EMR Flags Can Improve Care in Immunotherapy-Treated Patients

Electronic medical record (EMR) and telephone triage systems should be updated to reflect the unique risks of immune-related side effects faced by patients undergoing cancer immunotherapies, according to a speaker at the Oncology Nursing Society (ONS) 42nd Annual Congress, held May 4–7 in Denver.

Cancer immunotherapy is quickly becoming the “fourth pillar” of clinical oncology, joining surgery, chemotherapy, and radiotherapy, said Monica Fradkin, RN, BSN, MPH, OCN, of the Smilow Cancer Hospital in New Haven, Connecticut.

But it presents new patient management challenges that are unfamiliar to many cancer care providers.

“The rapid approval of agents is moving immunotherapy into a variety of clinical settings,” she said. “But immunotherapy is associated with a series of different potentially life-threatening immune-related adverse events, including severe dermatitis, enterocolitis, hepatitis, endocrinopathy, and neurologic and ocular effects.”

There is wide variation in how these immune-related adverse events are managed within and between facilities, and knowledge gaps about the risks and management of these side effects are common among oncology nurses and non-oncology healthcare providers, she said. Even EMRs have yet to catch up to immunotherapy with appropriate supporting documentation fields.

Particularly when patients receive care from non-oncology providers, early signs of immunotherapy-associated adverse events can be missed.

In May 2016, Fradkin and colleagues met to plan an initiative to improve technological support for the care of patients undergoing cancer immunotherapy, in order to improve patient safety at other sites of care.

The workgroup revised Epic and EMR flowsheets, and created smart texts and documentation and handoff communications tools to facilitate coordinated cross-disciplinary management of patients receiving immunotherapy. Among the changes to Epic EMRs was to send alerts to non-oncology healthcare locations caring for these patients: “This patient is receiving an anti-cancer immune therapy. Please contact the patient’s oncologist regarding an acute event to discuss management.”

They also revised existing chemo- and radiotherapy-centered telephone triage guidelines to include immunotherapy-related adverse events.

“These were questions that made perfect sense around chemotherapy, but when it came to immunotherapy, we weren’t asking the right questions,” Fradkin said. Questions were added on cramping and on blood or mucus in the stool, to help determine if a patient should be seen urgently.

Cross-discipline cooperation is key to effectively detecting and addressing immunotherapy-associated side effects, but such initiatives are inherently multidimensional and complex, she cautioned.

“Issues are interlocked; one change affects many other moving parts,” she explained. “The fast pace of drug development impacts the care provided and technology necessary to care for our patients. Changes are coming fast and furious now.”