I'm going to go into the
• 32:17detail of the elements on this
• 32:18slide into future slides,
• 32:19but we had a a five step process
• 32:22on what how we approached this work
• 32:24and the first thing that we had to
• 32:26do is we had to kind of understand
• 32:28we had to understand where we were,
• 32:30what was our current state,
• 32:31and in order to do this and we wanted
• 32:34to make sure that we represented
• 32:35all the areas across the ambulatory.
• 32:38Enterprise, so a key survey was created.
• 32:41We obtained information around
• 32:43role where people worked as well
• 32:46as what team they were.
• 32:47They were aligned with and
• 32:49there was a structured and
• 32:51unstructured questions we we wanted
• 32:54to know open comments which provided
• 32:56a significant amount of information
• 32:59and when you think about analyzing and
• 33:01aggregating the data we had, you know,
• 33:04open-ended questions can provide,
• 33:06you know a whole level.
• 33:08Of analysis that was created.
• 33:10The workflows that were not included
• 33:13because they were part of other working
• 33:16groups was the supportive care services
• 33:18and the access Access call management and
• 33:21intake was all part of other working groups.
• 33:25So we really focused on the
• 33:28clinical flow of patients.
• 33:31The survey had was open for eight days.
• 33:34We had almost 200 people respond,
• 33:37which shows that there was a
• 33:40real opportunity and engagement.
• 33:41From all different roles and disciplines.
• 33:45So we had a nice mix of responses,
• 33:5126% from physicians,
• 33:5232% from nursing, but we had pharmacy.
• 33:55We had lab.
• 33:56We had access staff research, everyone.
• 33:59We had multiple people that you know roles
• 34:02that completed this as well as modalities.
• 34:04So 2/3 were medical oncology,
• 34:06but we had a nice representation of radiation
• 34:09oncology as well as surgical oncology.
• 34:12And what's not on here is that we
• 34:14had a 5050 split of new like the
• 34:17New Haven teams and the network.
• 34:19So we really did get a great
• 34:23representation of the information
• 34:24that we were looking for.
• 34:26So once we took that,
• 34:27we spent a tremendous amount of time
• 34:29aggregating and analyzing the data.
• 34:31But there were ten common.
• 34:34Workflows that came up as the
• 34:37opportunities for improvement and
• 34:38what a group of us did is there we
• 34:41priority ranked them and there were
• 34:43about 70 plus people that that were
• 34:46involved in this and the priority
• 34:49rank also needed to intersect
• 34:51with the different working groups
• 34:53that were also functioning so.
• 34:56Well,
• 34:56this is a high level of the 10 different
• 34:59groups we we had to create different
• 35:02subgroups within that within those teams.
• 35:04So there were three different
• 35:07COVID related projects and we we
• 35:09deployed them to the COVID team.
• 35:12There was a working group already that
• 35:14was in place that could handle and
• 35:17manage those those groups but the non
• 35:20COVID related really fell into four
• 35:23different buckets that you can see here.
• 35:24We had more than 70.
• 35:27Participants,
• 35:27physicians,
• 35:28and staff of all different roles,
• 35:30as well as sites that were represented in
• 35:33these different groups and for clinic flow.
• 35:37We had three different working groups
• 35:40that are still actively working and
• 35:43meeting and right now visit type
• 35:45criteria was a proactive approach on
• 35:48how we could identify patients that
• 35:51would be televisit appropriate that
• 35:54would help minimize switching visits.
• 35:57Last minute and being able to
• 35:59designate those visit types.
• 36:01The patient visit readiness which
• 36:04Mandeep and Christina will talk
• 36:07about is really also about the
• 36:09patient and physician having the
• 36:12optimal visit and what can be done
• 36:15beforehand and after to ensure that
• 36:17those patients experience that visit
• 36:19and the checkout process is also an
• 36:23active working group around that
• 36:25communication of what needs to be
• 36:27done following the visit to ensure
• 36:29that things are communicated.
• 36:31And followed through on
• 36:33whether it's referrals,
• 36:35orders and imaging that have
• 36:36to be done or next visits.
• 36:38Infusion flow was really around labs
• 36:41and advanced release of chemotherapy,
• 36:43but at the same time there has been
• 36:46an initiative that we're implementing
• 36:48lean toss across the the ambulatory
• 36:51areas where infusion is done.
• 36:53So we are working on lean
• 36:55tasks right now and then.
• 36:56Patient education was really around.
• 36:59How can we utilize and leverage technology
• 37:02to provide patient and family education,
• 37:05especially when there's limited patients and
• 37:07family members that are allowed in clinic?
• 37:10That there's a way to do this
• 37:12in this more of a a video,
• 37:13you know telehealth forum
• 37:15and then imaging is really.
• 37:17We've heard a lot about access challenges
• 37:20for scheduling and how can we work
• 37:22together across the discipline with
• 37:24imaging to get patients scheduled,
• 37:26timely and appropriately at
• 37:28the right location.
• 37:32So while there are a lot of moving parts
• 37:34at all, these different working teams,
• 37:36we had a a template of how we
• 37:39would move forward with this work.
• 37:41First we needed to understand workflows
• 37:44we needed to do observations and did
• 37:47process mapping and really identifying
• 37:50barriers that could impact the flow.
• 37:52And then we had to just test it.
• 37:54And so we piloted we're
• 37:57piloting different initiatives.
• 37:58We had to be really selective.
• 38:00And how we determine the site, what teams?
• 38:03How are we going to measure this?
• 38:05Because the goal ultimately is that this is
• 38:08sustainable as we continue to move forward,
• 38:10and what adjustments we had to make.
• 38:13You know, using rapid change cycles
• 38:16and finally the goal is that once these
• 38:18pilots are really done, is that this?
• 38:20We get this out everywhere we
• 38:22want to be able to utilize our.
• 38:24You know, these efficiencies and
• 38:26opportunities to really go across
• 38:29which will enhance the smilow. 2.0.
• 38:33And so this is just to understand
• 38:35there were multiple tools.
• 38:36As I said,
• 38:37we want to be able to sustain this work.
• 38:39So we created within EPIC.
• 38:41There are tools we created
• 38:44standard operating procedures.
• 38:46We looked at the literature of what is
• 38:48said that on the work that we're doing
• 38:51to validate that what we are doing
• 38:53makes you know is is aligned with what
• 38:55else is happening out around the country.
• 38:58We graded metric based reports so we could
• 39:01share data so that people understand.
• 39:04How they're doing and where
• 39:06their opportunities are and
• 39:07to celebrate the successes,
• 39:09and finally,
• 39:10tell ASCO came out with some telehealth
• 39:12standards at the same time we were
• 39:14doing this work to ensure that we
• 39:16were doing the work that aligned
• 39:18with the with the ASCO standards.
• 39:21So these are the high level work that
• 39:23was happening and now what I'd like
• 39:25to do is switch it over to Christina
• 39:27and Mandeep to share how the work of
• 39:30the patient Visit Readiness project
• 39:33you know has taken the the framework
• 39:36of what I have shared into a pilot.
• 39:39Christina and Mandeep.
• 39:42Thanks Monica. So as Monica alluded to,
• 39:45our project was really on
• 39:47patient visit readiness long.
• 39:49The next five years,
• 39:50which has been showing that
• 39:52in this really patient visit,
• 39:54readiness is essential and it's
• 39:56an essential component of patient
• 39:58safety as well as clinic flow.
• 40:00In our ambulatory setting.
• 40:02So this included basically just making
• 40:05sure that your patients that were coming
• 40:08in were completed all the prep that
• 40:10was done ahead of time was completed.
• 40:12The next appointment you know
• 40:14disposition was actually completed
• 40:17prior to the the current visit.
• 40:19That's coming up and making
• 40:22sure that any consults lab,
• 40:24any imaging or studying and studies
• 40:26or any prior authorizations
• 40:28that were required are being
• 40:29done ahead of time as well.
• 40:31So what we realized is that without the
• 40:35adequate preparation that was going on,
• 40:38there were significant delays
• 40:40within the clinic errors.
• 40:42Sometimes last minute cancellations
• 40:43for patients and an overall patient or
• 40:47provider satisfaction had decreased.
• 40:53And as Monica had mentioned,
• 40:55there was multiple surveys.
• 40:56There was survey questions that
• 40:58were congregated and reviewed,
• 41:00and within those visits,
• 41:03what we realized is that there was.
• 41:06Practices carried concerning Preclinic
• 41:08prep and post clinic wrap up found.
• 41:11There was multiple variations
• 41:12within our House system.
• 41:14As you can see in this slide,
• 41:17you see that about 80% of the team
• 41:20did some sort of prep before about.
• 41:24But only about half of them really had
• 41:27some form of guidelines to follow or
• 41:30best practices within the clinic prep.
• 41:34In addition,
• 41:34a vascular majority of teams were
• 41:36also not doing any sort of post clinic
• 41:38huddle and most patients patients were
• 41:40leaving without any follow up appointment.
• 41:43Uh.
• 41:45Which again brought concerns to the team.
• 41:50We also surveyed uh clinic prep
• 41:52activities and found that the
• 41:53majority of respondents 84% do
• 41:55review the schedule ahead of time.
• 41:57But again,
• 41:58half did not use any standardized criteria,
• 42:01and.
• 42:01In addition,
• 42:02about a third do not review test results.
• 42:07Of course,
• 42:08do not communicate or review missing orders.
• 42:10And lastly,
• 42:11less than half did not evaluate
• 42:13ahead of time which patients could
• 42:16benefit from a nursing visit.
• 42:18McLeod.
• 42:23So when doing a literature review,
• 42:26as Mike had mentioned,
• 42:27there was reviews being done and
• 42:29in it what we realized was that
• 42:31we're starting to work on this
• 42:33initiative and needed to really look
• 42:34at the ambulatory areas and see.
• 42:38You know what was happening in other areas,
• 42:41so a major article that we
• 42:43reviewed was published in 2021,
• 42:45which found that researchers were
• 42:47performing a systemic review about
• 42:50of 49 studies that ranged around
• 42:5210 countries and highlighted about
• 42:548 previsit planning techniques
• 42:55that could be used.
• 42:56And with this review,
• 42:58it really suggested that prepare
• 43:01preparing for clinic can enhance the
• 43:03quality of patient care as well as
• 43:07patient to provider communication.
• 43:09And 84% of the authors reported
• 43:12that proactive visit.
• 43:14Patient preparedness was a
• 43:17really effective way to improve
• 43:19patient centered care.
• 43:24So when looking at what we've talked about,
• 43:27which is patient visit readiness,
• 43:30what does this actually mean
• 43:31and how do we achieve it?
• 43:33We needed to define this,
• 43:34so visit readiness really begins.
• 43:37Your post clinic wrap up from the
• 43:40prior visit as that will be outlined.
• 43:43You know, with an RN or a scheduler,
• 43:46at which time then you are looking at
• 43:48your next visit and really reviewing
• 43:50what what is required for those people.
• 43:52Preclinic prep sounds obvious.
• 43:54This is a proactive approach of
• 43:56reviewing what the practice nurse
• 43:59is looking at and all the elements
• 44:00that need to be completed before
• 44:02the patient comes in for the visit.
• 44:04And how do we achieve all that?
• 44:07It's through completion of your provider
• 44:10disposition to guide the Previsit
• 44:13prep as well as the the defined team
• 44:16huddles to improve communication
• 44:18for all the teams and then this can
• 44:20all be done virtually or in person.
• 44:22Weekly, daily or really,
• 44:24whatever works for your team,
• 44:26but it allowed you to have the what,
• 44:28how and when of what patient was it?
• 44:30Readiness looks like.
• 44:33Next slide.
• 44:36So I have seen really just to fix the team.
• 44:38This is Doctor Kirkman's team and the post
• 44:41clinic cuddle that they run is usually
• 44:44done weekly on Friday and as you can
• 44:47see he did it in person with his team.
• 44:51This also act as a wrap up for
• 44:53the general elements that are
• 44:55being done within the clinic.
• 44:57What we found is that it engaged
• 44:59the staff and increased efficiency,
• 45:02communication and collaboration,
• 45:03and these huddles can really be customized
• 45:07to each team and what exactly you are
• 45:10requiring for your team. However,
• 45:12we did outline key players for each channel,
• 45:15meaning the practice nurse,
• 45:17the provider and the scheduler.
• 45:20And I'm going to hand it
• 45:22over to Christina now.
• 45:23Casino.
• 45:27Thanks Randy. So when we began
• 45:30our process a long time ago,
• 45:32we developed this Visio map which
• 45:35really outlined every element from
• 45:37check out from the previous visit
• 45:39to the next visit that they were
• 45:41being seen to really understand
• 45:43this process and how we can improve
• 45:46this across the health system.
• 45:48We further broke this down and to the
• 45:50left hand side where you can see the
• 45:52different swim lanes that looked at
• 45:54the responsibilities of the provider
• 45:56versus the practice nurse versus the
• 45:58schedule as well as we incorporated.
• 46:01Via medical assistance or the ACA's.
• 46:04It was a lot of work to do it in this way,
• 46:06but it really helped to be.
• 46:09It really helped us to understand
• 46:11where we needed to improve our process.
• 46:14Next slide.
• 46:17So since we discussed
• 46:19the different elements that we focused on,
• 46:20we actually did develop some tools that
• 46:23were meant to be helpful for preclinic
• 46:26prep purposes and to lessen the
• 46:28workload of the practice nurse who is
• 46:31performing the preclinic prep elements.
• 46:33So the first is what's called
• 46:35the UNC Summary Nurse tab.
• 46:37It's actually located in the
• 46:39multi provider schedule.
• 46:40It allows the practice nurse who is
• 46:44performing the Preclinic prep one click area.
• 46:48To go through the different elements
• 46:50that she may find helpful to the
• 46:52Preclinic prep prep process.
• 46:55So this was developed to hopefully reduce
• 46:57the amount of time that the practice
• 46:59nurse has to spend doing preclinic prep.
• 47:01It involves many elements
• 47:02and components to the report,
• 47:04including treatment plan,
• 47:05the actual follow up disposition from
• 47:08the previous visit will be there so
• 47:10that they can actually understand
• 47:12what is needed for the next visit.
• 47:15To help streamline this process.
• 47:18So you can go the next slide.
• 47:20The other feature that we developed
• 47:22is what's called the Visit Ready
• 47:24feature on the multi provider schedule.
• 47:26This is a column that anyone can add
• 47:29to their provider schedule and it for
• 47:32those that are currently in the pilot phase.
• 47:35The physicians will actually see
• 47:36this being done in their areas,
• 47:38but you can see that once the
• 47:41patient is deemed visit ready,
• 47:42the practice nurse will actually
• 47:44go in and make the patient a green.
• 47:48Check for yes or a red X for no.
• 47:51We also included a column for Visit
• 47:54Ready comments and that allows the
• 47:56practice nurse to make comments in
• 47:58that specific area so that number
• 48:00one they could.
• 48:01It can remind themselves of who's
• 48:03to visit ready and who is not,
• 48:05as well as what they need to follow
• 48:07up on for that particular visit.
• 48:09This is also viewable by the provider
• 48:11if he rents it into your multi
• 48:14provider schedule.
• 48:15So that the providers are able to
• 48:17see their clinics prep as well.
• 48:19Isn't that the next slide?
• 48:22So in order to convey
• 48:23this new workflow, we performed formal
• 48:26team trainings to discuss this with
• 48:29each individual that included the
• 48:31discussion of the workflow itself,
• 48:34the huddles that we wanted them to do,
• 48:37as well as the tools that we developed
• 48:39to help streamline this process.
• 48:40We also offered initial first huddle,
• 48:44guidance and facilitation for the
• 48:46new Members that were being part
• 48:48of this pilot and the session
• 48:50involved all team participants.
• 48:52And were completed prior to the GO live.
• 48:55Go to the next slide.
• 48:58So as as we have alluded to,
• 48:59this has been a really big work in progress.
• 49:03We currently have North Haven,
• 49:05Guildford and Greenwich
• 49:07underway with our pilot sites.
• 49:11North Haven was our first site to
• 49:13go live in October of last year.
• 49:15Greenwich currently went live.
• 49:17I believe last week and we also
• 49:20have planned sites that are going to
• 49:22be going live in the near future.
• 49:24Thoracic oncology head and neck
• 49:26surgery GI met on.
• 49:28As well as classical hematology and
• 49:30malignant hematology and North Haven,
• 49:33we also have incorporated trumple as well.
• 49:35They're not on this side, but again,
• 49:38this is a work in progress and
• 49:41a huge team effort.
• 49:42And go to the next slide.
• 49:44So now on to the data.
• 49:46So we looked at many elements
• 49:48and we created this workflow and
• 49:49one of those included physician,
• 49:51disposition,
• 49:51compliance rate.
• 49:53This data represents 3 physicians from
• 49:56the North Haven site which looked at
• 49:59data from pre pilot to April of 2022.
• 50:03So as you can see the provider see and
• 50:06the green line really was compliant
• 50:09with this throughout they acted more
• 50:12as our control line or participant.
• 50:14And we saw that as we went into October,
• 50:18we saw a gradual increase in provider
• 50:21a during the pilot phase as and
• 50:25tapering off into about a 90th,
• 50:2890 high 90 percentile of completion
• 50:31as well as provider be as well.
• 50:34But the next slide.
• 50:36So in addition to the provider compliance,
• 50:40we also get practice nurse preclinic
• 50:43preparation compliance rates.
• 50:44This represents graphs in the
• 50:46Helix report format that we looked
• 50:48at from North Haven and Guilford,
• 50:51so you can see that North Haven had a
• 50:54huge uptick in their compliance when
• 50:57they actually started the pilot in October,
• 51:00and they really maintained that compliance
• 51:02rate into the above 95% throughout their.
• 51:06The time in this study within Guildford.
• 51:09They went live in February of 2022
• 51:11and you can see that with them it
• 51:13was a little bit more of a gradual
• 51:16rise in compliance,
• 51:16but overall has again tapered off
• 51:19into a great compliance rate for the
• 51:22remainder and go to the next slide.
• 51:25In addition,
• 51:26we also looked at patient visit
• 51:28unreadiness volumes and reasons for
• 51:30why patients are deemed unready
• 51:32for their visit for North Haven.
• 51:34We calculated that about 17% of
• 51:38patients 170 out of 1098 over the
• 51:41course of eight weeks were visit.
• 51:43We're not visit ready as well as Guilford,
• 51:45which was about 22% or 206 out of
• 51:49930 scheduled visits and the real we
• 51:52listed the actual categories
• 51:54for why this was.
• 51:55But we actually found that the
• 51:57most common theme was the test
• 51:59ordering and scheduling that they
• 52:01were not performed or testing
• 52:02was not completed in a timely
• 52:04manner by the patient.
• 52:05Go to the next slide.
• 52:11So in addition to our data collection,
• 52:13we are also really interested in feedback
• 52:15from the end user and ask them to
• 52:18respond to the following questions that
• 52:20you can see listed here for example.
• 52:22We have seen that the doctors
• 52:25have found fewer interruptions.
• 52:26They can review cases at the same times
• 52:29and our nurses have found that the
• 52:32huddles have really helped maintain
• 52:34helped manage patients efficiently,
• 52:37as well as some of the other
• 52:40providers noted that.
• 52:41Improving the preparation really
• 52:43highlighted what patients did not
• 52:45have done prior to their visit.
• 52:47Move to the next slide.
• 52:49So during this process we
• 52:51definitely learned a lot,
• 52:52including the fact that specific tools
• 52:55can really streamline the process,
• 52:57but it also requires training
• 52:59and consistent utilization.
• 53:01In addition,
• 53:02consistency with performing huddles
• 53:04as well as physician leadership
• 53:06and engagement is really a key
• 53:08player and a huge role in the
• 53:10success of this initiative,
• 53:11especially with regards to the disposition,
• 53:14completion and leading post clinic
• 53:16huddles in a A in a consistent manner.
• 53:21Next slide.
• 53:23So for our next steps,
• 53:24as we look to the future,
• 53:25we plan on working with it to refine
• 53:28our compliance tools and really
• 53:30refine our epic related tools based
• 53:32on feedback from the end user and we
• 53:35will continue to perform a systematic
• 53:37approach when rolling these out.
• 53:39To really ensure success of this program
• 53:42for those in the ambulatory setting,
• 53:44we'll likely be working with you
• 53:45in the future with you and your
• 53:48teams to help improve your clinics
• 53:49and enhance patient preparedness,
• 53:52and we really look forward to
• 53:53your collaboration.
• 53:53During this huge team effort.
• 53:56So thank you so much for your
• 53:57time and we will now answer any
• 53:59questions that make people may
• 54:01have with Doctor Kochanski as part
• 54:02of the discussion as well.
• 54:12Thanks very much.
• 54:15Questions.
• 54:22The you know the only thing I
• 54:24will there's a couple things.
• 54:25One that we also are looking at, the press.
• 54:28Gainey, we have to understand how
• 54:29this is what the meaning is for
• 54:31patients as we're doing this work.
• 54:33So we're looking at the press
• 54:35ganey aspect of of this.
• 54:37These this work and the only other
• 54:39thing I didn't get a chance to say is
• 54:41there are so many people that have
• 54:43been involved in this this the practice
• 54:45nurses the access team pharmacy.
• 54:47Obviously the physicians,
• 54:49the AP's and I just want to say
• 54:51a huge thank you to all of them.
• 54:53As well as Christina and Mandeep you
• 54:56know and Jeremy I'm going to ask
• 54:59you if you have any kind of pearls
• 55:02or words of wisdom that you might
• 55:04offer as an end user of this work.
• 55:07As we, you know, finish up.
• 55:10Sure, you know. I think for our
• 55:14team this this meeting has really
• 55:18been transformative for our group.
• 55:21And while there is a a core group that I
• 55:25think needs to be there which includes
• 55:27the the physician and the practice,
• 55:30nurse and PFA SII think that
• 55:35the larger the group is,
• 55:37the more productive those meetings are.
• 55:40And we have included in our meetings,
• 55:43our AP's the infusion nurse as well as
• 55:50pharmacy and in doing so you really
• 55:54capture all of the different ways that
• 55:57we need to prepare for the visits,
• 56:00not just including whether a scan has
• 56:03been scheduled as ordered and will
• 56:05be available in time for the visit,
• 56:07but also where chemo orders need
• 56:09to be entered.
• 56:10Or informed consents need to be completed.
• 56:14It's dedicated time to review the
• 56:17schedule with with PFA SI think we all
• 56:20of us you know have these long lists
• 56:22of patients that have acute issues
• 56:24that we need to get in and rather than
• 56:27being disrupted all throughout the day
• 56:29to to figure out when that should be,
• 56:31we now have dedicated time to do that.
• 56:34As a physician.
• 56:35It also allows me to follow up with
• 56:38infusion nurses and the APP's to find out.
• 56:41Uh,
• 56:41whether there are any urgent issues,
• 56:43dose modifications,
• 56:44things that need to happen with
• 56:46patients that I haven't seen that
• 56:48week so that everybody on the team
• 56:51is really understanding where all
• 56:54of the patients are in their course?
• 56:57You know who we can anticipate.
• 57:00Might be progressing,
• 57:01or is having a lot of trouble where
• 57:03you know there might be flags that
• 57:05we say oh we need to bring in OCMD
• 57:07or social work or palliative care.
• 57:09It really is a a holistic approach
• 57:13that can only be done when when
• 57:15you have some dedicated time.
• 57:17And while I know that for for my
• 57:20team we we take an hour on Friday,
• 57:23I understand that not everybody
• 57:26has that much time.
• 57:27But in that hour we review.
• 57:30All of the patients from the week that was,
• 57:33and all of the patients that
• 57:35are in the week that follows,
• 57:37and so it can be done in a shorter
• 57:40amount of time by just breaking
• 57:42it up into fewer days to review.
• 57:45You
• 57:46know, Jeremy, I think that the I think
• 57:48this team work is really essential.
• 57:50I think it can be done as
• 57:52an hour that you set up.
• 57:54I think that in some cases it needs
• 57:56to be a huddle in the morning.
• 57:59That I think it's really important.
• 58:02One of the things that can happen in that
• 58:04that huddle on the day of treatment,
• 58:06or for that matter the week before,
• 58:09is to identify patients where
• 58:11if it gets busy,
• 58:13that person might be able to be shunted
• 58:15to the infusion room because you know
• 58:18they're going to get a treatment anyway
• 58:20and see you afterwards as opposed to,
• 58:23you know, waiting for everything.
• 58:25I'm the one question I have is,
• 58:28and you may have.
• 58:29Said this,
• 58:30but to what extent have you been successful,
• 58:32either in New Haven or at
• 58:34some of the other sites?
• 58:36In pairing infusion nurses with
• 58:41physicians so that a physician
• 58:44isn't necessarily working with every
• 58:47infusion nurse in the infusion room.
• 58:51I and maybe you do that,
• 58:52it's just my experience in the past
• 58:54is that that has been challenging.
• 59:02You're on mute. Yeah,
• 59:03we, we actually haven't with this work.
• 59:06We have not focused on
• 59:08the pairing or the team.
• 59:11I mean, we definitely have an infusion
• 59:13nurse as part of the huddles,
• 59:14because whether they're, it's the charge
• 59:16nurse that represents the infusion,
• 59:18but we haven't done that.
• 59:19And with lean toss,
• 59:20I think we're going to have to.
• 59:21You know, we're looking at it a little
• 59:23bit differently, so I'm not sure.
• 59:26What that will look like just yet?
• 59:29So I guess to be determined.
• 59:31Yeah, I know we had looked at it
• 59:33initially in hematology a long time ago,
• 59:35and with the move from
• 59:37New Haven to North Haven,
• 59:39it kind of it didn't work correctly.
• 59:42But I do agree that there's
• 59:44a lot of value in that.
• 59:45It's always challenging with
• 59:47schedules and what have you.
• 59:48Although my my strong sense is that
• 59:51there's a real value of caring physicians
• 59:54with maybe not one person because
• 59:56that one person could be off, but.
• 59:59Two or three or four people, as opposed to.
• 01:00:0215 right in any case, I just want to
• 01:00:06say you all have done a great job.
• 01:00:08Thank you so much both for presenting
• 01:00:10the work, but more importantly,
• 01:00:11for all the all the really
• 01:00:13great work you've you've done,
• 01:00:15and there'll be more to come, I'm sure.
• 01:00:17Thank you so much for the opportunity.
• 01:00:19Ohh thanks all of you.
• 01:00:21Thank you so much. We appreciate it.
• 01:00:23Thanks, Jeremy. Bye bye. Bye bye.