A number of practices represented on the panel have implemented or are in the process of implementing internal specialty referral mechanisms. These “specialty clinics” are typically staffed by a small panel of urologists interested in prescribing newer therapies for advanced prostate cancer. The following exchange between several of the panelists highlights the challenges in developing internal specialty referral programs.
Gary Kirsh (Moderator): We have hired and trained a staff person (navigator) to review every luteinizing hormone-releasing hormone (LHRH) injection, every month, from the electronic medical record (EMR). We’ve developed an entire protocol that buckets patients into 2 groups: CRPC with metastases, and CRPC with no metastases but a PSA >5.
These patients are targeted for referral to a small, limited panel of 4 or 5 urologists within our practice. In terms of process, the navigator notifies the primary treating urologist that their patient qualifies for the CRPC clinic, then calls the patient and offers them an appointment with a urologist on the panel who can provide specialty care. These urologists all have a comfort level in prescribing and managing newer therapies such as Provenge, Zytiga, and Xtandi.
Jonathan Henderson: We began implementing a very similar program about 2 months ago. We realized that we had about 3600 patients who had received LHRH therapy, yet only about 20 to 30 of them had received Provenge. From the numbers alone, we knew that we were missing patients who would be eligible for Provenge and Zytiga.
The patient identification process at Regional Urology is a little different from the process outlined by Dr Kirsh. Our physician assistant reviews the charts of all patients who have been receiving LHRH therapy, and inputs CRPC and metastatic CRPC dummy codes into the EMR.
Deepak Kapoor: We recently conducted a pilot program in which we assigned a staff person to track every LHRH injection. It took about 2 business days to track all of the prior month’s LHRH injections. Similar to Dr Henderson’s practice, we used dummy codes M0 and M1 for CRPC and metastatic CRPC, respectively.
Kirsh: Use of dummy codes is one approach. If you are using an ancillary staff person to review and put those codes in, it works. If you rely on the urologist to put the dummy code in, the results may not be optimal.
Earl Walz: Perhaps we should start thinking about ICD-10, which is expected to break down code 185 (malignant neoplasm of prostate), into more detail than current ICD-9-CM coding. If we’re using dummy codes, can we use dummy codes to correspond with anticipated ICD-10-CM coding?
Kapoor: Unfortunately, for most EMRs, you will need to crosswalk your dummy codes into ICD-10, because we don’t really know the code architecture for ICD-10 at this time. Logistically, it may just be easier to create dummy codes using current ICD-9 coding and then crosswalk the code when your EMR is updated to ICD-10.
Kirsh: There are other issues in addition to the mechanics of identifying patients. We felt that it was important to involve our clinical research department. When we began speaking with all our stakeholders, we found that there were competing goals within the organization. Specifically, the research department operated somewhat independently in terms of their financial accountability to the organization. There was discussion about which patients should be referred to specialty urologists and which patients should be referred to the clinical trial program. We brought together all the stakeholders and worked out a protocol that everybody agreed was in the best interests of the patient.
Although we recognize the challenges of actively redirecting care from a patient’s traditional urologist to a specialty panel, we are committed to moving forward, and referring selected patients to the CRPC panel. Physicians participating on the CRPC panel must complete an educational orientation session, and we will institute periodic meetings to review and adjust protocols in response to clinical experience and new products as they enter the marketplace.
Henderson: Our practice has a shared compensation model, which removes any financial incentive for urologists to prescribe certain therapies. The panel is comprised of urologists who have a clinical interest in treating patients with advanced disease. So far, it is working out well for our practice.