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![Problem
Sarcomas are a diverse and relatively rare group of malignant
tumors that develop in soft tissue and bone.
According to NIH in 2014 in the US,
1. 15,000 cases of sarcomas.
2. Approximately 6,200 people had died [1].
The 5-year relative survival rate for both bone and soft tissue
sarcoma was approximately 65 percent [1].](https://image.slidesharecdn.com/958dfcd4-f6e1-4adf-82d0-c688a5ade1f4-170124220039/85/PTOS-3-320.jpg)
![ The duration of the entire treatment process takes 1-3 months and
often involves a combination of surgery, chemotherapy and/or
radiotherapy.
Studies have shown:
1. Relation between survival and outcomes to having an increased
diagnosis-treatment interval [2, 3].
2. Patients often become disillusioned and frequently depressed
during the process [4].
3. Other comorbidities such has hypertension, diabetes, poor
physical function, etc. have an effect on the post-surgical
outcome and patient health.](https://image.slidesharecdn.com/958dfcd4-f6e1-4adf-82d0-c688a5ade1f4-170124220039/85/PTOS-5-320.jpg)
![What is the Shah screening tool?
It is a 10 question survey
Developed at UTHealth Innovation Hospital.
Evidence based [5-7].
Relying on questions that are routinely asked during h&p but may
not be usually recorded in patient notes.
Created in RedCap and will be available in the EHR as a button.
Total of 30 possible points.](https://image.slidesharecdn.com/958dfcd4-f6e1-4adf-82d0-c688a5ade1f4-170124220039/85/PTOS-10-320.jpg)
![Questionnaire [8]
Disagree Agree
1. People who work here are committed to implementing this change. 1 2 3 4 5
2. People who work here will do whatever it takes to implement this
change.
1 2 3 4 5
3. People who work here want to implement this change. 1 2 3 4 5
4. People who work here are determined to implement this change. 1 2 3 4 5
6. People who work here feel confident that they can handle the
challenges that might arise in implementing this change.
1 2 3 4 5
7. People who work here feel confident that they can keep track of
progress in implementing this change.
1 2 3 4 5
8. People who work here feel confident that they can coordinate tasks so
that implementation goes smoothly.
1 2 3 4 5
9. People who work here feel confident that the organization can support
people as they adjust to this change.
1 2 3 4 5
10. People who work here feel confident that they can manage the politics
of implementing this change.
1 2 3 4 5](https://image.slidesharecdn.com/958dfcd4-f6e1-4adf-82d0-c688a5ade1f4-170124220039/85/PTOS-22-320.jpg)
![[HOW TO] Create High Performance Emergency Departments](https://cdn.slidesharecdn.com/ss_thumbnails/edperformancewhitepaper-140110130313-phpapp01-thumbnail.jpg?width=640&height=640&fit=bounds)
PTOS
- 1. Physical Therapy at OrthopedicSarcoma (PTOS) DIGANT SHAH 12/8/2016
- 2. Vision The UTHealth Innovation Hospital will consistently transform healthcare utilizing cutting-edge technology to improve patient safety and quality each day."
- 3. Problem Sarcomas area diverse and relatively rare group of malignant tumors that develop in soft tissue and bone. According to NIH in 2014 in the US, 1. 15,000 cases of sarcomas. 2. Approximately 6,200 people had died [1]. The 5-year relative survival rate for both bone and soft tissue sarcoma was approximately 65 percent [1].
- 4.
- 5. The durationof the entire treatment process takes 1-3 months and often involves a combination of surgery, chemotherapy and/or radiotherapy. Studies have shown: 1. Relation between survival and outcomes to having an increased diagnosis-treatment interval [2, 3]. 2. Patients often become disillusioned and frequently depressed during the process [4]. 3. Other comorbidities such has hypertension, diabetes, poor physical function, etc. have an effect on the post-surgical outcome and patient health.
- 6. http://drugabuse.com/wp-content/uploads/xdrugabuse_shutterstock-243591463-sad-teen-couch-flakka-CTA.jpg.pagespeed.ic.Uv4YcEWuLF.jpg https://t4.ftcdn.net/jpg/00/87/22/77/240_F_87227731_OdTkoeZJZsl5m8fzkdTHIYiMu1OEpLQ4.jpg Preparing the patientfor the surgery both mentally and physically is the need of the hour.
- 7. PTOS team AlexanderPenny - Project Leader and Head physical therapist Dr. Justin Bird and Dr. Ann Ngo - Physicians Digant Shah – Clinical Informaticist and Change Agent James Wang - EHR IT representative
- 8. Project Governance Division ofSurgery Chair Department of Orthopedic Sarcoma Chair PTOS team Physicians Communication Head Physical Therapist Support EHR IT representative Software Technology Change Agent Process Deployment
- 9. Project Plan Goalof the project: 1. Improve outcomes. 2. Reduce length of stay. 3. Generate revenue for the department. Identify the factors that can have an impact on the patient’s outcome by using the “Shah screening tool” and determine the type of pre-surgical intervention required. The interventions are: 1. Physical therapy and counselling. 2. Prehabilitation.
- 10. What is theShah screening tool? It is a 10 question survey Developed at UTHealth Innovation Hospital. Evidence based [5-7]. Relying on questions that are routinely asked during h&p but may not be usually recorded in patient notes. Created in RedCap and will be available in the EHR as a button. Total of 30 possible points.
- 12. Distribution of points 10 points: No intervention. 11-24 points: Physical therapy and counselling. 24-30points: Prehabilitation.
- 13. Advantages of usinga screening tool Identifying vulnerable population. Improving quality metrics for the institute. More data to draw information. Can serve as a database to carry out cross comparative research on having an intervention.
- 14. How will theprocess change? Sr. No. Current Process Future Process Gap analysis Individuals involved 1. No prehabilitation protocol present at the department. Assessment tool developed which will assist in judging if the patient requires prehabilitation. Develop 10 point questionnaire which can be completed in less than 5 minutes based on the information collected from the patient. Informaticist, senior physical therapist and orthopedic surgeon. 2. No questionnaire is used for presurgical physical therapy. The physician assistant/resident will complete a presurgical questionnaire for the attending physician. Training provided to the staff on the use of the questionnaire. Informaticist, physician assistant, resident and orthopedic surgeon. 3. Patient is in the waiting room where the physician assistant/resident takes the h/p. The physician assistant/resident along with taking the h/p completes the questionnaire based on the patient responses. Altering the workflow to incorporate the time required to fill the survey. Informaticist, physician assistant and resident. 4. Attending physician sees the patient in the clinic, takes h/p and performs required clinical tests. Attending physician sees the patient in the clinic, takes h/p and performs required clinical tests and based on the questionnaire score recommends intervention. Getting the attending physician to use the scoring tool. Informaticist and orthopedic surgeon. 5. Post-surgically the patient is seen by the orthopedic rehab team in the clinic. The orthopedic rehab team will see the patient pre-surgically and post- surgically. Modifying orthopedic rehab team workflow to incorporate the influx of patient for pre-surgical physical therapy Informaticist and orthopedic rehab team. 6. No billing for prehabilitation in orthopedics Patient or patient’s insurance billed for prehabilitation in orthopedics Need the billing team involved to clear the patient prior to providing prehabilitation Informaticist, physical therapist and institutional billing team.
- 15. How will itwork in the EHR? Source: http://twimgs.com/informationweek/galleries/automated/755/01_EpicResolutescreen_full.jpg http://cdn2.hubspot.net/hubfs/150313/make-medical-charting-easier.jpg http://orig13.deviantart.net/f5ed/f/2010/108/c/5/green_submit_button_by_rukiaxichigo15.jpg http://img.medscape.com/thumbnail_library/is_160224_doctor_computer_800x600.jpg
- 16. Types of Users Nurses Resident Assistants/Physician Assistants Physicians
- 17. Stakeholders Stakeholder group Rolein Charge Opinion leader Level of commitment needed to succeed Barriers to change Initial contact Attending Physician Team Directly Affected Dr. Justin Bird Internalization Always apprehensive about using a new tool. Skeptic about spending additional time. Resident Assistant Team Directly Affected Internalization Busy with patients. Additional work to answer the screening tool. February – 2nd week Physician Assistant Team Directly Affected Internalization Busy with patients. Additional work to answer the screening tool. February – 2nd week Nursing Team Directly affected Internalization Busy with patients. Additional work to answer the screening tool. February – 2nd week Physical Therapist Team Directly Affected Alexander Penny Internalization Needs assistance with patient scheduling. February – 2nd week EHR Informatics Team Indirectly Affected James Wong Busy due a different system Go-Live. Have drained existing resources. February – 1st week Insurance verification Team Indirectly Affected March – 1st week Patients Directly affected
- 18. Stakeholder individual PositionBarriers to change Initial contact Dr. Valerie Lewis Ortho Dept. Chair – Champion Extremely busy with patient, other on-going projects and meetings January – 2nd week Naruto Uzumaki Graduate Research Assistant January – 2nd week Dr. Tyler Who Surgery Division head – Champion, Opinion leader Extremely busy with patient, other on-going projects and meetings January – 4th week Steve Martin Rehab department chair Receives incentives based on the number of patients being treated in the department February – 2nd week Megan Taylor Patient Scheduler for PT Additional workload. March – 1st week
- 19. Communication Plan Who? What?When? Where? How? Target Audience Communicator Stage Message Timing Location Type Specific tools or approaches Dr. Ino Yamanaka Dr. Justin Bird Knowledge and persuasion Need for the change and “Go Ahead”. January – 2nd week Personal office Interpersonal Naruto Uzumaki Graduate Research Assistant Knowledge January – 2nd week January – 2nd week Personal cubicle Interpersonal Provision of Shah scoring tool and access to RedCap Dr. Tyler Who Dr. Valerie Lewis Knowledge Need for the change and “Go Ahead”. January – 4th week Personal office Interpersonal EHR Informatics Team James Wong and Digant Shah Knowledge and persuasion Proposed plan and expectations February – 1st week Conference room Interpersonal Attending physician team Dr. Justin Bird Knowledge Sense of urgency and proposed plan February – 2nd week Email Mass media Email – which includes the proposed plan and links to hospitals having prehab care. Physical therapist team Alexander Penny Knowledge Sense of urgency and proposed plan February – 2nd week Email Mass media Email with the proposed plan and links to hospitals having prehab care. Physician Assistant team, Resident assistant team, nursing team Digant Shah Knowledge Sense of urgency and proposed plan February – 2nd week Email Mass media Email with the proposed plan and links to hospitals having prehab care. Steve Martin Dr. Valerie Lewis Knowledge and persuasion Sense of urgency, proposed plan, expectations. February 2nd week Office Interpersonal Ortho department meeting Alexander Penny, Dr. Justin Bird and Digant Shah Persuasion Proposed plan, and communicating vision and strategy. February – 4th week. Conference room Interpersonal Visual aids and copy of the questionnaire.
- 20. Target Audience CommunicatorStage Message Timing Location Type Specific tools or approaches Megan taylor Alexander Penny Knowledge and persuasion Proposed plan and expectations March – 1st week Email Interpersonal Needs for the modified patient scheduling template. Insurance verification Team Alexander Penny Knowledge and persuasion Proposed plan and expectations March – 1st week Email Interpersonal as only 2 members are involved Ortho department Alexander Penny Persuasion Results of the pilot April – beginning of 3rd week Email Mass media Ortho department Persuasion Modifications required or not Monthly meeting – April 3rd week Conference room Interpersonal Ortho department PTOS team Decision “Go” or “No Go” May - 1st week Conference room Interpersonal Poll Ortho department and Dr. Tyler Who PTOS team Implementation Notification of implementation May – end of 1st week Email Mass media Ortho department and Dr. Tyler Who Dr. Valerie Lewis Implementation One month update June – 2nd week Email Mass media Ortho department and Dr. Tyler Who Dr. Valerie Lewis Confirmation 6 month update successful completion of project November Email Mass media
- 21. Readiness Assessment Beforethe Go-Live, users and department leaders will be asked to complete a survey to assess their readiness for the implementation. The criteria for this is 100% user training being completed.
- 22. Questionnaire [8] Disagree Agree 1. People who work here are committed to implementing this change. 1 2 3 4 5 2. People who work here will do whatever it takes to implement this change. 1 2 3 4 5 3. People who work here want to implement this change. 1 2 3 4 5 4. People who work here are determined to implement this change. 1 2 3 4 5 6. People who work here feel confident that they can handle the challenges that might arise in implementing this change. 1 2 3 4 5 7. People who work here feel confident that they can keep track of progress in implementing this change. 1 2 3 4 5 8. People who work here feel confident that they can coordinate tasks so that implementation goes smoothly. 1 2 3 4 5 9. People who work here feel confident that the organization can support people as they adjust to this change. 1 2 3 4 5 10. People who work here feel confident that they can manage the politics of implementing this change. 1 2 3 4 5
- 23. Time frame Jan 2017Feb 2017 Mar 2017 Apr 2017 May 2017 Nov 2017 Shah scoring tool created in RedCap Communication Integration of Redcap tool in EHR Pilot Modification of tool or system is required Departmental implementation Monitoring
- 24. Project Charter Timeframe– January, 2017 – November, 2017. Focus: 1. Pilot testing from March 2017 - April 2017 in Dr. Bird’s clinic. 2. Communication. Proposed budget - $50,000. Fund allocation: 1. Graduate Research Assistant (GRA). 2. Training. 3. Overtime.
- 25. Expected outcome Reducedlength of stay. Decreased recovery time. Improved patient satisfaction. Happy patients.
- 26. Challenges Non complianceby the user. Delay in getting the button the EHR. Training everyone before the Go-Live.
- 27. Factors needed forsuccess Support from leadership. Support from the user community. Timely delivery of the EHR button from the IT department. Feedback from the patient population on the effectiveness of this intervention.
- 28. References 1. https://www.cancer.gov/research/progress/snapshots/sarcoma. 2. McLaughlin,J. M., Anderson, R. T., Ferketich, A. K., Seiber, E. E., Balkrishnan, R., & Paskett, E. D. (2012). Effect on survival of longer intervals between confirmed diagnosis and treatment initiation among low-income women with breast cancer. Journal of Clinical Oncology, 30(36), 4493-4500. 3. Sandar, M., Hsiang, L. G., Yew, C. K., & Guat, L. B. (2014). Use of Population-Based Cancer Registry Data to Determine the Effect of Timely Treatment on the Survival of Colorectal Cancer Patients. Journal of registry management, 41(4), 130-138. 4. http://www.cancer.org/treatment/treatmentsandsideeffects/emotionalsideeffects/anxiety-fear- depression-and-cancer 5. Arshi, A., Sharim, J., Park, D. Y., Park, H. Y., Yazdanshenas, H., Bernthal, N. M., & Shamie, A. N. (2016). Prognostic Determinants and Treatment Outcomes Analysis of Osteosarcoma and Ewing Sarcoma of the Spine. The Spine Journal. 6. May, P., Garrido, M. M., Cassel, J. B., Kelley, A. S., Meier, D. E., Normand, C., ... & Morrison, R. S. (2016). Palliative care teams’ cost-saving effect is larger for cancer patients with higher numbers of comorbidities. Health Affairs, 35(1), 44-53. 7. Houdek, M. T., Beahrs, T. R., Wyles, C. C., Rose, P. S., Sim, F. H., & Turner, N. S. (2016). What Factors Are Predictive of Outcome in the Treatment of Soft Tissue Sarcomas of the Foot and Ankle?. Foot & Ankle Specialist, 1938640016666925. 8. Shea CM, Jacobs SR, Esserman DA, Bruce K, Weiner BJ. Organizational readiness for implementing change: a psychometric assessment of a new measure. Implement Sci. 2014 Jan 10;9(1):7. PMCID: PMC3904699.
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Editor's Notes
- #2 Good evening ladies and gentlemen. Thank you for providing me the opportunity to present my project at the Division of surgery review committee. My name is Digant Shah and the topic of my presentation is “Physical Therapy at Orthopedic Sarcoma” short for (PTOS).
- #4 Soft tissue sarcomas form in cartilage, fat, muscle, fibrous tissue, blood vessels, and other connective or supportive tissues of the body. What seems to be the problem? Sarcoma are a diverse group of tumors affecting the soft tissue and bone. According to NIH in 2014 there were around 15,000 cases and about 6,200 people died due it. The 5-year relative survival rate was 65%.
- #5 But is survival everything?
- #6 The duration from the time of diagnosis to treatment initiation is long and involves a combination of surgery, chemotherapy and radiotherapy. There have been studies that have shown a relation between survival and outcomes and the diagnosis to treatment interval. Other factors such as comorbidities, poor physical function, mental health can have an impact on recovery time. The health of the patient may not be the same on day if the surgery as compared to the day of diagnosis.
- #7 Preparing the patient for the surgery both mentally and physically is the need of the hour.
- #8 These are the members of the PTOS group. We have our head physical therapist serving as the project leader. Dr. Justin Bird and Dr. Ann Ngo the physicians. I am the Clinical Informaticist and change agent for the project and James Wong the EHR IT representative.
- #10 Our goal for the project is to improve outcomes, reduce the length of stay and potentially generate revenue. The last part will be due licensed healthcare professionals such as physical therapists and occupational therapists providing counselling and other treatments. Identify the factors that can have an impact on the patient’s outcome by using the “Shah scoring tool” and determine the type of pre-surgical intervention required. The interventions are physical therapy and counselling and prehabilitation.
- #11 What is the shah scoring tool? This is a 10 question survey developed at MD Anderson Cancer Center. The questions are evidence based and rely information routinely collected during history and present illness but may not usually be recorded in patient notes. Total of 30 possible points.
- #12 This is a paper copy of the tool. As you can see there are 10 questions each covering different topics such as falls, comorbidities, cognition, clinical appearance, etc. all that can impact the recovery time. Lets consider the 1st question. Has the patient had any falls in the past one month? There are 3 possible options. The answer will have 1 point, 1 fall 2 points and >=2 falls 3 points. In the same way the left most column will have 1 point, center column 2 points and the right column 3 points. A total of 30 points.
- #13 The points are distributed as follows: 10 points: No intervention. 11-24 points: Physical therapy and counselling. 24-30points: Prehabilitation.
- #14 These some of the advantages of having a screening tool. Identifying vulnerable populations, improving quality metrics. We can measure the impact the of an intervention on recovery.
- #16 So how will it work in the EHR? The user logs in the patient medical record. There is button on top labelled at “PTOS”. When clicked the user will be directed to a new window with the screening tool is preloaded. The user will answer the questions based on the patient response. Once the submit button is clicked, the user will be prompted possible intervention based on the total score. Here they have the option of accepting the result or modify it based on their experience. The entire process takes about 3 minutes based on the results of a study group.
- #24 This is the estimated timeframe for the project which will include a 1 month pilot and a 6 month post implementation monitoring phase. There are 4 planned milestones. 1st one at the integration of the tool in the EHR, the second one at the end of the pilot. The 3rd after the implementation and the last the end of the 6 month monitoring phase.
- #25 The timeframe for the project is from January 2017-November2017. Our focus will be on the pilot in Dr. Bird’s clinic and communication. We are asking for $50,000 for the project. The funds will be allocated to hire a Graduate Research Assistant who will aid in created the tool in RedCap, training and other. Training and to cover any overtime costs incurred.
- #28 For the project to succeed we need support from the leadership and the user community. We need the EHR IT to stay within the timeframe and we need inputs from the patients on the impact of this intervention. I know you’ll must be thinking that why will the patient spend more money on something new. But i know that given the chance we all are ready to go the extra mile if it means helping and saving our loved ones.
- #29 Here are some of the references I have used for the presentation.
- #30 Our main aim in starting the project was to take the patient from here
- #31 To here. Thank you.