Jorne Meijer, Xander Verbeek 12-04-2015

Making trees out of paper Computer supported implementation and evaluation of clinical practice guidelines

Netherlands Comprehensive Cancer Organization (IKNL)

• IKNL is the knowledge and quality center for oncological and

palliative care and cooperates with managers, care professionals

and patients on continuous quality improvement.

• Netherlands Cancer Registry (NCR)

• population based registry since 1989.

• medical data of 2,3 million cancer patients (>200 million data items)

• +100.000/year.

• Clinical practice guidelines

• Development, maintenance, implementation and evaluation.

• 60 guidelines oncological care (www.oncoline.nl).

Care quality cycle NCR

International Context

• Registration

- Registration at the source, but what is the source?

• Guidelines

- More effective development, implementation, evaluation.

• Patient involvement

- Shared decision making.

- PROMS.

• Information standardization.

In the consultation room Dr. Smith, surgeon

Mrs. Johnson has a consultation with Dr. Smith.

Mrs. Johnson has a breast tumor.

It has been a while since Dr. Smith has seen a case like this…

Gap between research and practice

Mrs. Johnson is interested in the best possible treatment. For herself.

She is entitled to it.

Dr. Smith wants to provide high quality of care to Mrs. Johnson. Even

more, it is his duty.

To keep up to date Dr. Smith has to read 27 scientific publications.

Every day….

….for breast cancer only…

27/day

10/day

Multidisciplinary oncological care

Tumor Board

Field research decision making in practice

Reinterpretation of data during tumor boards

Field research: reinterpretation, new insights.

Scientific research*: different interpretation radiology 40%,

pathology 20% different treatment 10%.

* Newman, E.A., et al.,. Cancer, 2006., Lim, H.K. et al., ANZ J Surg, 2014. Whelles SA et al, Otolaryngol Head Neck Surg. 2010, Wiggans MG et al,

HPB Surg. 2013, van Hagen P et al, Int J Clin Oncol 2013, Santoso JT et al, Int J Gyn Cancer 2004,

Tumor board report as source

Higher level aggregated source document with new insights as basis for:

• Delivered care to patient.

• Transparency towards patients.

• Starting point (shared) decision support.

• Accurate registration.

Post Pre

Tumor

board

NCR

Guide-

line

Closed loop New knowledge generation

Decision Support Tumor board, shared decision making

Registration at the source PROMS, Tumor board report

Ambition healthcare informatics innovation program

Patient

Information

standard

From guideline via tumor board to registry

Send to NCR

Guideline recommendation: Surgery

Tumor

board (EHR)

NCR (database)

Guide-

line (IKNL

knowledge

server)

Tumor

board (EHR)

NCR (database)

Guide-

line (IKNL

knowledge

server)

OncolinQ and Oncoguide

Information

standard

Richtlijn werkgroep

mammacarcinoom

Oncoguide OncolinQ OncolinQ

Linking Information

Sources for Quality

Oncoguide

Decision trees and

knowledge server

Oncoguide

Oncoguide

• From guideline to decision trees and information standard

- Decomposition of care pathway.

• Successfully applied to national Clinical Practice Guidelines:

- Breast cancer: 229 pages (>100.000 words) 115 data items, 73 decision trees.

- Colorectal, prostate cancer: concept.

http://www.google.nl/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&ved=0CAcQjRw&url=http://skierbob.ca/2012/02/great-news/&ei=W_0PVbvXD8HuPNCMgYgF&bvm=bv.88528373,d.ZWU&psig=AFQjCNFOLVbo6AqyV6Kft47NSMrdS_cSEA&ust=1427197645726317

Sneak preview

Primary treatment

Vervolgbeleid na neo-adjuvant

Grade

Eerste keuze

OF

Tweede keuze

4 x q3wk AC

cT-diameter

≤G1

>G1

Vascular invasion

<2cm

cTNM

≥2cm

Tamoxifen

≤L2

OF

Hormonale therapy

RT with Boost

L3

OF

4 x q3wk AC à 12 x q1wk paclitaxel

RT with Boost

>L3

FAC

Hormonale therapy

<cII

Chemotherapy

Vervolgbeleid na neo-adjuvant

Vervolgbeleid na neo-adjuvant

Neo-adjuvante therapy

Diagnostiek bij neo-adjuvant

FEC

≥cIII

Mrs. Johnson, 67 jaar | breast cancer

Primary treatment: Neo-adjuvant therapy by chemotherapy

___

Clinical staging Pathological staging

2,3 cm

cT-diameter

cIII

cTNM

G3

Grade

≤G1

Vascular invasion

Primary treatment

Vervolgbeleid na neo-adjuvant

Grade

Eerste keuze

OF

Tweede keuze

4 x q3wk AC

cT-diameter

≤G1

>G1

Vascular invasion

<2cm

cTNM

≥2cm

Tamoxifen

≤L2

OF

Hormonale therapy

RT with Boost

L3

OF

4 x q3wk AC à 12 x q1wk paclitaxel

RT with Boost

>L3

FAC

Hormonale therapy

<cII

Chemotherapy

Vervolgbeleid na neo-adjuvant

Vervolgbeleid na neo-adjuvant

Neo-adjuvante therapy

Diagnostiek bij neo-adjuvant

FEC

≥cIII

Mrs. Johnson, 67 jaar | breast cancer

Primary treatment: Neo-adjuvant therapy by chemotherapy

___

Clinical staging Pathological staging

2,3 cm

cT-diameter

cIII

cTNM

G3

Grade

≤G1

Vascular invasion

Primary treatment

Vervolgbeleid na neo-adjuvant

Grade

Eerste keuze

OF

Tweede keuze

4 x q3wk AC

cT-diameter

≤G1

>G1

Vascular invasion

<2cm

cTNM

≥2cm

Tamoxifen

≤L2

OF

Hormonale therapy

RT with Boost

L3

OF

4 x q3wk AC à 12 x q1wk paclitaxel

RT with Boost

>L3

FAC

Hormonale therapy

<cII

Chemotherapy

Vervolgbeleid na neo-adjuvant

Vervolgbeleid na neo-adjuvant

Neo-adjuvante therapy

Diagnostiek bij neo-adjuvant

FEC

≥cIII

Mrs. Johnson, 67 jaar | breast cancer

Primary treatment: recommendation not yet possible, enter Vascular invasion

___

Clinical staging Pathological staging

<2 cm

cT-diameter

cIII

cTNM

G3

Grade

Vascular invasion

Primary treatment

Vervolgbeleid na neo-adjuvant

Grade

Eerste keuze

OF

Tweede keuze

4 x q3wk AC

cT-diameter

≤G1

>G1

Vascular invasion

<2cm

cTNM

≥2cm

Tamoxifen

≤L2

OF

Hormonale therapy

RT with Boost

L3

OF

4 x q3wk AC à 12 x q1wk paclitaxel

RT with Boost

>L3

FAC

Hormonale therapy

<cII

Chemotherapy

Vervolgbeleid na neo-adjuvant

Vervolgbeleid na neo-adjuvant

Neo-adjuvante therapy

Diagnostiek bij neo-adjuvant

FEC

≥cIII

Mrs. Johnson, 67 jaar | breast cancer

Primary treatment: Neo-adjuvant therapy by 4 x q3wk AC à 12 x q1wk paclitaxel OR RT with Boost

___

Clinical staging Pathological staging

<2 cm

cT-diameter

cIII

cTNM

G3

Grade

>L3

Vascular invasion

Phased approach

• App and website.

• EHR systems.

• Quality and regulatory.

- Class 1 medical device.

- MDD, CE-certification.

- Maintenance and post market surveillance.

- NEN 75xx

• Clinical evaluation.

OncolinQ

OncolinQ – Information standard breast cancer

81

data-

items

134

data-

items

115

data-

items

NCR Dataset

Information analysis

200 tumor board

reports

Guideline analysis

OncolinQ – Information standard breast cancer

81

data-

items

134

data-

items

115

data-

items

~50% NCR items in

tumor board reports

44 33

~30% guideline items

already monitored in NCR

60

Only ~60% guideline

required items currently in

tumor board reports

OncolinQ – phased approach towards information standard

NCR

Tumor

board

Guide

line

Patho-

logy

Radio-

logy

Lab

Information

Standard

1

2

2 3

4

Better guidelines faster

Transparent decision making

More efficient registration

Transparent and better care

NCR

Tumor

board

Guide-

line

Patient

www.iknl.nl

www.linkedin.com/company/iknl

twitter.com/iknl

Roadmap

Informatie-

standard/

Decision trees

IKNL

Knowledge server

Research/

Clinical

evaluation

Pilots

App/Web

2014 2015

Mamma

Colorectaal

Prostaat

Long

Hematologie

Gyn

Nomogram/

Trial alert

2016

Melanoom

SUS evaluation

POC Source

registration

Methodology

from guidelines to flowcharts /

information standard

Impact QoC Prospectief

Impact QoC Retrospectief

Shared decision making

PhD

MDO / EPD

interface

Oncoguide

POC Decision

support