Webinar
January 18, 2019

Building and Implementing Lung Programs

Chelsea Simpson is a Thoracic Nurse Navigator at Wesley Medical Center in Witchita, KS. When Chelsea became the Wesley Lung Nurse Navigator in 2015, there was not a lung cancer screening or incidental pulmonary nodule program.

To build each program, Chelsea had to identify physician champions and build step-by-step process infrastructure. Today, Wesley’s Lung Programs are thriving and over 1,300 people have been enrolled. Chelsea currently manages 110+ incidental pulmonary nodules and 625+ lung screening patients. In this webinar Chelsea shares how she built the Wesley Lung Cancer Screening and Incidental Pulmonary Nodule Programs from the ground up

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Transcript

Dr. Aki Alzubaidi:

I think we should get started. Hi Chelsea how’re you doing? Good to see you.

Chelsea:

Hi everyone. I am doing well, how are you doing?

Dr. Aki Alzubaidi:

Good to talk to you again.

Chelsea:

Me too.

Dr. Aki Alzubaidi:

So we met Chelsea through our work with the continental division of HCA and they’ve been dedicated to incidental nodule management for quite a bit and Chelsea has been really one of the most seasoned and I think one of the best nurse navigators. She is also a huge patient advocate that I’ve come across. She graduated from IU in 2011 she’s been a nurse for seven years.

She started on the post-surgical floor and then ended up also doing cardiothoracic surgical floor work as well. Chelsea got an opportunity to become a lung nurse navigator and started the incidental and lung cancer screening program in 2015. In 2017 she became an oncology certified nurse. She has been taking these patients through complete care continuum from detection of a lung nodule all the way through their journey post-diagnosis care and tracking them.

In terms of her environment, it’s a high volume center that has PCPs, thoracic surgeons, pulmonologists, and admins. She understands a complex environment and she’s done it very well. With that, we wanted to invite Chelsea to share some of her knowledge and her experience with everybody else. Chelsea, if you want to introduce yourself some more and get started let’s do it. Thank you so much for joining us.

Chelsea:

Hi, thank you for that wonderful introduction dr. Aki. he basically went over most of it and hopefully, with this presentation, I can give some insight on building and implementing lung programs. I started this at Wesley Medical Center in 2015 and the program has been a great success over the last three years.

So first we’re going to go over a market assessment and then the incidental nodule program, requirements, follow-up guidelines, implementation tracking and the multidisciplinary team approach for the nodule program. Then I’m going to repeat the same process with a screening program in a separate presentation.

Know your market

It’s very important that you meet with your physician relations team to determine the market driver of outpatient follow-up care such as primary care physician or pulmonologist. that way you can target these physicians in order to gain early involvement and start the education process right away.

Meet with your marketing team to develop promotional pieces for physician and patient use in order to get a promotional data rollout. as well as have a direct contact number for all promotional pieces so that it’s helpful for the users. We actually started a specific phone number for all the screenings so that anyone can call for questions.

For example in 2015, I went to every primary care physician office and delivered folders with education materials and gained insights on physician needs. I will discuss the material in this folder in a bit.

What is a lung nodule?

Nodule is a small aggregation of cells in the lungs and mostly benign and very common. They can be a solid or subsolid and solid nodules can represent various etiologies that could be lymph nodes, scar tissue. They have specific follow-up recommendations.

Ground glass or part-solid have a higher risk for malignancy so they require closer follow-up.

An incidental nodule is found on a diagnostic scan in the emergency room or in the hospital. The program is designed specifically to capture incidental nodules and ensure the physicians are aware of these. Also, to ensure that they get the appropriate outpatient follow-up.

The link here contains everything you need to know about the basics of lung nodules, subsolid and solid nodules, risk factors, guidelines, etc. It’s very basic and a helpful website.

Requirements of the incidental nodule program

A software IP program is used to filter these images like CT scans or CT angiograms in the ER to pull those reports and send patients to your coordinator.

You will require standard follow-up guidelines based on Fleischner Criteria, we and a lot of radiologists use it. Make sure that your radiologists are following the Fleischner Criteria so there’s a standard follow up recommendation for every imaging report.

Develop a multidisciplinary team of specialty physicians along with a radiologist to help you implement the standards and review patients scans and suspicious nodules that are more concerning for malignancy.

Fleischner Criteria Guidelines

These guidelines were updated in 2017 to reflect greater than six-millimeter lung nodules. That’s all that we follow and that’s all that your software program should kick out to you is six-millimeters nodules or greater. It has two separate type nodules- solid and subsolid nodules, and different follow-ups required for different types of nodules.

It’s important to note that under the Fleischner Criteria, there are some patients that don’t apply. Under age 35 is not in the Fleischner guidelines considering the low risk for malignancy for those patients as well as patients with current cancer diagnosis because they obviously have an oncologist following those modules.

Implementation and Tracking

Develop a specific organized process for your program and notifications. The first step is a process to alert your physicians. So, everything is to be done through the PCP to set a notification process for the doctors.

An order for enrollment which lets you control if you are following up a patient in the nodule program or not and for that you require follow-up letter templates. The link contains some templates that I use which you might find useful and it also requires legal review.

A system for tracking the patient data and follow ups. There are multiple software programs to help track data of patients as well as full analytical data which enables you to look into the benefits of these programs and what they are doing for their facilities and patients. Excel spreadsheet can also be used to track data which can have patient information, an X-scan date, follow-up date, etc. A dashboard which notifies about all closed alerts and tracks patients data.

A notification process for multidisciplinary reviews and follow-up recommendations.

Cover Sheet

On the left there of the sheet is order to enroll with three options: okay to enroll, do not enroll, okay to enroll as well as any subsequent patient. Patients are entered automatically in the program with a three month follow-up plan. The cover sheet is faxed to the primary care physician along with a CT scan report. The program pulls out all the patient data which is then shared with the primary care physician.

Another example is a follow-up letter with a 6-12 months reminders to the patients stating that they had a CT scan that showed a nodule that requires follow-up. The letter is sent to the patient so they know that a follow up is due with the primary care physician.

Chain of events

Firstly, nurse navigator uses the software program to identify nodules which would  either meet Fleischner Criteria or they don’t.

Those nodules that does not meet Fleischner Criteria are maybe not incidental nodules which is unknown already and that wouldn’t apply on patients under age 35. If patients are under hospice care or have a current cancer diagnosis, there are chances that the software sends lung nodule of densities or even when the patient has a current pneumonia or septic pneumonia, so that wouldn’t apply. Nurse navigator will be required to use her own judgment on such patients.

If patients meet Fleischner Criteria then you need to fax that to the primary care physician along with the letter and the CT scan report.

The physician can enter them into the program and then a follow up is required with the physician to check up on the status of the patient. Incase no response is received from the physician, then enter those patients into the program anyway.

When the patient is due for follow-up CT scan after six months, contact primary care physician and the nurse navigator to look into the process of follow up CT scan. Plenty of patients complete their scans and have been followed up  until the nodule became stable. While other patients whose nodule is suspicious concerning for malignancy- greater than eight-millimeters or maybe their follow up shows an unstable nodule that’s growing inside so that’s when you want your multidisciplinary team to be involved.

Multidisciplinary Review

The lung team consists of physician leaders that are alerted to highly concerning nodules as well as radiologists, pulmonologist, cardiothoracic surgeons, and oncologist. At Wesley, I have two cardiothoracic surgeons and radiologists on my team.

First of all, primary care physician must know about the suspicious nodule. I call the primary care physician and notify them of this is suspicious nodule and then I make sure that they’re going to give authorization for the lung team to take a look and give a recommendation.

Notify the team by following the process. For instance, Denver follows a nodule program that does a weekly review of any nodules greater than eight millimeters in a conference room.

At Wesley, we text the surgeons and the thoracic radiologists to come and review the CT scan in the office. The process is made as quick as possible to notify the primary care physician. He is then given a call and also fax a follow-up letter that says that the lung team took a look at this patient and recommends follow-up. The multidisciplinary process is to take help from the whole team to expedite this process and make sure to name the cardiologists for the ease of the team because they can’t choose on their own.

I send this letter to primary care physicians which has a couple of options. Patients either usually need a pet pan, biopsy or sometimes they need a three months follow-up CT scan. With those patients we go ahead and do the same process that I did previously. We’ll send them to a surgeon, or PCP will send it to an oncologist or a pulmonologist. If it’s biopsy then we will notify the lung nurse navigator or a patient that’s been diagnosed with lung cancer.

I can follow the patient and then eventually know about this patient down the line as the oncology nurse navigator.

At the bottom of this letter is the legal part which says that the Wesley lung team provides a courtesy recommendation and it’s not responsible for follow-up testing and/or treatment orders unless the PCP orders a consult with a member of the lung team.

It’s important to note that when you go out and meet these physicians that there is a multi-disciplinary review that these recommendations are still in their hands. Receiving this letter doesn’t mean that the cardiothoracic surgeon who has never met this patient is going to be ordering any kind of scan, etc. and that it’s still up to them to decide their patient’s plan of care.

Any questions about the nodule program?

Q&A Section:

Question: What software automatically create letters?

Chelsea:

Eon Direct is the one that I use which automatically create letters.

Dr. Aki Alzubaidi:

She chooses Eon Direct and I think she’s been using eondirect since about eight months now maybe?

Chelsea:

Yes, since June.  

Question: do you navigate other patients beside monk patients? are your job responsibilities centered around the lung screening program?

Chelsea:

I run the incidental nodule program, lung cancer screening program and I follow patients with lung cancer. I also run the survivorship program but I also have a GI nurse navigator who follows patients with GI cancer.

Dr. Aki Alzubaidi:

Awesome!

There is a huge difference between incidental pulmonary nodules and lung cancer screening patients. The first section was just about incidental nodules and we’re taking questions about the incidental nodule program and there is going to be a second presentation that would focus lung cancer screening patients.

Question: what about patients who have a low dose CT scan?

Those are lung cancer screening patients which are totally different with a different management, and different data entry requirements.

Chelsea:

There is a lot of overlap between the screening program and a nodule program.

Question: How many of these nodules does your program identify each month?

Chelsea:

It varies each month.

It definitely slows down at the beginning of the year but November and December are definitely the highest month for the nodule program when people decide to go the ER. It is dependent on how many patients are going to the ER.

Question: what about the patients that are less than six millimeters and then another question is you’re only following six-millimeter nodules are bigger with your incidental nostril progress so maybe you can talk about the six-millimeter cutoff?

Chelsea:

That’s just based on the Fleischner Criteria, it has a specific risk and under six millimeters is a very low risk for becoming a malignancy especially if it’s a solid nodule. They’re very common nodules and so anything under six millimeters is most likely benign and that’s why I follow Fleischner Criteria and that’s what they have for their follow-up guidelines. I do not follow any patients that have nodules under six millimeters unless ground-glass even under six millimeters that’s 160 millimeters.

Dr. Aki Alzubaidi:

Okay I also say that when you have software that’s identifying incidental nodules the volume of total nodules that are identified are extremely high.

We actually did a study where there was nozzles that were marked by radiologists using a tracker code and then we used our identification software which identified ten times as many incidental nodules as the radiologists were flagging.

If you think about it there’s actually a huge FTE burden in regards to the number of nodules that are just going to be identified and so what we suggest is that you do a volume check over the first three months to determine if you want to manage all incidental nodules or if you want to manage the ones that are higher risk under the Fleischner Criteria.

I think that’s really why there’s that six-millimeter cutoff in high volume areas. There are so many small nodules that it makes it very difficult to really do all the non-software tracking and management and communication to PCPs for that volume of nodules.

Question: he’s asking about I think the ratio of novels that meet Fleischner Criteria that can be anticipated to be malignant?

Dr. Aki Alzubaidi:

There are different studies that that state if you have an incidental detected nodule, the percentage of malignancy would be anywhere from 15 to 40 percent depending on where you live.

If you’re in the histo Belt if you’re in different regions in the states you may have a ton of nodules and the majority of those may be benign and some of those may be malignant just based on your regional.

Question: Is eon direct nurse friendly?

Dr. Aki Alzubaidi:

we’ve been doing LNP for three years we’re needing a computer program.

Question: Was it easy to transfer patients to the computer program?

Chelsea:

Well they uploaded for the nodule program they uploaded all the patients into the program so I didn’t have to do any of that data entry. I did go through it to make sure every single patient had because I have a lot of notes on my spreadsheet so I did go through and make sure just every single patient had everything I wanted to know about that patient in the program, but the transition for the nodule program was very easy.

Dr. Aki Alzubaidi:

We’ll talk about some of the issues with transitioning screening from an excel file to the software program, some of the ACR conflicts and kind of gray areas that have been made some of the transitions a little more difficult. But now that the ACR is getting some of their act together, that should be a lot easier going forward and we can talk about that too.

Chelsea:  

The nodule program was easier than the screening program because  they could see our piece but the nodule program transition was very easy and it wasn’t as complex.

Dr. Aki Alzubaidi:

Yep more volume but you talked about that already. The volume does increase whenever you do add a program that identifies nodules. There’s multiple programs out there, we’re one of them. You’re definitely going to have an increase and we have a use case of that too that shows the expected increase in incidental nodules.

Question: does the software interface with hospital radiology system or do you manly input it?

Dr. Aki Alzubaidi:

We do have an interface with the hospital radiology system but for screening patients, there is a possibility that there is going to be manually entered data. Chelsea’s system definitely has some manually entered data from the screening program no doubt. We do have zero entry systems which depends on the type of implementation that we do or any software does really depend on the implementation prowess and the complexity of the implementation that decreases the amount of manual input.

Chelsea:

Yeah and then with the nodule program it inputs quite a bit of data so it obviously inputs all the patient’s basic information name, date of birth, address, the CT scan report is obviously transferred into yon directly and then there is some manual information and according to putting the size of the nodule as well as the follow-up.

You still have to review the report which is good anyway. If you want to read the report and enter six to 12-month follow-up, I would want to put that in manually just to ensure everything is correct and the patient has the exact follow-up that you want.

Its minimal data entry with the nodule program.

Question: Once an incidental finding are flagged if they’re identified as ineligible would you delete them from the system or inactivate them?

Dr. Aki Alzubaidi:

Chelsea system has them not even come in to the tracking system.

So that’s Penny.

Hey Penny! how you doing?

Penny’s from Grand Junction, Chelsea.

So, they said they delete everybody who’s less than six millimeters. They are not there.

Chelsea:

The old program I used did not do that, the workload was heavier when I had to go through and just spend a lot of time clearing out all these patients. It would also send me a lot of patients that already had cancer.

Question: what makes eon stand out from incidental software?

Dr. Aki Alzubaidi:

I think that from my annum bias attack we have a superior solution and that we work with everybody. Our clients extremely well to get to the promised land no software’s utopia. If you expect software to be utopia, I think that you’re going to be let down.

There’s multiple environments and this is a complex claim submission, complex tracking and to me our biggest differentiator is how close we work with people like Chelsea. To get to a better place, a better solution and help track these patients. That’s what I think makes us stand out the most.

Chelsea:

It’s hard for me to compare because I would say the first couple years it was just a spreadsheet. The only software I can speak towards is Eon but I would say that one of the main benefits is the communication that they have. They do communicate a lot and that’s a really helpful thing. Communication is key with these programs and building the software to fit your own needs.

so, I can’t speak to other software though I’m not interested.

Dr. Aki Alzbaidi:

Absolutely Jill we’re going to answer your question after we do the lung cancer screening program and then we’ll ask Chelsea if she’s able to share the letters. If she can, then we’ll definitely share and if she’s not able to, then obviously we can’t.

Lung Cancer Screening Program

Chelsea:

In 2015 Centers for Medicare and Medicaid Services issued a national coverage for low dose CT scans for patients meeting the eligibility requirements. It’s important to note that this exam is covered annually so this is the first time there has ever been a screening for lung cancer in the history of time. This is something new and an actual way to define lung cancer early .

So patients who are eligible are between 55 and 80, no signs or symptoms of lung cancer because it is a screening current, smoker or quit smoking within the last 15 years and then a smoking history of at least 30 pack years which is 1 pack per day for one year, so if they smoked two packs per day for 40 years then they’re an 80-year any pack your smoker.

Some Of The Requirements

Center for Medicaid Medicare services requires a written physician order that reviews all of that eligibility that I just went and a shared decision-making visit that’s an informative visit that provides counseling, annual adherence and smoking cessation guidance.

They also require all facilities doing these screenings to submit data like Dr. Aki was saying they have to you have to enter data into a CMS approved registry for every single screening patient.

Then just like the nodule program, you need a software to filter out all these screenings for review.

Dr. Aki Alzubaidi:

A lot of people are asking about the age requirements and she put a 55 to 80.

55 to 77 is CMS, commercial is 55 to 80 and that’s why she put 55 to 80 on her slide.

Chelsea:

I think it’s important to have a software program that filters all screenings and send them to have the coordinator review. I know places just go ahead and do the screenings and then the primary care physician just get the screening later on whenever it’s sent to them but I think it needs to be reviewed by the person that is running the program in case there are any suspicious screenings. That way it can be pushed along faster that’s kind of the point is catching things early and having someone review it as they come.

So, a software program is required for that and then you’ll want standard follow up guidelines along rad version and assessment categories it’s what we use the radiologists use that as a standard. You’ll want to make sure that they’re all using the same standard.

Just like with the nodule program you’ll need a standard follow up guidelines for your radiologists.

You also need a multi-disciplinary team of specialty physicians that can review these lung cancer screenings and assist with that implementation and then a radiologist to help with those guidelines and participate in the one team.

So one of the ways I made this faster the primary care physicians is I made this order form.

This order form covers absolutely everything that insurance CMS BlueCross BlueShield requires. That way they literally can just fill out this one piece of paper this one order form and it will cover everything that they need. It can be a baseline screening or an annual. It has the check one order below and it has the pack your history, a number of years, screen smoking and age and like he was saying 55 to 80 is on this form.

But, that’s just to cover all the age groups and so it’s very beneficial for the primary care physicians for ease of access and ease of ordering to have just a one-page sheet. Whenever I implemented this, I went ahead and went to every PCP office, made sure they had these and then I met with the Wesley scheduling team to make sure that they knew that every single patient that needs a screening has to have this order form filled out. I provided them all with education and information on lung cancer screenings and once every physician was told, no you have to have this sheet then they all just started using this one sheet.

It’s been very beneficial and quick. By assigning this order, I’m certifying at the very bottom. I also took it out of our hands to do the shared decision discussion, so, it says “patient has participated in a shared decision discussion with a physician” so this is put in the hands of the primary care physician as well as smoking cessation.

In the beginning when I very first started the screening program, we had very little screening. I actually met with every single screening patient before their exam and did an in-person PowerPoint but don’t do that because as soon as your volume increases, it’s going to be too much. This has been the best thing that’s really increased our screens. And because they have to do that shared decision-making process what we did was made this counseling form.

It has everything that TMS requires to be reviewed. A CMS is only one that requires the shared decision-making process, so.  this is everything that they want reviewed and every single physician has a copy of this. They can give these to patients and it covers everything that they need.

The Lung Cancer Screening Registry

This is the information that you need there is what the link looks like you can go ahead and I would get if you’re going to start the program. I would start this early on to get this rolling and then that link down there has got a cute though Q&A; website on the registry and how that works and has every question you could ask as everything that you would need answer wise on that I would get you with your director of radiology if you want to do this because they’re going to be the one that has to have the scanner imaging information the radiologist NPI numbers the facility IDs they’re going they’re going to have everything that you need so I would get with your radiology director and I’m probably the medical director of radiology to go over this kind of registry process.

Lung-rads Version 1.0 Assessment Category Follow-up Guidelines

It looks like the five star guidelines in accordance to the standard for not the size of the nodules and everything bit so I has a category these categories one two are most likely benign or negative screening in general three is just a little bit more suspicious six month low dose CT scan and then 4a and 4b are going to be those that need a multidisciplinary review so every single radiologist at your facility should be putting this and the impression the category one two that way it’s all standardized.

Implementation and Tracking

The lung cancer screening program success is widely determined by community and physician involvement.

I gave these folders to every single primary care physician in Wichita I met with him. It has the patient eligibility on the very front of the folder and then when you open it up, it actually has what they need ready to go-it’s got the order form,shared decision counseling sheet and then a patient promotional sheet that just has what the patient needs to know about screenings.

This has been great and they really appreciated us going and giving them these packets. It has my contact information on the inside, it also has other pieces they need and also, it has a card that has the guidelines. Not only does this card have guidelines for screening but it also has the guidelines reflection criteria.

We gave these to every single primary care physician in Wichita and they use these folders, they call me, they have the direct lung line and they call me on that too. I had plenty of primary care physicians call me directly with questions and so this is going to be where you can really meet with them and screening isn’t exactly something that you have to really pitch physician so how beneficial it is and as long as you give them the education and resources and a quick easy ordering process then they will do it.

Along with the promotional pieces you need a tracking system and analytical reports kind of like with the module program and then also annual reminders so we track these patients.

My teammate Tanisha actually does the annual reminder. We send a notification we faxed a letter whenever their patients are due. We’ll fax them the letter that says these patients are coming up tuned for their annual screening and the PCPs really appreciate us letting them know when their patients are due for their screening so that’s been really beneficial, we’ve had a lot of positive feedback.

This is the dashboard that I used. This is the Mr. analytical tracking system that I did for a couple years. There are software programs available that can track those screening patients and when they’re due for their annual screening or do the analytical reports for you so those are nice and then you’ll also have to have the notification process or the multidisciplinary team.

These are the pamphlets that I just showed you in this folder, so, we have a patient version. When we first started doing this space and they put 962 lungs on everything they put it in the newspaper. They put it in the Weslie newsletter, mailed out 20,000 pamphlets with that number to get patients and community involved and aware that this was an option and to talk to their primary care physician.

and then we also you know met with every primary care physician and provided them with the pamphlets for their patients as well as a lung cancer screening program pamphlet for them that way they could read about it.

It’s good to have these quick and easy handouts because physicians don’t want to talk to you for a long time you know they don’t have a lot of time if they have a one-sheet that they can review then there’ll be more up to order these screenings.

Multi-disciplinary review is basically the same as the nodule program so anytime you have a 4a or 4b suspicious screening then you’ll want to call the primary care physician and let them know that there was a positive screening and get authorization for the lung team to review that low-dose CT scan.

Then once the lung team can take a look and I do the same process for the screening program as I do the individuals and text my two surgeons to let them know and the thoracic radiologists to take a look. And then I’ll call the primary care physician with the recommendations a courtesy recommendation on what to do with the screening patient.

Then I’ll call them with the recommendations and then I fax this letter. It looks basically almost the same as the nodule program letter but it does say a low dose CT scan multi-disciplinary review and it’s the same kind of information maybe they just need a three-month follow-up or maybe they need to be sent to the lung nurse navigator.

So like I said before, this screening program saves lives. This isn’t something that you really have to pitch, it’s something that is beneficial for everyone. I have a patient right now in surgery that had a screening and was positive and now she’s having a robotic lobectomy.

Also, yesterday I had a patient who they found a positive screening. She had actually two bilateral upper lobe lesions so on both sides right up her little left upper lobe, went on to do the multidisciplinary review and then was sent to a great a thoracic surgeon, had a PET scan, both the lesions lit up.

They did a biopsy on both lesions actually to see and because there was no lymph node involvement although less tests were negative. There was no lymphadenopathy so they were concerned and it turns out that she actually has two stage one primary lung cancers- one Adenocarcinoma one squamous on bilateral lobes so that’s a crazy case. She was actually discussed at the tumor board this week on the plan so we had cancer tumor board we talked about her and then I went to her appointment yesterday and they’re going to move forward on a surgical intervention.

These programs do save lives and it’s not a difficult thing to pitch to primary care physicians. on the importance of these screening, is just the first time we’ve ever had a screening for lung cancer and it’s the highest mortality rate cancer by far.

So, any questions?

Q&A Session:

Dr. Aki Alzubaidi:

Perfect! we do have questions, Chelsea, believe it or not.

Question: how about reminders? do you call patients and remind them they are overdue for their annual screen so do you talk to patients at all?

Chelsea:

Tanisha will call the patient if she hasn’t had anything from the physician she keeps calling and she hasn’t got anything back then she’ll call the patient.

Question: And then once a patient is taken to the multidisciplinary team and recommended from surgery do you drop them out of the program at that point when do you stop tracking patients for you?

Chelsea:

As soon as they’re sent to a specialist, so if you have a positive screening and they’re sent because I don’t have any pulmonologists on my lung team, they are a private physician group in Wichita so if they’re sent to a pulmonologist, surgeon or an oncologist as soon as they’re there’s steps taken to diagnose or do further diagnostic imaging or biopsy, then that’s when they’re not in a screening program anymore because that’s when we found something that’s more concerning.

if everything turns out negative, if the PET scans negative then they can very well still be in the program and still have an annual screening or sometimes say they have concerning Nigel’s eight millimeters. But it was everything was negative on pet then I’ll actually call the primary physician and ask if they want to enroll them in the nodule program and then we’ll just go ahead and order follow-up CT scans versus doing screenings.

Dr. Aki Alzubaidi:

And we’ve seen a variable throughout different programs so that’s definitely variable.

Question: how many patients do you screen in the year?

Chelsea:

We have over 600 patients in the screening program. I know in the first year that we did it we had maybe around like 80 or 90 but as you know it’s an annual exam so the next year it was closer to 150 so every year your numbers will increase because you have that annual follow-up. So you have new baselines and then you have annual screenings and we have actually found lung cancers in annual screenings. We do send out an update annually of what you know what the program has done so far.

In 2017, 248 new patients were enrolled in the program and there’s over 300 patients enrolled in general. Total 37 had nodules greater than six millimeters, three patients were found positive for lung cancer and were offered nurse navigation and treatment options.

Dr. Aki Alzubaidi:

That answers another one of her questions about the number of patients that are diagnosed with cancer. So, if you look at the total number of screens that you have, 25% of them are gonna have a nodule, about 1% are gonna have cancer that was from the population that was actually the trial.

In the real world what we’re seeing is that there’s a little bit more in terms of the percentage of patients that actually have a nodule. It’s about 2% of total screens that will actually be diagnosed with cancer. There’s regional variations in that as well.

Hi Emily, I haven’t talked to you in a while. that question was from Emily. This is a question about lung rads – they’re just asking about the process but if you don’t mind Chelsea for lung-rads one and two there’s a baseline exam and then there’s annual exams after. So, it’s 12 months after what we try to do is try to minimize the amount of time that people are spending on lung-Rads one and two but there’s a pretty big data entry and submission requirement and so for us our strategy is the ones twos and threes is that we want to automate as much as possible in terms of the data entry, the follow-up, the communication.

These are low risk patients that you really shouldn’t be spending a ton of your effort and time on and we want to make that as fast as possible. So in that case you know, Shelley, I hope that answers your question.

Lynne, in terms of what’s the process for screening patients that fall into category two unless you’re talking about NCCN Group one and group two. Lynne, if you want to clarify, we can talk about NCCN as well – but I know that Chelsea you use lung-rads.

Question: out-of-pocket expense for screenings?

Chelsea:

If a patient wants that they don’t meet eligibility requirements actually on that order form, there is a check box that says “patient does not meet eligibility requirements” they can just check that. Some patients just want to have it even if they’re not eligible on here in two hundred and forty-nine dollars.

Question: the icd-10 codes for current versus former smokers and how do you handle those codes or what do you do how do you know the status?

Chelsea:

So on the form that we have them fill out, it has current or quit within the past 15 years and the number of years they have since quitting smoking. The PCP is required to fill that out so we’ll know if it’s a blank number of your “since quit smoking” than they are current smoker and if they quit then we need to know the “number of years”, so that’s automatically on this form.

Dr. Aki Alzubaidi:

Catherine’s asking about other incidentals like thyroid kidney.

I don’t think you do. do you?

Chelsea:

I don’t do any of those, no.

Dr. Aki Alzubaidi:

Our application does do thyroid kidney mass etc. So any incidentals we definitely have a solution for that.

Question: the physicians having a separate counseling appointment of the patient or the patient can come in for an annual follow-up to be able to discuss the LD CT scans?

Dr. Aki Alzubaidi:

I think this is just a question about who’s doing the shared decision visit and the counselor, or maybe the smoking cessation visit. the two elements that are required prior to doing a low dose, who’s doing those for you? you are not centralizing those, are you?

Chelsea:

The primary care physicians are doing those it’s on the order form for them to have gone over that CMS only requires it for baseline so they only have to do a first time.

Dr. Aki Alzubaidi:

You can centralize your shared decision visit making. Some sites do that and they do both the smoking cessation and shared decision visits centralized then they put an order in. If you’re going to centralize it, you need to do a consult order. The consult order will be what triggers that shared decision visit and smoking cessation that centralized the thing

Question: she’s asking about what’s included in the order to the PCP and that’s just to make sure the patient is eligible?

Dr. Aki Alzubaidi:

She’s asking about it you’re sending notification to the patients as well I know you said that Tanisha calls but she’s sitting a letter to the patient as well. Is that correct?

Chelsea:

A notification for annual?

Dr. Aki Alzubaidi:

No no! so let’s say a patient gets a low-dose CT scan and they get resulted. are you communicating that result to the patient in any way?

Chelsea:

No, the primary care physician is the manager of their care. The primary care physicians would manage, get the result and they inform the patient. I’ve had patients call me directly on that 962 lungs just wanting to know before they see their primary care physician but their PCP should be managing that, they ordered it, so they have to inform them of the results.

Dr. Aki Alzubaidi:

That’s normal for a lot of places and if they have a centralized shared decision visit then normally then they’re contacting patients a PPS would contact patients at that point in that environment

Question: let’s say you call the patient and you’re trying to get them to come up and they refuse to follow up do you notify the PCP and drop them up the program what do you do?

Chelsea:

We drop them out of the program and then yeah, we notify the PCP. We have access to the scheduling system so if a PCP order is screening, and then it’s then they try to schedule and it says “patient refuses” or the same thing with the nodule. They order a CT scan follow-up and they refuse then we’ll just let them know they also get a fax from the scheduling department saying that they’re refusing to go then we’ll go ahead and let them know.

And we will drop them from the program.

Question: as Medicare doesn’t cover more than one a year

Chelsea:

Medicare doesn’t cover, so the primary physicians can order a low dose CT scan, six months follow-up for follow-up of us or nodule doesn’t have to be a screen so a low dose CT scan can be just a low dose CT scan but screaming is only a low dose CT scan.

So you can order a low-dose CT and it not be a screening but only but screenings are only low dose CT scan.

Dr. Aki Alzubaidi:

We go through a procedure library with all of our sites and there’s a low-dose CT scan initial, which is the baseline. A low-dose CT scan annual and then you can have a low-dose CT scan follow-up. That’ll handle Medicare’s requirements.

If it’s a lung rad 3, you should get a six-month low-dose CT follow-up. There are different data entry requirements for annuals baselines and follow-ups.

Question: who’s involved in your multi-D team exactly which specialties?

Chelsea:

I have a thoracic radiologist and then two cardiothoracic surgeons on my team.

Question: where can I start with PCPs, I work in a high smoking low screening area I feel like PCPs are not on board with screening.

Chelsea:

Okay then I would just start showing up during their lunchtime to share some information on screening.

I mean they’ll be annoyed like plenty other care physicians were not happy to see me and discuss this but, eventually they’ll understand how important it is. If you make it easy for them with the order form, then it’ll eventually start happening and then also one way you can go around the PCP is have your community marketing-wise screenings.

Find out if you qualify, talk to your primary care physician, and then they’re going to start asking for it. So the PCP are going to come and ask you about it.

Dr. Aki Alzubaidi:

Absolutely! and I hit the streets to myself. I’m a interventional pulmonologist and when I started the screening program back in 2014, I went to every single PCP and talked to them personally.

Hitting the streets and just talking to people is the best way in terms of getting PCP buy-in and you just gotta keep beating the drum Brian just keep beating the drum keep beating the drum the drum and eventually you know there’s gonna be something that switches in your market in your region and they’ll start ordering lung cancer screens.

So guys, it’s 12:01 and there’s still 16 open questions here what I’ll do is that we’re going to get these questions.

I appreciate everybody who’s jumped on and joined us. If you have any questions, please continue to send them to eon health. You can always go to our website and jump on the chat and we can chat there.

Chelsea, it’s great to talk with you today. I think that what you’ve done is amazing for your patients and you’re an amazing nurse navigator and really just applaud you for everything that you’ve done. Thank you so much for coming and you can tell that people just desire this information and can’t wait to talk to you soon.

Chelsea:

Thank you for having me.

it’s been a pleasure and let me know if you need help with any of those questions and thanks everybody for listening.

Dr. Aki Alzubaidi:

Thank you, guys! appreciate everybody jumping on.

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