PROJECT LEAD(S): Jaqueline Simpsons RN MSN

                                  Mackenzie Clark PharmD co-lead

                                  Sherry Chen Rph  co-lead

EXECUTIVE SPONSOR(S): Dr.Karen Chee MD Medical Director of Hematology San Mateo

ABSTRACT 

Chemotherapy education is fundamental for increased patient engagement in shared decision making, higher levels of satisfaction, improved medication adherence, and better clinical outcomes. Although interpersonal teach via telephone or zoom is the most common modality in delivery of this information to patients in the oncology setting, patients are often not able to process large amount of new medical information in a short amount of time making education less effective. Additionally, labor cost remains a significant portion of hospital expenditures and traditional face-to-face chemotherapy education has been a big part of nursing and pharmacy workload. At UCSF, over 7000 chemotherapy plans (both IV and oral) are initiated each year. Nevertheless, there is no standardization in education content leading to variability. On average, chemo education takes about 30-60 minutes. That’s equivalent to 3500-7000 hours of non-billable service performed by nurses and pharmacists. Currently, oncology digital education resources are lacking at UCSF. We propose to develop and implement therapy specific digital education videos as primary method of teaching to fill the unmet gap in this growing telehealth era. By utilizing Mytonomy, which is an existing video-based patient engagement platform that USCF already has partnership with, this project will streamline patient education, increase patient accessibility, reduce costs and provide opportunities to reallocate resources to billable services.

TEAM 

Edna Miao PharmD, Carlo Legasto PharmD, Craig Thompson RN, Jaime Fornesca RN, Anna Re RN, Michelle Louie RN, Norma Jones, RN, Maritza Zavaleta RN

(Special thanks to Jennifer Wild MS, RN , OCN, Kara Merski RN, OCN, NPD-BC and Alan Huang PharmD for mentoring this project! )

PROBLEM 

• Chemotherapy education empowers patients and improve health status during and after cancer treatment
• Currently, patient education in the UCSF oncology clinics is performed by nurses and pharmacists at an in-person, telephone or video visit and is considered as non-billable service. Altogether, UCSF initiate over 7000 chemotherapy plans per year. With each chemo teach averaging about 45 minutes, this would result in more than 5250 of non-billable hours
• Lack of standardization in both content and delivery of information across different clinics and sites means there is no consistency in the quality of education
• Ineffective patient education may lead to increased stress, suboptimal retention, decreased treatment compliance and poorer clinical outcome
• A number of studies have demonstrated that digital educational videos can be successfully incorporated into the oncology setting to improve patient knowledge recall, reduce anxiety and standardize practice[1,2,5,6,7]
• Oncology digital education resources are lacking at UCSF
• The future continues to trend toward a digital world. Addressing the gaps and barriers of digital and telehealth equity now will foster better health outcomes in our communities

TARGET 

The goal is to develop and implement a standardized chemotherapy educational program that utilizes regimen specific digital videos as the primary form of teaching.

 Targeted ROI :

• Significant return of productive nursing and pharmacist time that can be reallocated to billable services such as infusion
• An estimate of 5250 hours saved per year assuming average chemo teaching is 45 minutes ( previous survey indicate most new start education sessions are 30-60 minutes)

The main advantages of digital education tools for patients are accessibility and consistency. Patients can watch videos anywhere, anytime. Patients can adjust the speed and repeat viewing as often as they like to gain better understanding. Videos can be shared with family members or friends who are unable to attend teach sessions. Moreover, the need for note-taking during teach is eliminated since these resources are available 24/7. The language and information given will always be consistent. In one study, a group of breast cancer patients who received videotaped education prior to consultation visits reported higher satisfaction, lower stress levels, higher quality of life and increased preparedness8. Another study identified that patients who received chemotherapy education through traditional method plus addition of a video had a higher retention of information and higher likelihood to report side effects when compared to standard in-person teaching group13.

From the hospital’s perspective, the benefits of utilizing digital resources include increased circulation and distribution (potential to scale beyond UCSF), reduction of expenses(i.e decreased OT hours or reallocation of pharmacist and nurse FTEs to other tasks), reduce variability in practice and low ongoing maintenance cost(i.e UCSF already has partnership with Mytonomy which will be explained further below).

Wiscosin’s largest cancer program, Aurora Cancer Care started implementing video teaching in 2018 and reported that digital video teaching saved an average of 30 minutes per patient which results in a week of saved nursing time for every 80 new chemotherapy starts⁹.

GAPS 

• No regimen specific chemotherapy educational videos available currently at UCSF, all teaching done by nursing or pharmacy staff via in person, zoom or telephone encounter
• Lack of consistency in content and quality of teaching across multiple ambulatory clinic and infusion sites
• Teaching sessions often go over scheduled time which can lead to incomplete tasks and burnouts in nursing and pharmacy
• Patients not able to process large amount of new information in a short period of time making education session ineffective
• With traditional teaching, patients often have to commit to a time during business hour and place for chemo teaching and therefore, potential miss works and extra financial toxicity

INTERVENTION 

Due to the large scale of this project, development of teaching videos can be done in multiple phases in order for real-time evaluation and improvement. Phase 1 will be the pilot phase and will focus on non-complex regimens such as immunotherapy, monoclonal antibodies and targeted therapy in the adult oncology outpatient setting. These regimens are well standardized across many disease sites making them ideal for exploratory purposes and data collection. The second phase will be a soft launch phase where one disease site will be selected to be site champion. The importance of having a site champion is that it would help drive necessary practice change and facilitate smooth launching of this program. During the final phase, the goal would be to expand to other disease sites and roll out 5-10 regimens at a time to allow adequate time for review and revisions and ensure quality control. A team of multi-disciplinary in-house champions with oncology background including nurses, pharmacists, oncologists, certified medical translators, and social workers will be invited to form an oncology digital health literacy committee and responsible for content development to ensure accuracy and validity. Videos will also be submitted to the UCSF education committee for final approval. 

Example of Phase 1 pilot regimens

• Pembrolizumab
• Avelumab
• Ipilimumab/Nivolumab
• Nivolumab
• Bevacizumab
• Encorafenib/cetuximab
• Encorafenib/panitutumab
• Durvalumab
• Atezolizumab
• Enfortumab
• Rituximab
• Daratumumab

Step 1 : Literature search

The first step is to conduct broad literature search on content development. Each standardized video will include a section on chemotherapy regimen specifics, take-home medications, side effects and management, frequently asked questions, and when to call clinic.

Step 2 : Video production

Previous studies have shown that animated videos under 16 minutes with voice over seem to be the most ideal for knowledge recall and retention³. This step can potentially be simplified by utilizing existing resource such as Mytonomy, which is a video-based patient engagement platform which allows patients to stream 3000+ digital videos on different topics of disease from cardiovascular to infectious disease. UCSF already has a partnership with Mytonomy and the main advantage of using this platform is that it offers the flexibility to develop content and microlearning videos tailored and customized to each organization’s needs. The award-winning platform leverages epic MyChart Bedside and Cerner and provides Netflix-like experience for patients that allows them to conveniently learn and prepare at home on any Smart TV and tablets.  

Step 3: Implementation and Feedback

The third step is implementation and feedback gathering which includes patient survey pre and post intervention. It is also necessary to use metrics to demonstrate the value of the program on patient experience and clinical outcome. Data collection will include viewing percentage per month and average view duration, stress level, satisfaction rate, adverse event reporting and hospitalization rate.

The main challenge in implementing digital literacy is health inequity among the non-digitally literate population. There is the assumption that digital tools may be a potential barrier for older patients. In reality, tech users in the age group of 65 and up have grown in the past decade. In a study of uro-oncological patients, older adults were reported to be more willing to engage with digital technologies as part of clinical trials than younger adults. Currently at UCSF, mychart usage is greater than 84% in the 65 and older group( see table below), demonstrating the elderly population is not as digital illiterate as we believe.

For those who lack internet access, videos can easily be transcribed into text/print material through converter application or the audio version of the videos can be played via phone. Another way to overcome health disparities is by offering digital videos with subtitles in different languages to address language barrier. Medical assistants can also identify patients with low digital health literacy at visits by asking simple questions, such as the following:

• Do you have internet access and reliable connectivity?
• Do you have a device that meets appropriate telehealth system requirements?
• Do you use emails?
• Can you download a mobile app?
• Do you want to receive your education via a video or traditional teach?

Once identified, an in person or telephone education session can be offered using the same print materials transcribed from videos to ensure consistency and quality of teach. Digital health literacy workshops can also be offered to increase patients digital skills. Offering in person digital health navigators might be another educational strategy. 

 Mytonomy is also committed to promote health equity and decrease health disparities.  Their contents are designed to deliver the highest possible patient engagement rates including reaching the most vulnerable and underrepresented populations. Some key features include a diverse range of clinicians and patients portrayed throughout a topic , utilization of plain language and multi-language subtitling,  adoption of visual models and diagrams, different playlists for different cultures and Spanish clinical library. In an IRB study with Duke health and Columbia University, it was found that Black patients watched Mytonomy’s videos at double the rate of their non-hispanic white patient counterparts. Hispanic patients also performed higher than non-hispanic white participants.

 Another potential barrier to implementation is compliance enforcement. Given the responsibilities to watch these videos are now shifted to patients, there needs to be proactive workarounds in place as safety measures. One strategy may be to have medical assistants check in with patient on first day of infusion at check-in and offer patients a tablet device (i.e clinic phone, clinic desktop/laptop) to watch these education videos in waiting area. Another solution would be to implement follow up phone calls or Mychart messages 48 hours prior to scheduled infusion appointment to assess comprehension of videos and answer questions.

PROPOSED EHR MODIFICATIONS

 None

RETURN ON INVESTMENT (ROI) 

Clinical Nurse and pharmacist salary range from $84.78 to $109.85 hourly. With the projected 5250 hours saved, the projected direct cost savings is estimated to be $445,095 - $576,712.50 annually. This does not take into account indirect cost savings such as reduction in preparation time for chemo teach, cutback in printing materials, time to schedule chemo teach appointments , and additional revenue generated if saved time is converted to billable services (Explained below).

Additional Revenue per year (Ideal Scenario)

In the most ideal scenario, assuming ALL of the saved nursing hours are converted to chemotherapy infusion services across all  sites, the current average net income from infusion operations at UCSF Cancer Center San Mateo for example, is approximately $450,000 per week. The average nursing hours needed to staff 1 day of infusion with 12 infusion chairs is about 57 hours. 5 day infusion week is equivalent to 285 hours.

Out of the 5250 hours saved from this proposal, 3265 hours are nursing hours and remaining is pharmacy hours. This translates into 3265/ 285 hours =  11.5 weeks of potential nursing hours to staff infusion. Assuming chair availabilities and patient volume are not limiting factors, the estimated maximum revenue generation in a year from all sites would be:

11.5 weeks of infusion x $450,000 income generated per week = $5,175,000.00

Since there will be cases where traditional face-to-face teach is necessary and beneficial , assuming 50% conversion, the potential revenue in a year would be :

0.5 x 11.5 weeks x $450,000 per week = $2,587,500.00

Chair availability is unlikely to be a limiting factor as our current chair utilization capacity is not yet maximized. In the last 6 months, San Mateo averages at about 67.8% chair capacity and mission bay averages only at 24%, meaning there is plenty of room for growth.

Whilereallocating staff to infusion services is possible at San Mateo , we recognize that other sites such as mission bay maybe using a different practice model. At San Mateo, our practice nurses doing the chemo teaches are also crossed trained in infusion. Practice nurses at mission bay do not staff infusion currently and 99% of what they do is non billable work. For these sites, the financial benefit is tied to nursing time saved to do other clinical work like symptom management or reduced need for more FTE as our organization grow. For example,  the Parnassus heme onc group recently hired 3 additional nurses to help with chemo teaches which approximate to $508,680-$659,100 in payroll expenses.

SUSTAINABILITY 

Since UCSF is already subscribed to services from Mytonomy, this program is anticipated to sustain beyond the funding year. Key process owners will be the same stakeholders in the oncology digital health literacy and education committee. These stakeholders will be responsible for reviewing contents and language of the videos for clinical accuracy and ensuring they meet UCSF standards.

BUDGET 

We are asking for $50,000 in funding to support the infrastructure for program development, data analysis and evaluation.

REFERENCE

1. Bouton ME, Shirah GR, Nodora J, et al.: Implementation of educational video improves patient understanding of basic breast cancer concepts in an undereducated county hospital population: Video Breast Cancer Concepts. J Surg Oncol 105:48-54, 2012
2. Dawdy K, Bonin K, Russell S, et al.: Developing and evaluating multimedia patient education tools to better            prepare prostate-cancer patients for radiotherapy treatment (randomized study). J Cancer Educ 33:551-556, 2018
3. Feeley TH, Keller M, Kayler L. Using Animated Videos to Increase Patient Knowledge: A Meta-Analytic Review. Health Education & Behavior. 2023;50(2):240-249
4. Frentsos J: Use of videos as supplemental education tools across the cancer trajectory. Clin J Oncol Nurs 19:E126-E130, 2015
5. Kinnane N, Stuart E, Thompson L, et al.: Evaluation of the addition of video-based education for patients receiving standard pre-chemotherapy education. Eur J Cancer Care (Engl) 17:328-339, 2008
6. Matsuyama RK, Lyckholm LJ, Molisani A, et al.: The value of an educational video before consultation with a radiation oncologist. J Cancer Educ 28:306-313, 2013
7. Sulakvelidze N, Burdick B, Kaklamani V, et al.: Evaluating the effect of a video education curriculum for first time breast cancer patients: A prospective RCT feasibility study. J Cancer Educ 34:1234-1240, 2019
8. Walker MS, Podbilewicz-Schuller Y. Video preparation for breast cancer treatment planning: results of a randomized clinical trial. Psychooncology. 2005 May;14(5):408–420. doi: 10.1002/pon.858
9. Weese, J. et al.: Drug specific videos for patient chemotherapy education. Acc-cancer. May-June 2018. https://www.accc-cancer.org/docs/documents/oncology-issues/articles/2018...