rectal cancer neoadjuvant chemotherapy

so welcome to this session onimproving the cancer service system. we have four presentations. and we'll be taking questionsat the end of each talk. so speaks about 10minutes to present. and then we'll haveup to about five minutes of questionsafter each speaker. so i'm pleased towelcome and introduce dr. andrew knight fromfairfield hospital

for our first presentationof the session on toward seamless cancer care. what do gps need tofacilitate better integration with cancer services. so welcome, andrew. [applause] hi. andrew knight is my name. i am from fairfield hospital.

but i'm actually a gp workingwithin fairfield hospital. so i straddle both worlds, whichis part of the point, i guess. this is our project. and this is our team. it's been a really strategicteam to bring together. so it's got the gpunit that i'm part of that's part of newsouth wales university. so that's an academic unitthat we have a clinical service as well.

geoff delaney ispar of our team. he's the head of cancer servicesat liverpool or in southwest sydney local health district. afaf girgis is the executivedirector of the translational cancer research unit atthe ingham institute. and then rene pennock is theceo of the medicare local. so that's a powerfulcoalition, because it's got the lhd and the medicarelocal and some academic input so yeah, this iswhat we aim to do.

we wanted to find out whatopportunities were there to improve communicationcontinuity of care between primary specialistsand cancer care. what were the barriersand the enhancers to it? so we wanted to talk to gps. that's what we decided to do. and particularly, we wanted tofind out some concrete ideas that we could then go on toimplement in our local health district, medicare local.

so what did we do? well we designed aqualitative study, because we wanted rich dataabout what people thought and their ideas. and we purposively sampledgps across the region. we ended up getting22 gps to participate. that wasn't easy forthe reasons, i guess, that john outlined. but the cancerservices gave us a list

of people who'd referred tothem in the last 18 months. that was very helpful. and we then went and tried tohave them diverse for the five local government areasand the number of patients they'd referred, so if they werecommon refers or rare refers, the size of their practice, andalso the socioeconomic status of the patients thatthey were serving. and we did the usual thing. we had a series ofquestions in our interview.

and we analyzed those as we wentalong, first of all together, myself and an assistant. and then we went aheadand did more interviews. and we used a softwareprogram to record those themes andgroup the themes and a historyprocess that went on until we started tonot hear anything new. and it did work. it was good to see it work.

what did we learn? well, geoff delaney wasreally pleased to hear that the gps were very positiveabout cancer services actually. they appreciated thesupport that they had from cancerservices and felt that they had pretty goodaccess to getting people in. and it was interestingthat in our area it emerged that we had areal center of excellence. and that's useful, becausewe can think about, well,

why is it working in thatparticular local government area? in this area, we usecaution, because it is an area with a higher--it was southern highland. so it's got a highsocioeconomic index. and it's a smallerarea in terms of gps. but those gps felt that theywere known by the local cancer service. and they felt that theyknew it themselves.

they knew the name ofthe local oncologist. they could ring that person up. they knew that the nameof the local nurse. and most people rang them. so there was a senseof relationship around the patients thatthey were caring for. and there wascommunication both ways. and they had a senseof clear roles. they knew what thecancer service did.

and they knew what they did. and then you went totalk to each other. so really, i think, listeningto what john has said and listening towhat [inaudible] said this morning,one of the things that i see as reallyimportant emerge from our work is the importanceof the relationship between the playersin the local field. it's very local.

it's a bit like amarriage in some ways. how is it like a marriage? well, i guess theyknow each other. and they're known by each other. they communicatewell, hopefully. and there are clearroles in the relationship about how to behave. so they want to know. and a few new gps said,i'm a new gp in this area.

and i don't really know whatthe cancer services are like. and i'm havingtrouble finding out. i said, well, how new are you? i've been here for three years. that didn't soundthat new to me. but it made me realize that wasa bit difficult to penetrate local services andknow what was going on. they knew localspecialists, people who they'd used before,people sometimes they

had a relationshipwith for many years. and they liked to refervia local specialists, rather going straight totheir local cancer service. and they were looking for cpd. they actually asked for that. a number of them said,we'd like to have that. so they want toknow about cancer. and they want to knowabout their local service. and they were havingdifficulty knowing that.

but they also want to be known. so those new gps feltthat they were still invisible to the system. they didn't feel like theywere on databases or receiving information. so some way of inductingnew gps in an area may be very important forcancer services and services generally to beintegrating well. they want it to beon the database.

they wanted communication. they wanted to be ableto get communication in. and they reporteddifficulty with this. they reported not quiteknowing what number to ring. and if they did ring,sometimes not quite getting the right person, beingoffered a phone call back or taking a long time. so if they had a person sittingwith them who had cancer, and they needed to act quickly,or they had very concerning

symptoms, they haddifficulty getting in. and the main thing they reportedwith the communication coming out was difficultywith timeliness. they actually foundthat the communication was good in terms of quality. they appreciated whatthey were getting. but it was slow. so often, the patient wouldbe back in front of them before they havethe information.

and this bears up whatjohn found in his review and his colleaguesfound in the review. and they talkedabout clear roles. again, when we talkedabout shared survivorship and after-care,they saw themselves as having a veryimportant parallel role, playing a role often ofinterpreting what the cancer service had said tothe patient, dealing with the emotionalupset often with family,

and then also providingall the other care aside from the cancercare to the patient. so certainly, thegps saw themselves as having a very important role. and interestingly, john, ithink, you found 90% of people were willing to take on therole in your prostate study, willing to take onthe shared-care role. we found most of the peoplewe interviewed saw themselves as having a rolewith cancer care,

were willing to take on more. but there was a minoritythat said, i'm too busy. and i actually thinki'd like the cancer care services to do that for me. all right. here's a couple ofquotes just capturing the flavor of what people said. i'll just let you read those. so that's capturingsome of the stuff that

emerges from theliterature about support, emotional issues, but alsoreinforcing and ensuring that cancer treatment iscarried out, but then also all the other stuff, that peoplestill need their flu vaccines and to get theirregular medications. and they get coughs and coldsand all the other things that happen the gps deal with. so that's very awkwardto have someone coming in with a serious condition.

and you really don'tknow what's going on. so if you do have theinformation, sometimes you need to find it out. and finding it out isextremely difficult. who do you ring? it takes a long time. you're on the phone. you're getting peopleto fax you things. it just makes a trainwreck of the waiting room.

it's a difficult problem. so timeliness was a bigissue in communication. so what strategies emergefrom what we found out? well, in terms knowing,it seems obvious that we can improve theavailability of information to gps. i was just looking atthe [inaudible] website at the store there. that goes a long waytowards doing it.

but also some preferwritten information. so maybe there's somethingwe can do about that. one thing that alot of them said was, i want to beable to get in. some people talked aboutbeing in queensland and being able to fax thingsin and having a specialist look at that and get backto them very quickly. and they thought of thatas best practice to them. they want a hotline ora hotfax with someone

on the other endwho doesn't have to know all about the particularcancer they've got but has to know the system verywell and can say, yes, look. send them in tomorrow afternoonfor our assessment clinic. or, ok, you needto see this person. and i'll tell youwhen you can get in. that sort of arapid information, rapid referral in asense, so not by protocol, was what they're looking for.

fax was possible. they wanted it for referral. they also wanted it for advice. so if they're doing theaftercare and something goes wrong, they need tobe able to get in and get that information quickly,very much the sorts of things that john'sliterature was showing about good source,good roots backing to care if they're sharing care.

one thing thatcame up was they'd like to havevisible oncologists. they'd like to know who theirlocal oncologist were, so, perhaps, having people come andpresent at cpd events, partly for the informationof the cpd but partly to show their face so thatpeople get to know them. and you advertise theservice and access. they want it to be known. so they want timely personalizedcommunication to them.

and they want to be onthe database and be rung. and i guess that's a bigrole for the medicare local. and i'd underlinewhat john said. i'd reiterate that the medicarelocals are a huge resource and have a job todo in connecting up the services betweenthe lhd and gps. so communicationagain-- a hotline in and improved timeliness issomething that we can work on. and you're probably awarethat all over the country, gps

have been busilyinstalling secure messaging in their software programs. i don't know if you are aware. first of august wasthe deadline in order to get the pit paymentfor secure messaging. in our practice,we just made it. and i think many gpshave just made it. and that means wenow have the capacity to send a secure message andreceive a secure message.

and practices all overthe country have that. and are we takingadvantage of that? clear roles. they want cleardischarge summaries which state, youneed to do this then. gps have good systemsfor recalling people. they have a whole systems,medicolegally defensible systems for recalling people fortests and all sorts of things. and you can use that.

but they need toknow what to put in. and they needmonitoring protocols. and there's a whole push innew south wales, isn't there, for care pathways withthe medicare locals. and i think that's a potentialsource of working out some of these protocols. it's a potential strategy. so where to from here? well, we're currentlyusing what's

left of our funding to do alittle quantitative survey on the timeliness and qualityof treatment summaries. and we're looking athow we can enhance the web-based informationon cancer services. and we're very pleased to havegained another chunk of funding from the cancer instituteof new south wales to actually do aquality improvement job on the timelinessof communication, because that's somethingthat gps identified as really

important. so we're going to gettogether a group of clinicians and administrators and all thepeople in that critical part to look at how we canspeed up communication. and particularly, we're goingto see if we can use secure messaging to make thathappen a bit better. so i want to say thank you tothe cancer institute of new south wales, because thefunding idea precipitated the four groupsgetting together.

well, we get on fine. but we wouldn't have gottento know each other the way we have got on if we hadn't beenworking around a joint project. so that little bit of fundingthat's been put out there that we weresuccessful in getting has really enhancedrelationships in our region. and i think it'sbeen very positive. and it shows in the way we'vemanaged to get a little bit more money to doa little bit more.

so i think thoserelationships will actually be really importantas time goes on. and particularly,obviously, it's all about the bottomline, which is improving patient care forpeople with cancer. thanks. thank you very much, andrew. it's very nice to see a lotof the synergy with what i was saying and some veryinteresting findings.

so anyone who wouldlike a question, please come up to the speakersand introduce yourself. john stubbs is my name. i had leukemia 14 years ago. i think one of the clear thingsthat's come through to me is about secured messaging,because patients are actually demanding more access too. we don't want the healthsystem to be like the banks, where smss and-- well,they will sms you,

because you can'tsend an email through. so i applaud that interms of secure messaging. i think the cancerclinicians, the specialists, probably need alittle bit of a prod to get that information back tothe gps as quickly as possible. now, i think, again, thatmight be a system thing. or the onus might be onthem in their practice. but i think that probablyneeds a little bit more work. i know that specialistsare very busy, as are gps.

but getting thatinformation back and keeping the patient in theloop is very, very important. i think that's when patientsdon't fall through the cracks. their expectations are met. and i think that goes a lotto better outcomes for cancer patients. look, i'd agreewholeheartedly with that. and i don't know if you've gota patient-controlled electronic health record yet.

i have. it hasn't got anything in it. but i think it's goingto be a very useful tool. sometimes the specialisthas well and totally dictated the information bythe end of the consultation. and sometimes it's atranscription issue. there's all sorts of reasons. so we're actuallygoing to process map the information path.

and the idea thenis we'll find a way. and it may be that we can get itput up on the electronic health record. in which case, the patientcan see it, as well as the clinicians. and i think in thelong run, that's going to be the wayto really ensure we have fewer peoplefalling through the gaps. but i agree wholeheartedlywith what you say.

i think we better move on. but thank you very much. that was a very, veryinteresting presentation and a really good example of howimportant that partnership is to get this work happening. so thank you. so i'd like now to introducedonna gillies from john hunter hospital. and her presentation is onthe emergency department.

is it the right place for me? ed utilization by colorectalcancer patients pre and post diagnosis. so welcome, donna. thank you, john. i'm from the hunternew england area, which is where john hunteris, in case some of you people aren't reallysure of the location. so what i'm goingto look at today

is the utilization of the eddepartment by colorectal cancer patients pre and post diagnosis. ok. so just a bit of background. a lot of people may know this. colorectal cancer represents13% of all cancers. and courtesy of thecancer institute website, we have the information, thehighest colorectal cancer rate in the state inthe hunter new england.

and our emergencydepartments these days are required to meet kpis. they're meant to seepatients within four hours. they're meant to examinea variety of patients. and they're restrictedwith patients being admitted by theavailability of beds. so what our cancerservices decided to do following someinformation, issues that we had in our area, we didan order of colorectal cancer

patients that were admittedto john hunter and belmont and we looked at many things,such as delays in diagnosis, which i've got a posteroutside related to that today. and we looked at emergencypresentations as well. so our aim was to identify thenumber of emergency department presentations colorectalcancer patients utilized pre and post definitive procedure. we wanted to look at andidentify some of the issues. and then we want tobe a bit subjective

and ask whether the emergencydepartment is actually the right place forcolorectal cancer patients. so when we weredoing this, we have to define a criteriaof how we were going to identifythese patients. and we looked atany patient that was admitted to john hunterand belmont district hospital. and they're the twohospitals that most of our colorectaland general surgeons

that do colorectalsurgery work at. so they had to be admitted undera general or colorectal surgeon for the last sixmonths of last year, with a colorectal cancer thatwas reportable to the cancer registry. and when in saying that, thepeople that we identified were not necessarily did theyhave their definitive treatment in that period or were theydiagnosed in that period. some of those people werediagnosed many years before.

so you have to keepthat in consideration when i'm going through this. we matched up the mrnto area-wide emergency presentations. and we went til the endof february of this year. so the actualmaturity of the number of emergency presentationswill continue. there will be more thanwhat's actually in the data that i'm presenting.

we excluded anypresentation that wasn't related to their cancer. some of the presentationswere a bit vague, such as a patient who came inwith a little cut on their foot but was worried aboutgetting an infection, because they're on chemotherapy. so just an overviewof the patients. some of these patients had morethan one definitive procedure, because they went on to havesecond cancers and liver

surgery. but there were 164 patients. and just looking at theirfirst definitive procedure, there were 113 elective,35 emergency procedures, which is a little bitless than the nhs that was presented this morning. that was 21% we haveand 24% in the nhs. three patients actuallyhad no procedure. and 13 patients hada procedure outside

of john hunter orbelmont hospital. and when i talkabout a procedure as well, because some of thesepatients had a colonic stent, and i called that a procedure,a definitive procedure, because that's what it was. so the results-- 350emergency presentations. so that was 69% of allpatients actually dropped into the emergency departmenteither pre or post diagnosis. and it was in 15emergency departments

across our area health service. so they were all over the place. this is just a divisionlooking at-- have we got a pointer on here? yep. no, can't do that. i'll just have totalk about this. so we've got the 113 patientsthat you can see there. and it goes on this side.

66 patients in that group. so that was 40% of the whole164 that actually presented prior to theirdefinitive treatment. and 78% on the other side. so total number ofpresentations on one side, pre-definitive treatment, was125 and 225 on the other side. a lot of patients, about half,get admitted on either side. it just gives you a basic ideaof what these people were. when i also divided thatinto when they presented

on the line, in the middleis when their surgery started or their definitivetreatment there. and base the 40 and thisbit here, the 40 and 12 are those people who hademergency procedures usually and then in hospitala day or so before. i'm going to do a little talkabout a patient in this group here. but some of these peoplepresented a few years before their actual treatment.

so this slide. how they're referred wasone thing that i looked at. i was interested to see if theywere self-referred or referred by the gp and whatactually happened to them. so in this group here, the gpreferrals, 20% of that group went on to actually havea definitive procedure once they were referred. and in this grouphere, it was 16% that went on to have adefinitive procedure.

i thought the differencebetween pre and post diagnosis was quite interesting,that a lot of the people in thepost-definitive group were self-referred andnot coming from a gp. the other, this grouphere, was people that we usually transferredfrom another hospital. and most of those wenton to have surgery. so before moving on, whati wanted to have a look at is some red flag symptomsof colorectal cancer--

abdominal mass or abdominalpain, iron-deficiency anemia, blood mixed with schools,or a change in bowel habits. and i'm wearing red today,because of the red flag. so again, looking at ourpre-definitive surgery, there were 125, 66 patients,72 ed presentations with 53 patients admitted. 28 progressed onto planned surgery. some of those were transferredto john hunter hospital to have their surgery.

and some of them bypasseded when they came in. so there was all a mixedmash of different things. in the people thatweren't presented, there were 30 patients. and 13 of those, actually wheni went back and had a look, had red flag symptomsof colorectal cancer. but they were discharged fromed with another diagnosis, such as hemorrhoids,gastroenteritis, constipation. yeah.

so it was really bizarre. three of those patientswere transferred without actually beingadmitted to the hospital. and these were from not justjohn hunter and belmont. they were frommany ed departments throughout our areahealth service. so i'm just going to have a lookat one patient in this group of 13 and go through whathappened to this patient. so this is 74-year-old male.

he, in february, hadsome investigations. and it was on our system. he had anemia screening. and he did have iron-deficiencyanemia-- red flag. so a month later, he presentedat the emergency department at midnight. and he's a 74-year-old guy, notan 18-year-old out on the grog, with abdominalcramping-- red flag. bowels opened five timesin the last 24 hours

and had said thathe'd had his bowels investigated for the last threemonths-- red flag, red flag. but he was discharged homewith a primary diagnosis of abdominal pain. and this is straightfrom our ed notes. a month later, he came backwith similar pain-- bowels not opened for two days now. so now, he's constipated. says he doesn't drink water andonly eats toast and multigrain.

and he was dischargedfrom the ed with constipation andclinically-appeased constipated, accordingto his x-ray. he was given some movicol. i'm not sure what happenedover the next few months. but after a while, hewent back to his gp. and furtherinvestigations were done. he actually had a ct. and he was referred to acolorectal surgeon in august,

was seen two weeks later. and he had hisdefinitive treatment, which was neoadjuvanttherapy, which was about seven monthsfrom his initial february iron-deficiency anemia. and he had his surgery. and his delayeddiagnosis probably resulted in his t3n2 outcome. so i thought of this as thepre-diagnosis side of it.

i looked at it. and i thought, only20% of ed presentations progress onto surgery. many of the patientsare sent home from ed with no followup andan incorrect diagnosis. and patients who present withsymptoms of colorectal cancer would not routinelyrequire admission. however, they do requireprompt investigation. and there's nopathway or system that

can help them atthe moment for that. so post-definitive surgery,those 225 presentations, 78 patients, and15 ed departments. so 117 presentations wereadmitted in 57 patients. and they stay abouta week on average for that group of people. and there was 108 presentationsnot admitted and 48 patients. a lot, as i said before,were self-referred, which indicates that there'slimited gp involvement and even

limited coordinationof care and limited, not a good pathway forpeople to come back into our system, whichis a bit of an issue. so i went and had a look atthe reasons for presentations. and the light blueis no presentation. that hasn't come up there. obviously, something'shappened there. but a lot of thesethings, like pain, could be dealt with, ifit was done properly,

when they were discharged. post-op complications,some of those, when the renal urology oneswith people who had ureteric stents in. the unwell, the peoplelike, i don't feel great. and that's what theed notes were saying. so there's a whole lotof things in there. but a lot of those thingscould be dealt with and not utilizingthe ed department

if they had bettercoordination of care. the other thing thati was looking at is-- and you talk tocancer patients about this. they come to an ed. they generally present atthe ed closest to their home. and they have torepeat their story to the ed doctor, whois usually the intern. and the ed department thatthey're presenting to usually have limited knowledgeabout the patient.

and so you find thatthere then ends up being a limited communicationwith the treating team. however, these patientsusually have a treating team who are known to them. and why do theyhave to come back into the ed for this process? so just going on to anotherexample of a case scenario, which i looked at. this was another patientthrough post surgery.

he had his surgeryin october 2011. he had long-courseneoadjuvant therapy pre-op. he had a complicated surgery. and then he hadadjuvant chemo post-op. so when you talk to thesurgeon, he was a [inaudible] for an infection or an abscessor something to go wrong. so he went on and had his chemo. in july 2012, while hewas having his chemo, he presented to the edof a different hospital.

and he was unwell. and he was dehydrated. and he had no stomaoutput for five days. and they stopped his chemoat that point in time. and he was admitted for 27. the surgeon was never notified. he was discharged. but two weeks later, hepresented to a different ed closer to his home this time.

and he was admitted withpyrexia of unknown origin. and he had a 51-day admission,still the surgeon not notified. and then he was transferredback to the first ed, the hospital where he was at. and he had a two-day admission. and it was at thatpoint that they realized there was somethingsurgically related. and he was transferredto the surgical hospital. and he had an abscessand pelvic infection.

and he ended up being inthe hospital for 83 days. so to me, is theemergency department the right place for me? 91% of patientsself-refer, which suggests thepathway for re-entry for colorectalpatients is limited and suggests themanagement by gp post-discharge or post-surgeryis limited as well. and the coordination of care forthese patients is also limited.

the process for communicationsbetween the treating clinicians is limited. there are significant delaysand often, or sometimes, major complications, inthe case that i've shown. and about half thepresentations actually do not require admission. if you want to actuallylook at our system impact, we're all about neat andnest targets at the moment. i believe that the ed isan unsuitable environment.

and it's not adequatefor a diagnostic workup for colorectal patients. the ed department is apressured environment. they have lots ofpeople coming in. they have their four-hourrule with targets. and they have limitedbed availability on the other end ofthe spectrum as well. and most patients whoare presenting to ed don't meet the criteria foremergency presentations.

and the reasons that they arepresenting post-procedural is often expected and known. so my answer to myinitial question is, is the ed the mostappropriate place for me? no. thank you. thank you very much. this is a reallyimportant issue. does anyone have any questions?

i might just start. i'm really interested inthose people at the left end of your slide, the pre-diagnosisones who had presented up to a year before and that waswith symptoms that were clearly associated with-- yes. there was one guywho presented to ed. and on his firstpresentation, he was diagnosed with hemorrhoids.

and he a month laterpresented back to ed with the hemorrhoidcream not working. and he presented another monthlater with the hemorrhoid cream not working. and i couldn't believe it. when i was doing thisreview, the lady that i share my office with, i kepton going, oh my god. oh my god. and people i wastalking to today

who were looking atmy poster outside, they also come acrossthe same situation, where people are presentingto eds with red flags. it's not just related toour area health service. i think it's a genericproblem out there where people who are presentingto eds do have red flags. and they're missed. we've got time forone more quick one. and then we'll haveto move on i'm afraid.

you're very polite. donna, you presentedvery compelling data. but do you have someideas about what can be done to address that? so if the ed is notthe right place, how can you redirectpeople so that they're not going through thesehorrible scenarios that you've just presented? i think with thepre-diagnosis part of it,

i think that one is arelatively easy one. if people do present toeds with these symptoms, it's got to be a multi-thing. you have a direct pathway to aclinic where these people can go on to have a colonoscope. if they meet the nhand mrc guidelines to have a colonoscope,they should be going straight to aclinic or an endoscopist for that to happen.

at this point in time,people aren't thinking. so ed departments needto be more educated. and that's the pathway. i think post-diagnosis,there needs to be a bit of carecoordination, more involvement with gps as well, to ensure thatthese processes do not happen. also the post-op side ofthings, a lot of patients-- at the moment now,we have a phone call to the patient day one post-op.

but it's not covering alot of their cancer stuff. they need to be maybefollowed up a week or so later to have bettercare coordination related to what's happening. and i think that wouldhelp a bit of it as well. thank you very much, donna. that was a great presentation. so i'd like now towelcome alexandra hawkey from the university of sydney.

and she's going to bediscussing the role of gps and patients in mdtdecisions for cancer care. so welcome, alex. good morning, everybody. and thank you for comingto listen to me discuss a project i've been involvedwith over the last few months, looking at the roleof a gp and patients in terms of the decision makingthat happens within an mdt environment.

so a little bit ofbackground about mdts. mdt is considered the bestpractice in cancer care. and that's becausethey're associated with moreevidence-based treatment and also a bit of astreamline in terms of the continuity ofcare for patients. they're aimed tofind and develop the most appropriate treatmentplan in terms of an environment with relevant specialitiespresent-- the surgeons,

oncologist, radiologist, andalso of the allied health specialists. so currently in newsouth wales, there's approximately 170practicing mdts. and gps and patientsare actually often not present atthese discussions. record of md discussions canactually be sometimes informal and not included inthe patient's notes. and it's been identifiedthat poor communication

between specialistgps and patients is actually a major barrierto effective cancer care. so what where we trying todo in our research project? first of all, to seek thepreferred role of gps, in terms of the decision makingthat happens within mdts, also identify with gpsa preferred format in terms of what sort of contentthey would like from an mdt, and also in terms ofconsumer involvement. develop a consumer mdtreport and also investigate

the appropriate environmentfor decision making for them. and lastly, we're wantingto run mdt reports past healthprofessionals involved in multi-disciplinaryteams to make sure they're appropriatefor a working environment. so this study is actuallystill taking place. and so i'm going to concentrateon the first two aims for the discussion today. so what have we done?

so gps are recruited from anexisting research database. and we sent out approximately1,400 invitations via fax and post togps in new south wales. we then conducted in-depth,semi-structured phone interviews with 25 gps. and data was transcribed,coded, and analyzed by two researchers individually. we used the program nvivo. so just a little bit ofinformation about the gps

that participated in our study. as you can see, predominantly,they're from the syndey and offshore andbeaches medicare local. and participating gps werefrom a range of bulk-billing, fee-paying, and a mixof both practices, as well as we had a fewgps from rural areas, as well as metropolitan areas. and gp interviews range frombetween about 8 and 32 minutes, depending on how much timei could squeeze out of them.

so interesting themes thatcame out of the dialogue. the first one was lookingat gps experiences with cancer mdts in termsof their participation and also thecommunication that they're received back withtheir patients. and so gps areactually really invited to participate or attend in themulti-disciplinary discussions of their patients. and i think out of the25 that i spoke to,

one was actually onlyformally invited. and i think twohad actually teamed in the mdt discussionof their patient. and i really got asense from the gps that they really felt leftout of the decision making, especially in terms ofwhat happens at an mdt. and would such, the patientsdisappearing into black holes is actually quite common. in terms of communicationexperience with mdts,

unfortunately, gpsfound, first of all, that they're mainform of communication was through specialist letters. but this was by no meansin detail, quite often just a one sentence at the endof a specialist letter, saying that theirpatient will be referred or has been seen at the mdtand then a couple of sentences about what the process isgoing to be from their own. and many gps haveno communication

regarding the mdt oftheir patient at all. and sometimes, gpsactually hear the outcomes through the patients and thefamily members themselves. and as is mentionedin the talk earlier, communication canbe very untimely. and that was really stressedwithin the interviews i did. in terms of gpsparticipation in mdts, what is their preferredlevel of involvement? and i guess there is areally wide spectrum in terms

of what gps want to put forward. and it was on a spectrumfrom not really wanting any involvement at allto absolutely wanting to be there for every oneof their patients' mdts. and gps' need for involvementwas really case-dependent. gps were often saying,if it's a complex case or if i've got a patient andi've known them for many years and i think i can put somehistory context into that, then i'd really like to attend.

and gps recognizetheir limitations in terms ofspecialist knowledge. they're quite modestin terms of knowing that they don't, perhaps,have the skills to put forward suggestions andtreatment options, but really felt that they couldput other important information towards that discussion. and some gps sawinvolvement as educational. and that's not only justbeing at the mdt receiving

but they used theword up-skilling to describe benefits interms of also becoming familiar with differenttypes of cancers, different types oftreatments, and, also, the side effects thatoccur from those. and also linkingonto another talk that we had today interms of teleconference, gps are actually really keen. i had some positivefeedback in terms

of being involved inteleconferences of mdt meetings for their patients. so to continue onwith that, where do gps see their role interms of decision making outside of the mdts? really one of decisionclarification support. and that really came out quiteprominently within the data. so gps preferred role andcontribution within mdts. they really felt that they couldprovide to psychosocial context

and the bigger picture ofthe patient's cancer care. and gps often say thatthey've got relationships with these patientsfor 20 years. they're treating their children. are now, they're treatingthe grandchildren. so they really know their familyhistory, their medical history, and also the livingcircumstances, which often determinesthe treatment plans that people receive.

in terms of barriersto mdt involvement, it was really surrounding time. and i think that'sno news to anybody. gps are really busy people interms of logistically getting to the meeting, taking twohours out of practice time to listen to a 10-minutediscussion about their patient, and then the fact thatthey'll be losing billing time and having patients buildingup back at their consultation rooms.

in terms of the informationrequested from mdts, gps really wanted ananticipatory cancer care plan. what's going to happen? what's the time sequence? it's that thought thatthis is going to happen. and also, what i needto watch out for. treatment decisionoptions and rationale. and this is a reallyimportant thing, because gps saythat often they're

in a situation where they'vegot a patient in from of them saying, my specialist issaying i should really get a mastectomy. but why can't ihave a lumpectomy? and quite often,the patients are having to scramble to tryand put together the story and find out actually whyis this option being chosen. and who was present in the roleof the cancer team members? was there an ot there?

was there physio there? was a psychologist there? do i need to referon to those people? the patient'spsychological state. so has the patient actuallyaccepted their diagnosis? expected treatment side effects,another really important thing that came out the data. the role of the gp. so if side effect aor b was to happen,

what should i do as a gp? and who to contact whenthings aren't going well. and actually gpshighlighted that an electronic simplereport template would be an effective methodand a preferable method to receive this information in. so finally, the main thing, thepurpose of the mdt information, what a gp is going to do withthis to improve their practice. and i guess one of the biggestthings was to keep informed.

and this has been touchedon before that gps use the word embarrassingto describe situations where they had patientsin front of them. and they hadn'trealized that they're three months intotheir treatment. information for decisionclarification and support for patients. so as i said, that's what gpsconsider their important role. so if they don't havethat sort of information,

they're really notproviding an environment for informed decisionmaking for their patients. managing the sideeffects of treatment. and that's not just interms of what sort of drugs. it's prevention oftreatment, making the family and the patientaware of the things that they could experience. and coordinationof continuing care. gps often use the wordpivotal or captain

of the ship to describehow they see themselves within the treatmentgenerally of their patients. and also information toprevent readmission and delays. and this was anotherimportant point that was brought up in termsof the time that it takes [inaudible], try andfind an oncologist. and sometimes, thepatient actually gets readmitted to thehospital, because they're not able to get hold ofthe appropriate people

in a timely manner. so what does this mean? i guess desired gpinvolvement in mdts was really foundto be quite varied. but there are some gps thatreally would like a greater role in the treatmentdecision making that occurs. and quite often, theyfeel that they're on the periphery of that. gps pay an essential role inpatient support and treatment

clarification, as wesaw from the data. however, they oftenfeel ill-equipped to be able to do thisproactively, because there is a lack of informationand communication of that informationback from specialities. and i guess what the take-homemessage is that there really is a need for effective,timely communication and effectivecommunication strategies. and so i guess we're posing anelectronic mdt report for gps

may help actually fill this gap. and in terms documentationof mdt information as well, an mdtreport may actually improve the documentationof those discussions and enhance their value in termsof downstream evaluation of mdt effectiveness. and it's importantto know that there were some limitationsin this study. first of all, that it'sa small sample size.

we only had around 25 gps. and the gpdemographics are really skewed to moreaffluent practices. so our followup data. we're currently in the processof actually developing the mdt reports for both thegps and consumers. and these are going to bedelivered round to the consumer group gps and also themdt health provisionals. and we are interestedin seeing what

they have to say about them. so many thanks tothe cancer institute for funding the project, pc4for helping with the consumer recruitment, participatinggps, and thanks everybody for listening. so does anyone have anyquestions for alexandra? i think, again, it'sreally interesting. and what strikesme is the variation in different gp perspectiveas to how much they

want to get involved. but there were clearly somewho, if it were made feasible, they would actuallywant to attend, even if it was remotely. and that really was the case. and i don't thinkthat there were any gps that didn't want toreceive information from mdts. all gps wanted to be involved. and in terms of thespectrum of gps,

i guess that just meansthat when you come out with care models or policy andthings like that, that you do need to have somethingthat's quite flexible to be able to accommodate for thosedifferent prefixes and gps involvement. alexandra, judith trotmanfrom concord cancer center, where we do have a veryformal mdt operating procedure and proformer thatwere proceeding this afternoon in hematology.

and i'm very interested inhaving you actually come out and sit on our mdt andgive us some advice about how we can refine our proformer toactually give better feedback to gps about the key informationthat they really want, because you've got someextremely important information that you've given us today. and i really applaud youon your research project. so i'd now like to welcomenina mackay from illawarra shoalhaven localhealth district.

and she's going to be presentingabout the implementation of an oncologyinformation system, the inpatient experience. so welcome, nina. this morning, we've heardabout the general practice and the emergency department. and now, i'm going to bringyou into the inpatient setting in talking about introducingan oncology information system. and that is mosaiq.

i should give a quick warning. some of these slides do rotate. so just in case you experiencevertigo, you might [inaudible]. medication errors are continuingand seemingly intractable challenges for ourhealth care system. they're thesecond-most common type of medical incidentreported in hospitals. and although administrationerrors occur more frequently, it is the prescribingthat is recognized

as one of the greatestsources to error. this is the illawarra shoalhavenlocal health district. that's our area of service. and it's over 200 kilometers. it's got four localgovernment areas. it consists of three oncologyoutpatient departments and one inpatient setting, and that isthe one i'm referring to today. these are the medicationerrors in 2010, which occurred acrossour entire service.

and you can see thatadministration errors with medications werenearly 600 in that year. so chemotherapy drugs possesnarrow therapeutic windows and are associated withpotentially high instance of toxicities, even whenthey're dosed therapeutically. protocols can be very complex. and the same drug canhave a variable dose depending on thepatient's diagnosis and also the protocolthey've described.

within the chemotherapysetting, the settings are found to produce lowerrates of medication errors. but it's actualpotential for error, which can besignificantly higher. and the preventionof medication errors is a high priorityfor our service. and one way of improving thequality of our prescribing administration is through anoncology information system. and stated by the safemedication practices,

electronic prescribingwith proper system design, implementation, and maintenancecan contribute significantly to the prevention ofmedication errors today. so to have a look at the bigpicture, on the right-hand side just portrays that we havethe inpatient setting, who continue to functionwith a paper process with our chemotherapyprescribing. and on the otherhand is the remainder of our cancer services.

it's our three oncologyoutpatient departments. the three departments aregoverned by an information system which is builtfor outpatient care. and that's mosaiq. we want to achieve betterresults or better care for all of our patientswith our service. so our goal here is tounite these apartments by exploring the full potentialof this oncology information and so c7 hematology/oncologyinpatients

at wollongong hospitalis our inpatient setting. and this is achemotherapy prescription that we use in the inpatients. as you can see, it's messy. it's hard to read. treatments are not happeningon consecutive days. so we can see we'vegot days one and three. oxaliplatin doses. we've got 160 permillisquare or milligrams.

and then we've got 130. so it doesn't reallygive us a reason why we're havinga dose reduction. so it's quiteambiguous, that chart. so to identify the problemswithin the inpatient setting is that we don'thave standardization in our prescribing. we had lost orders,transcriptions. drugs are being emitted, verypoor communication, and, also,

a great dividebetween the practice between our departments. so why change? well, it's to improvepatient safety ultimately. we wanted to ensurethat we were using standardized eviq protocols,that all supportive care associatedwith our treatment was being builtinto our protocols, and that we would have a centralelectronic location for all

our patients'oncology treatment. and in 2011, mosaiqoncology information system was implemented to theoutpatients department of our service. and it provided acomplete paperless, patient-centered process. this involved the prescribing,administration, assessment, scheduling, pharmacy ordering,and also clinical documentation for those outpatients.

it was a great success thatit provided a 63% reduction in medication errors,which exceeded our overall aim for the project. on this graphic,you can see here that that was 2010, the yearpreceding our implementation. there were 14 errors. and this is in thetotal medication iims in our wollongong orillawarra cancer care center. in the year ofimplementation in 2011,

that's where we hadthat 63% reduction just in that first year. and we remainedconsistent in 2012. and we're yet to, obviously,received 2013's data. this is an example of ournew chemotherapy prescription within the system. it's clear. it's concise. and say you've got [inaudible].

it's a standardizedregimen out of [inaudible], which has been brought on. so the momentum foruptake of mosaiq into our inpatientsetting is unstoppable. we could now become thefist location in australasia to implement anoncology information system into ourinpatient setting. so now, i'll take youthrough our journey into implementing thisinto our inpatient setting.

so we learned frompast experience that we had to utilizeour product support. we needed significantbuy-in from our doctors and a team dedicatedto our project. the dedicated team isfrom all areas of practice and, most importantly,including our project manager, who was dedicated fulltime and implementation coordinator from theward, which was myself. highlighted by lawrenceshulman, as with any technology,

integration into a clinicmust be accompanied by a carefulassessment of workflow, as it's a verydisruptive process. so we had to make someassessments-- firstly, assessing the environment andour workflow, the supportive equipment. is it possible toimprove on what we had? and this is an example ofour nurse-patient allocation on the ward.

it was something weneeded to look at. and it infrastructureto support our change. so we began to mapthe processes using our current practice,which is paper-based. it was very laboriousand, obviously, came with its incidences. the hybrid version,which we thought was half electronic and halfpaper chemotherapy prescribing and administration,which we found

to open up to a whole newrange of potential areas. and then there was a completeelectronic chemotherapy prescribing process. we found it reducedthe potential for error at half the journey from thatprescription to administration. and it also reduced the chanceof [inaudible] implementation. some challenges weexperienced along the way heavily included thecomplex care plan offering, so entering hematologytreatments into the system.

we had treatmentsgreater than 60 days. and they were breachingthat 24-hour barrier, which, essentially, theprogram was not designed for. also creating locations,like how would we know that patientsare on treatment? so we redesigned thenurse-patient ward allocation into an electronic process,creating a live report from our emr system. and we also utilized thisbig, 46-inch touch screen--

you can't really quite getthe concept of the size of it here-- to displaythe patients that were receiving chemotherapywithin our system. other barriers. so maintaining momentumhas been a challenge. and it's requiredus to reinforce the benefits of thesystem [inaudible]. so you can see there'splenty of other barriers we came up to withresistance to change

and also down to decidingon what portable devices we needed. now, some riskswe identified were how to schedule our patientsinto the inpatient setting. scheduling was used bythe outpatient department. but it proved to bequite problematic for inpatient setting. so the cons to the schedulingwas once we scheduled a patient into the system, wecouldn't actually

honor that booking inthe inpatient setting. we couldn't guarantee a patientwas going to be discharged or that there was a freebed on that particular day. also, the schedule wasset monday to friday. and to change this to a24-hour, seven day a week, inpatient rating, it affectedall the outpatient setting. each day's treatmentwould need scheduling. do 60-day hematologycore care plans. who was going to maintainthat schedule for us?

and the alternative option wascreating a checklist location, basically using themessaging system that we use to communicateacross the system. we used that. it enabled us to createa specific location, called c7 chemotherapy on treat. by appending onemessage, it would exist with thepatient's admission for that delivery ofthat chemotherapy cycle.

the location could bedisplayed continuously on a dedicated screen. so the nurses arealways aware of who was being treated on the ward. and it was able to be lockeddown as a read-only access. and that all could also beaccessed from other locations. education. we just ran over saying thatother barriers were being able to recruit patientnurses on 24-hour rotating

rosters was quite difficult. and on top of that, wehad high ward acuity. their patients took precedence. rotation of junior medicalstaff was very consistent. and having access to thedevices and computers that we needed to educatewas sometimes difficult. so we did eventually golive on july 31, 2013. we're probably about four orfive months into our project. it was a phasedapproach we took,

using single day, simpleprotocols, and immense support for the ward. we provided newchemotherapy trollies for the inpatient setting. and that was consistentwith the oncology care departments overour entire service. so it was not onlyfamiliarity for our patients. but it was also thattransition from nurses between departments.

and it was makingit easier for them. we provided the doctors withfalter trolleys and laptops, so they could have that bedsidepatient interactive experience and just so they'd beable to show them scans, track chemotherapyat the bedside. and then our new tablet devices. so we managed toupdate our old devices, use the firstwindows 8 application that was available to australia.

and this is our firstadministration within mosaiq. and it was,obviously, a success. so as a futurescope, you can see these are the c7inpatient medication iims over three years. we can see herealtogether that's 145 medications incidencesoccurred within that three-year timeframe. 53 of those wererelated to chemotherapy.

and we identifiedthat 23 of them had the potentialto be prevented through an oncologyinformation system. and that's almost 50%. that's quite significant. an example, so tosay, what we presume to look preventable,such as five if you prescribed on days oneand two instead of days one and three.

so having electronicstandardization of protocols could potentially preventthis from happening. the immediategains for the ward. it's a tool tomanage improvement, reducing our iims byimproving processes, eliminating variablesin transcriptions, identifying operationalworkflow changes, such as our coordination role. it's always a rolethat's been scrutinized.

and we can beginto design that role and structure itaround our new system. and tracking and providingfeedback after adverse events. as a service, we can begin tobenchmark with other districts, have that transition of carebetween our departments, and have a communication trial. and importantly,provide a remote access for our clinicians 24-7. so now, we caninterrogate our system,

interrogate thesystem for the data. use this data to begin toembark on quality projects. and as an example,something we'll looking in doing inthe very near future is look at the data of howmany patients were using outpatients regimens that arebeing admitted to our ward and begin to redirect ourcare where appropriate. so push them to theoutpatient setting, where it's appropriate.

so as you can see,it's a tool for change. we're very proudto say we now have a complete record forour cancer services. and what that meansto us is that we've got a very excitingfuture ahead of use. thank you very much, nina. these are very difficult thingsto implement such big changes. so i think it's veryimpressive that you've managed to achieve this.

any particular questions? john. is there any way of bringing thepatient into the loop earlier? i mean you knowyou're going into have your chemo at rpa on thursday. and you may knowthat you're getting 140 mg of cyclophosphamide. so is there a notice thatcan be sent to the patient before, so there's a cross-checkso that they can actually

identify that-- you'reasked your hospital number. you're asked your name,date of birth, et cetera. so that's a cross check. but most patients don'tknow what they're getting. and would that be anotheradded check for the system? would you have already beento an outpatient setting? beg pardon? you would already berecognized in the system? you would.

yeah, i agree. i don't get what you mean. i don't know whether ornot it's another-- look, you do to a dentist. and they say, you're bookedin here today for a crown. you know the day beforeyou're going to have a crown. so you go for your chemotherapy. but you know what doseyou've got to get. look, it's just a thought.

i don't know. it's about the patient takinga bit more control as well. well, we've thought aboutinvolving gp and having more care in the community. we have thought aboutinvolving gps in having access to the system and things likethat, so we will be able to, obviously, get your information. it was just a thought. i was interested that you'rethe first to implement

this across australia. yeah, australasia. really? and so for people inthe audience, what would be your two tipsif they wanted to do it? well, follow the guide. have that importantteam involved in that. have someone dedicatedto the project. i said having the productsupport was really, really

important to get this going. having someone from theward who knows the workflow, because implementing thisinto a ward environment, the ward can't fit the product. it's the product that's gotto fit in with the ward. excellent. it will be interesting tosee the longer-term data. we've got a long way to go. well done.

so i think this has been areally interesting session. we've covered abroad range of topics and some really interestinginnovations in service development and flaggedsome very important issues and opportunities toimprove their cancer journey along the way. i'd like to thank allfour speakers for keeping to time and some very clear andvery interesting presentations.

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