When ACCC began its journey to explore how cancer programs and practices around the country are meeting the demands of increased precision medicine testing, the concept of precision medicine stewards—a nuanced approach to navigation that is focused exclusively on biomarker testing processes and results reporting—was fairly new. Yet the variety of models and titles that have since emerged continue to multiply and are breaking down the complex precision medicine landscape into streamlined workflows to improve efficiency and better support growing test volumes.
One such model is currently in place at Astera Cancer Care in New Jersey, where it has developed a unique approach by creating a centralized Molecular Processing department and team of dedicated staff to support the multiple aspects associated with molecular tests orders and results. ACCC recently talked to Lauren Kiley, MSN, APN-BC, AOCNP, advanced practice provider and director of patient navigation, and Melissa Cruz-Tanner, LPN, OPN-CG, manager of patient navigation and molecular processing, at Astera Cancer Care to learn more about their precision medicine stewardship model.
Astera Cancer Care has eight medical oncology outpatient clinics, eight radiation oncology hospital-based locations, and two breast surgery centers located across New Jersey, and offers multidisciplinary cancer care through a team of medical and radiation oncologists, hematologists, breast surgeons, pharmacists, advanced practice providers (APPs), and navigation and social support staff. While centralizing its molecular testing processes was critically important to Astera Cancer Care with the increased testing volumes, it was too much for their existing navigation team to handle. In examining the extensive time spent by patient navigators on tracking molecular tests, associated administrative tasks, and follow-up, the team at Astera Cancer Care determined that they needed to reassign this important, albeit time-consuming, task.
As Kiley explained, “My focus as director was to remove that task [tracking of molecular tests] from navigators and have them focus on the navigation involved [with molecular testing], rather than the administrative follow-up, but ensure that the process was not being lost. So we determined that because it does require knowledge on medical terminology and involves collaborating with pathology departments, we decided to hire a medical assistant who would function full time, remotely in the role of [molecular] order processing and follow-up tracking. The case was presented, as such, to our leadership—that molecular test processing is taking away from our navigation process and is outside of their scope of practice. Leadership agreed, and we were able to develop a molecular task force.”
At Astera Cancer Care, the precision medicine stewardship’s responsibilities are essentially distributed between patient navigators and molecular processors. With clear distinctions and separate responsibilities, this tag-team ensures precision medicine processes are seamless and bottlenecks and other delays do not occur.
Patient navigators, who are required to hold licensed practical nurse licensure to ensure they have the clinical background to execute physician orders and handle inquiries associated with testing, play an important role in the day-to-day precision medicine stewardship processes. While they are responsible for traditional navigation services, including explaining the clinical importance of molecular testing and assisting patients in sourcing and completing financial assistance and pre-authorizations required for testing, they are also responsible for prioritizing the orders in the electronic health records (EHR), ensuring accuracy and molecular processors (who actually enter the orders into the portal) have full clinical support. This means, in cases when a confirmation is needed for diagnosis or pathology, the navigators are readily available to molecular processors to assist and ensure orders are placed without delays.
Meanwhile, molecular processors act as the primary point of contact throughout the precision medicine stewardship process and are responsible for orders processing. They input all information into the order within the portal, generate requisition forms that are placed into the EHR (and sent out if it is for liquid biopsy), and maintain relationships and communications with each of the preferred laboratory vendors. Next, they handle one of the most critical aspects of the process—monitoring and tracking test results. Molecular processors, who receive regular updates from vendors, enter the EHR and provide status updates on specimens to providers every 72 hours. This enables providers to know exactly where in the process the test is and significantly improves efficiency and reduces turnaround time. Beyond this, molecular processors are also responsible for quality testing and evaluation.
As Cruz-Tanner explained, “On a minimum of two times per day, we access the portal in real-time, and we manually upload all the results that are available. Sometimes, it will just be verbiage that is updated, but providers generally request an updated PDF file. Some facilities have an interface base where they are automatically incorporated in the EHR, but that is not always the case. We have some vendors that send over results via fax, but you run the risk where it is put in the wrong patient’s chart, it’s incomplete, or the whole thing did not go through. So we have found [that] it is more reliable for our staff to go into the portal and upload [the] results themselves.”
While the team at Astera Cancer Care are proud of their current model and have been successful in establishing the role of these molecular processors, in retrospect, they recommend building the case for multiple processors to meet test volumes during the initiation phase, rather than seek approvals one at a time. Another recommendation is to establish clear guidelines with vendors to place increased responsibility on vendors rather than the cancer program, such as providing a dedicated liaison for communicating results or issues with specimens and providing a weekly spreadsheet with updates.
To those around the country who are looking at implementing a similar model, Astera Cancer Care gives this advice: “Be patient, because it's going to be an uphill battle but definitely remain steadfast. Make sure that you establish the most important objective—to decrease the time between the results and the patient receiving treatment—which is overall the most effective form of patient care. That, and ensuring that you capture measurements, activities, and [key performance indicators], anything that can document the volume of patients that are going to be significantly positively impacted by this new role, then that'll be more likely for it to be accepted by the organization,” Cruz-Tanner said.
Check out the latest CANCER BUZZ TV episode “Getting the Green Light for Precision Medicine Stewards,” where Cruz-Tanner discusses how cancer programs and practices can streamline their testing processes to improve efficiency and improve the patient experience. For more information on the Precision Medicine Stewardship education program, visit the ACCC website or contact Rifeta Kajdic-Hodzic, ACCC program manager.
The ACCC Precision Medicine Stewardship education program is supported by AstraZeneca and Blueprint Medicines.
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