Jorne Meijer, Xander Verbeek 12-04-2015
Making trees out of paper Computer supported implementation and evaluation of clinical practice guidelines
Netherlands Comprehensive Cancer Organization (IKNL)
• IKNL is the knowledge and quality center for oncological and
palliative care and cooperates with managers, care professionals
and patients on continuous quality improvement.
• Netherlands Cancer Registry (NCR)
• population based registry since 1989.
• medical data of 2,3 million cancer patients (>200 million data items)
• +100.000/year.
• Clinical practice guidelines
• Development, maintenance, implementation and evaluation.
• 60 guidelines oncological care (www.oncoline.nl).
Care quality cycle NCR
International Context
• Registration
- Registration at the source, but what is the source?
• Guidelines
- More effective development, implementation, evaluation.
• Patient involvement
- Shared decision making.
- PROMS.
• Information standardization.
In the consultation room Dr. Smith, surgeon
Mrs. Johnson has a consultation with Dr. Smith.
Mrs. Johnson has a breast tumor.
It has been a while since Dr. Smith has seen a case like this…
Gap between research and practice
Mrs. Johnson is interested in the best possible treatment. For herself.
She is entitled to it.
Dr. Smith wants to provide high quality of care to Mrs. Johnson. Even
more, it is his duty.
To keep up to date Dr. Smith has to read 27 scientific publications.
Every day….
….for breast cancer only…
27/day
10/day
Multidisciplinary oncological care
Tumor Board
Field research decision making in practice
Reinterpretation of data during tumor boards
Field research: reinterpretation, new insights.
Scientific research*: different interpretation radiology 40%,
pathology 20% different treatment 10%.
* Newman, E.A., et al.,. Cancer, 2006., Lim, H.K. et al., ANZ J Surg, 2014. Whelles SA et al, Otolaryngol Head Neck Surg. 2010, Wiggans MG et al,
HPB Surg. 2013, van Hagen P et al, Int J Clin Oncol 2013, Santoso JT et al, Int J Gyn Cancer 2004,
Tumor board report as source
Higher level aggregated source document with new insights as basis for:
• Delivered care to patient.
• Transparency towards patients.
• Starting point (shared) decision support.
• Accurate registration.
Post Pre
Tumor
board
NCR
Guide-
line
Closed loop New knowledge generation
Decision Support Tumor board, shared decision making
Registration at the source PROMS, Tumor board report
Ambition healthcare informatics innovation program
Patient
Information
standard
From guideline via tumor board to registry
Send to NCR
Guideline recommendation: Surgery
Tumor
board (EHR)
NCR (database)
Guide-
line (IKNL
knowledge
server)
Tumor
board (EHR)
NCR (database)
Guide-
line (IKNL
knowledge
server)
OncolinQ and Oncoguide
Information
standard
Richtlijn werkgroep
mammacarcinoom
Oncoguide OncolinQ OncolinQ
Linking Information
Sources for Quality
Oncoguide
Decision trees and
knowledge server
Oncoguide
Oncoguide
• From guideline to decision trees and information standard
- Decomposition of care pathway.
• Successfully applied to national Clinical Practice Guidelines:
- Breast cancer: 229 pages (>100.000 words) 115 data items, 73 decision trees.
- Colorectal, prostate cancer: concept.
Sneak preview
Primary treatment
Vervolgbeleid na neo-adjuvant
Grade
Eerste keuze
OF
Tweede keuze
4 x q3wk AC
cT-diameter
≤G1
>G1
Vascular invasion
<2cm
cTNM
≥2cm
Tamoxifen
≤L2
OF
Hormonale therapy
RT with Boost
L3
OF
4 x q3wk AC à 12 x q1wk paclitaxel
RT with Boost
>L3
FAC
Hormonale therapy
<cII
Chemotherapy
Vervolgbeleid na neo-adjuvant
Vervolgbeleid na neo-adjuvant
Neo-adjuvante therapy
Diagnostiek bij neo-adjuvant
FEC
≥cIII
Mrs. Johnson, 67 jaar | breast cancer
Primary treatment: Neo-adjuvant therapy by chemotherapy
___
Clinical staging Pathological staging
2,3 cm
cT-diameter
cIII
cTNM
G3
Grade
≤G1
Vascular invasion
Primary treatment
Vervolgbeleid na neo-adjuvant
Grade
Eerste keuze
OF
Tweede keuze
4 x q3wk AC
cT-diameter
≤G1
>G1
Vascular invasion
<2cm
cTNM
≥2cm
Tamoxifen
≤L2
OF
Hormonale therapy
RT with Boost
L3
OF
4 x q3wk AC à 12 x q1wk paclitaxel
RT with Boost
>L3
FAC
Hormonale therapy
<cII
Chemotherapy
Vervolgbeleid na neo-adjuvant
Vervolgbeleid na neo-adjuvant
Neo-adjuvante therapy
Diagnostiek bij neo-adjuvant
FEC
≥cIII
Mrs. Johnson, 67 jaar | breast cancer
Primary treatment: Neo-adjuvant therapy by chemotherapy
___
Clinical staging Pathological staging
2,3 cm
cT-diameter
cIII
cTNM
G3
Grade
≤G1
Vascular invasion
Primary treatment
Vervolgbeleid na neo-adjuvant
Grade
Eerste keuze
OF
Tweede keuze
4 x q3wk AC
cT-diameter
≤G1
>G1
Vascular invasion
<2cm
cTNM
≥2cm
Tamoxifen
≤L2
OF
Hormonale therapy
RT with Boost
L3
OF
4 x q3wk AC à 12 x q1wk paclitaxel
RT with Boost
>L3
FAC
Hormonale therapy
<cII
Chemotherapy
Vervolgbeleid na neo-adjuvant
Vervolgbeleid na neo-adjuvant
Neo-adjuvante therapy
Diagnostiek bij neo-adjuvant
FEC
≥cIII
Mrs. Johnson, 67 jaar | breast cancer
Primary treatment: recommendation not yet possible, enter Vascular invasion
___
Clinical staging Pathological staging
<2 cm
cT-diameter
cIII
cTNM
G3
Grade
Vascular invasion
Primary treatment
Vervolgbeleid na neo-adjuvant
Grade
Eerste keuze
OF
Tweede keuze
4 x q3wk AC
cT-diameter
≤G1
>G1
Vascular invasion
<2cm
cTNM
≥2cm
Tamoxifen
≤L2
OF
Hormonale therapy
RT with Boost
L3
OF
4 x q3wk AC à 12 x q1wk paclitaxel
RT with Boost
>L3
FAC
Hormonale therapy
<cII
Chemotherapy
Vervolgbeleid na neo-adjuvant
Vervolgbeleid na neo-adjuvant
Neo-adjuvante therapy
Diagnostiek bij neo-adjuvant
FEC
≥cIII
Mrs. Johnson, 67 jaar | breast cancer
Primary treatment: Neo-adjuvant therapy by 4 x q3wk AC à 12 x q1wk paclitaxel OR RT with Boost
___
Clinical staging Pathological staging
<2 cm
cT-diameter
cIII
cTNM
G3
Grade
>L3
Vascular invasion
Phased approach
• App and website.
• EHR systems.
• Quality and regulatory.
- Class 1 medical device.
- MDD, CE-certification.
- Maintenance and post market surveillance.
- NEN 75xx
• Clinical evaluation.
OncolinQ
OncolinQ – Information standard breast cancer
81
data-
items
134
data-
items
115
data-
items
NCR Dataset
Information analysis
200 tumor board
reports
Guideline analysis
OncolinQ – Information standard breast cancer
81
data-
items
134
data-
items
115
data-
items
~50% NCR items in
tumor board reports
44 33
~30% guideline items
already monitored in NCR
60
Only ~60% guideline
required items currently in
tumor board reports
OncolinQ – phased approach towards information standard
NCR
Tumor
board
Guide
line
Patho-
logy
Radio-
logy
Lab
Information
Standard
1
2
2 3
4
Better guidelines faster
Transparent decision making
More efficient registration
Transparent and better care
NCR
Tumor
board
Guide-
line
Patient
www.iknl.nl
www.linkedin.com/company/iknl
twitter.com/iknl
Roadmap
Informatie-
standard/
Decision trees
IKNL
Knowledge server
Research/
Clinical
evaluation
Pilots
App/Web
2014 2015
Mamma
Colorectaal
Prostaat
Long
Hematologie
Gyn
Nomogram/
Trial alert
2016
Melanoom
SUS evaluation
POC Source
registration
Methodology
from guidelines to flowcharts /
information standard
Impact QoC Prospectief
Impact QoC Retrospectief
Shared decision making
PhD
MDO / EPD
interface
Oncoguide
POC Decision
support