Benjamin Tooke: Thank you. I appreciate it.
Daniel Joyce: Tell us where did the idea of this study come from and why did you choose to pursue this in non-muscle-invasive bladder cancer?
Benjamin Tooke: So I think, as most urologists know, the surveillance and treatment for non-muscle-invasive bladder cancer is pretty complicated for both providers and patients. And there are no resources available right now to be able to standardize that across risk stratification or across providers. And it's pretty much up to you, and the burden remains solely on you to track each patient through their surveillance. So as a resident in clinic with multiple attendings who have different workflows, I really thought that there was a way with this wonderful health record we have to be able to automate some of these processes for both standardization for adherence to guidelines and just ease of workflow.
Daniel Joyce: So walk us through that. How does that work? How did you harness the EMR bioinformatics to make that happen? And what does it look like in real time?
Benjamin Tooke: Yeah. So first we had to figure out where in the electronic health record we wanted to put this, and we considered a number of different areas, but one area that Epic itself is actually trying to expand is the health maintenance module. And that's where you see a lot of the vaccine schedules and cancer screening. So this is one of the first applications of health maintenance for actual cancer treatment and surveillance post-diagnosis. And it's a really helpful tool because you can create pretty complex schedules that you need for things like low-intermediate and high-risk bladder cancer pathways that are longitudinally active and visible to both the provider and the patient.
Daniel Joyce: Walk me through, in Epic, where this health maintenance schedule, where can I see it? Is it something I see or is it something that pings or alerts patients of the appointments? How does that work?
Benjamin Tooke: So you're alerted when you put in the first diagnosis of bladder cancer for the patient, that they're appropriate for a bladder cancer pathway. You, as the clinician, then decide if you want to enroll them on the low, intermediate, or high-risk pathway. And if they have muscle-invasive disease, then you cancel the alert. Once they've been enrolled onto a pathway via the health maintenance topic that you see below the care gaps on the patient dashboard, you can open their entire treatment and surveillance schedule and see what that's going to look like over the course of the next 10 years.
Daniel Joyce: Wow. Very cool. So talk to me about how did you study this in your work that you're presenting and what did you find?
Benjamin Tooke: We started it with six pilot providers at UCLA, and that was a mix of urologic oncology trained physicians as well as general urologists. And it's an iterative process, as many informatics and quality improvement projects are, with real-time feedback from both the providers and the build expertise folks. And we wanted to focus on getting patients onto the risk stratification arms and see how they were moving through those within the first few months. So we're about nine months in with those six pilot providers, and at six months we had enrolled 263 bladder cancer patients, about 60% of which were high-risk patients with that most complex schedule.
Daniel Joyce: Wow. And so do you plan to look at how compliance and scheduling is different now that you've implemented this versus how it was before?
Benjamin Tooke: 100%. And it's tricky because we talked about the inter-provider variability with how physicians document their cystoscopies, how they document CPT codes, diagnoses, and things like that. So there is going to be a growing period of meeting in the middle between the providers and the people with the build expertise to figure out what's the best way to do so. But the eventual goal is to be able to compare post-implementation data, adherence to guidelines, missed appointments, patient attrition, to the pre-implementation data that we have.
Daniel Joyce: Do you get a sense right now how physicians are responding to this? Do they like it? Do they not? Is it burdensome?
Benjamin Tooke: Yeah. Anytime you add clicks to a physician's workflow, you're definitely going to have some pushback. But when you think about one click that then generates an entire bladder cancer schedule for you versus the burden of having to copy forward your note, have a dot phrase for each risk stratification arm, mentally doing the math of what's three months from now since they're two years from their diagnosis, that it takes quite a bit of that burden off. But there are varying opinions on it, and that's why again, it's an iterative process, and we've since made some changes to it based off the feedback that we've gotten to try to streamline it.
Daniel Joyce: Yeah. I mean, I can imagine there'd be some tweaks along the way, but man, my clinic is always invariably running two hours behind. I'm going to see that cysto patient. Now I've got to calculate, okay, cysto's clean, when's the next maintenance BCG? When's my cysto going to be? That is a lot of cognitive burden in the clinic that probably slows my clinic down, honestly, just having to specify, make sure the nurse knows, here's when we're ordering the next set. And then I can't even count the number of times that I have a patient come in misscheduled, that their cystoscopy is two months early and they're not scheduled, they don't really need to be there and then they have this meaningless visit that screws up the whole schedule. So I do think there's going to be huge value to this. Were there obstacles that you encountered in implementing this? What was the biggest challenge?
Benjamin Tooke: The biggest challenge was figuring out where to put it within the health record. There are many different ways that Epic can be utilized for treatment plans like this, health maintenance, care paths, treatment summaries. As a urology resident, I was pretty unfamiliar with a lot of the intricacies of that, which is where having the acumen in informatics and participating in the resident informaticist program at UCLA was extremely helpful. But once we pinned down health maintenance, the actual building of the tool with the full team that we had was relatively straightforward with the resources that we got from both Epic and UCLA.
Daniel Joyce: So how easy is this to scale then? Could I do this at my institution? What would it take?
Benjamin Tooke: It would take a team of people who are wanting to push this through. This was a project that I started in the middle of my third year, and it went live at the end of my third year, and we've been following it throughout my research time. I was just at XGM, which is one of Epic's national conferences, and there is interest from their health maintenance team to expand, once again, health maintenance to post-diagnosis treatment and surveillance. And it's certainly possible that with the right work from Epic on their end, that this could be something that is eventually built into foundation and would be available to all institutions.
Daniel Joyce: Yeah. So what I'm hearing you say is that Epic is working on this currently, but maybe not with as much engagement from the GU oncology world as some of the other specialties or primary care. So hugely important that we're at that table as these things get built into the record that we use.
Benjamin Tooke: 100%. We need to be at the table throughout this whole process, especially since the informatics world is pretty dominated by a lot of primary care physicians. And when they're in charge of creating the medical record or making changes, sometimes it can leave oncology surgery by the wayside, and we have a health record that's more optimized towards ambulatory resources than cancer or surgery. So this is definitely something that is scalable for not just bladder cancer even. And frankly, it would be probably easier for other types of malignancies that have more straightforward surveillance than your non-muscle-invasive bladder cancer.
Daniel Joyce: So what is the next step here? Where do you plan to go next with this work?
Benjamin Tooke: So next step, we'll be continuing our work with Epic to escalate some of the work and some of the build to their urology steering committee, which there are many urologists from all over the country who give their input on these types of tools. And with the help of their building and the addition of some other clinical decision support tools within it, I think that we can make a pretty convincing and standardized health maintenance tool that may eventually be in foundation for Epic and available to everyone. That's going to take some time. And in the meantime, once again, it's something that is available and that I know we at UCLA are happy to share the build to show that you can do this for, again, any type of malignancy, urologic or non, to be able to demonstrate the utility of it.
Daniel Joyce: I'm just thinking too, there are some spaces where we have very clear guidelines on what those follow-up schedules should be. And I think in general, we, as practitioners, agree on that, but then there's others that are widely variable like localized kidney cancer, for instance, that's the AUA guidelines are not the same as NCCN active surveillance for prostate cancer. There's no decided upon way to do that and how to schedule that. It seems to me that you could use these kind of frameworks, one, to get more consistent care across institutions, but two, to study how variants in these kind of plans impact care. Would you agree with that or am I misinterpreting what's offered here?
Benjamin Tooke: No, 100% because with the data that you have on utilization of the module, you can see which physicians are using it and you can follow those outcomes and compare those outcomes eventually. And the other nice thing about this tool is if a patient misses an appointment or something like that, it still shows in health maintenance that that was never done. So at the completion of a patient's bladder cancer journey, you can look back, and if they missed a substantial number of cystos, and you have a number of patients who have missed that, is that a sign that we need to look at these surveillance schedules again once-over and see if they're either too aggressive or not aggressive enough? We have this new repository of this scheduling.
Daniel Joyce: So what happens if a patient, for instance, wants their cystoscopy done at 9:00 AM and not 2:00 PM, or they're going on a cruise during that week that the system says they should get their cystoscopy. How does that interaction with the patient look, and how does that look on the back end of were they compliant or not with this treatment plan?
Benjamin Tooke: So a lot of that now is still manual. The automation of satisfying the health maintenance topics to demonstrate that a patient got their cysto, they got their CT urogram, they got their intravesical therapy, that is a big next step for us. And some of that does require some standardization of practices across urologists. So standardized procedural notes would be very helpful because you could easily link those to the cystoscopy health maintenance report, and that would satisfy it without the physician having to make any clicks whatsoever. Similarly, CT urogram, the completion of that, again, satisfies that. So as of now, that patient who waits a week to go on a cruise and comes back, it is manual by the physician to input when they got it, but they will be notified that they are either due soon or overdue for that cystoscopy.
Daniel Joyce: Got it. And really, really, really fascinating work. Important work, I think, for us to just provide better care for our patients and have better even expectations for our patients, less workload on us as clinicians eventually, although maybe we're not there yet, really exciting work. And I do think your point is well taken that bioinformatics, and with an extension of that, artificial intelligence is here whether we like it or not. And if we're not engaged and guiding that conversation with the EMR creators, it's going to be made for something that doesn't work for us. So I really admire and congratulate you on your work, and excited to see what's next.
Benjamin Tooke: Thank you. I appreciate it.