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Innovators Share How To’s for Practice Transformation

Authored by

JCP Editors


J Clin Pathways. 2020;6(8):43-44.

Image 1In a recent “Ask the Board” column on how clinical pathways are growing, Journal of Clinical Pathways editorial advisory board member Ray Page, DO, PhD, FACOI, FASCO, shared his perspective: “As we continue to see evolving payment policies from both private payers and Medicare’s Quality Payment Program, providers have increasing incentives for financial reward by showing value-based care (VBC) for their patients.”1

Aligned with those above remarks, sessions from the ACCC 37th [Virtual] National Oncology Conference held September 14-18, 2020, showcased the ways cancer programs and practices are devising and integrating new tools to move forward in the value-based environment. This year, following “how we did it” presentations from the 2020 ACCC Innovator Award winners, were real-time interactive sessions with presenters and physician champions. These innovators offered their experiences and insights along with specific “how to’s” for improving care coordination and quality.  

Spotlighting Tennessee Oncology


Demonstrating improvement in these areas also aligns with goals of the Oncology Care Model (OCM) pilot. For many OCM participating sites, care transformation has included taking aim at two of the biggest drivers of overall health care costs: emergency department (ED) visits and hospital admissions/readmissions. This year, ACCC recognized Tennessee Oncology, a large physician-owned community-based practice headquartered in Nashville, TN, with an Innovator Award for developing a tool that leverages real-time hospital data on patient ED and/or hospital admissions and discharges to inform practice transformation. “This tool enables us to determine why a patient went to the ED and find out the source of the problem,” said Johnetta Blakely, MD, MS, MMHC, Executive Director of Health Economics and Outcome Research at Tennessee Oncology. “If we know what is happening, we will know how to counteract it.”

In a conference session titled “Utilizing Technology to Identify Patient Co-Morbidities and Reduce Hospital and ED Admissions,” Larry Bilbrey, Care Data Systems Manager, Tennessee Oncology, explained that transitioning to value-based care has long been a focus at the multisite practice. While Tennessee Oncology has been successful in the OCM, Mr Bilbrey said entering two-sided risk raises the bar on reducing cost and resource utilization while maintaining high level of quality care. To achieve these goals, Tennessee Oncology and its Innovation Team, led by Natalie Dickson, MD, president and chief medical officer, isdoubling down on care coordination. 

Despite steps already in place, such as a 24-hour patient call line and a “Call Us First” patient education campaign, lack of information on when patients are seen in the ED, admitted to the hospital, or discharged from either care setting creates barriers to coordinated care. Considering these scenarios, the Innovation Team asked the following questions:

  • Could the patient’s problem have been handled in the clinic?
  • If so, why did the patient go to the ED?
  • Was there duplication of work by the ED, for example, were tests repeated unnecessarily? 

A game changer for Tennessee Oncology has been the ability to access real-time hospital data on practice patients admitted to the ED or the hospital and/or discharged from either. An opportunity opened when the state of Tennessee contracted with a third-party vendor to monitor state Medicaid admissions at all participating hospitals. Tennessee Oncology contracted with the third-party vendor for access to the practice’s patient data. 

Working with the vendor, the practice is leveraging this access to real-time hospital data to develop targeted patient management algorithms. By mining its OCM data, the practice identified four comorbid conditions as the cause of most of the local health care costs: chronic obstructive pulmonary disease, congestive heart failure, diabetes, and pain. Developing algorithms to identify patients with these comorbidities has enabled the practice to focus on improvement of management strategies for patients with these comorbidities. 

To act on this new data, Tennessee Oncology had to develop a new workflow with the practice’s nurse care coordinators serving as the communication linchpin. Through the new data tool, nurse care coordinators are alerted by email when a Tennessee Oncology patient visits the ED and/or is admitted to the hospital. The workflow maps out the process so that nurse care coordinators can facilitate contact, connection, and communication among care settings to achieve more seamless coordination of patient care and reduce duplicative resource utilization (eg, redundant testing).

With access to real-time hospital data, Tennessee Oncology is building its capacity to quantify data and identify trends and patterns. At the time of Mr Bilbrey’s presentation (recorded in late August 2020), the practice had analyzed about 1 month’s worth of data. Even at this early stage though, the data were “eye-opening,” he said. As the data matures, Tennessee Oncology looks forward to integrating predictive analytics to further inform practice transformation. 


1. JCP Editors. How clinical pathways are growing. J Clin Pathways. Published June 16, 2020. Accessed October 6, 2020.

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