Clear Ownership and EHR Triggers Can Close Gaps in Oncofertility Referrals

Drawing on her background in business administration, Melody Rasouli, MD, MBA, FACOG, a reproductive endocrinology and infertility specialist at HRC Fertility in Newport Beach, CA, spoke with CancerNetwork® about the operational breakdowns that most often delay or prevent timely fertility referrals in oncology clinics. According to Rasouli, the most common problem is unclear ownership, as fertility counseling sits between oncology and reproductive medicine.

She noted that American Society of Clinical Oncology (ASCO) guidelines frame counseling as the responsibility of health care providers broadly rather than oncologists alone, making it a team effort, and suggested that a dedicated navigator can build the step into the workflow. Rasouli also described how electronic health record (EHR) triggers, similar to those used for sepsis protocols and medication allergy alerts, can automatically prompt a referral to reproductive endocrinology and infertility (REI) when a new cancer diagnosis is entered, and why documenting the offer before the first chemotherapy order matters.

Transcript:

Rasouli: From an operations perspective, the most common breakdown is probably unclear ownership. Fertility counseling sits somewhere between oncology and reproductive medicine, so it’s hard to know whether one team has covered it before the other. What’s interesting is that ASCO’s updated guidelines broadened the responsibility, changing it from the oncologist to the health care provider, which rightly makes it a team effort.²

It’s a shared task, so it’s good to have multiple people thinking about this component. We’re not relying on just one person who also has so many other components of that patient’s medical journey to keep track of and be responsible for. Having a navigator within the care team who can take ownership and build this step into the workflow would improve it on an operational level.

We’ve used EHR triggers for other indications that have worked well, such as sepsis protocols or reminders about allergies and cross-reactivity of medications. Going back to the operational standpoint, you take the human component out of it a bit and let the technology work for you, which is always great. If the EHR sees that a new cancer diagnosis was added as a problem, that should trigger a referral to reproductive endocrinology and infertility [REI]. It’s a simple click, and it’s already in the order set. That removes the factor of forgetting to do it.

In terms of documentation, it’s also great to have it in your note: “I offered, and the patient accepted,” or “I offered, and the patient declined the referral,” and to have that done before the first chemotherapy is ordered. That captures both your counseling and the patient’s choice, and it makes sure that conversation really happened.

Reference

Loren AW, Mangu PB, Beck LN, et al. Fertility preservation for patients with cancer: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol. 2013;31(19):2500-2510. doi:10.1200/JCO.2013.49.2678