The financial toxicity order set: A simple intervention to better connect patients with resources.
Authors: Thom Bridgette , Chino Fumiko , Allen-Dicker Joshua , Rao Nisha , Doyle Stephanie , Liebhaber Allison , Sokolowski Stefania , Newman Tiffanny , Abu-Rustum Nadeem , Gany Francesca , Aviki Emeline Mariam 
Published: June 2022

6596

Background: Rising cancer care costs have led to significant hardship for patients and caregivers, defined as “financial toxicity.” Prior research has focused on experiences of financial toxicity and identified risk factors, but there are limited interventions, despite a growing need for both patient-level and systems-based solutions. We present a novel electronic medical record (EMR) financial toxicity order that streamlines referrals for financial assistance and/or counseling for patients in need. Methods: A multidisciplinary team developed, tested, and implemented an EMR order set to refer patients directly to patient financial services, due to specific financial concerns. Following a 3-month service-based pilot, the order set was activated enterprise-wide March 2021. All team members could place the order, and referrals were tracked on an institutional dashboard. Order indications and frequency of orders across patient and provider demographics were evaluated. Results: From March-December 2021, 617 orders were placed for 580 unique patients, by 272 individuals across 49 services. Nurses placed 45% of orders, followed by advanced practice providers (20%) and attending physicians (14%). Primary indications for the order included high/outstanding balance or out-of-pocket costs (41%), difficulty meeting basic needs (i.e., transportation, food; 30%), co-payment assistance (28%), or out-of-network insurance (11%); 29% of referrals included multiple reasons. Most orders (69%) were placed for patients on active treatment. Compared to the distribution of institutional averages by age, more patients 30-39 years (8% of all orders vs. 5% of all patients), 50-59 years (22% of all orders vs. 19% of all patients), and 60-69 years (33% of all orders vs. 26% of all patients) received an EMR financial toxicity order. Compared to institutional race and ethnicity averages, Black patients (15% of all orders vs. 9% of all patients) and Hispanic patients (12% of all orders vs. 7% of all patients) were over-represented among orders. Disease sites over-represented among orders included breast (25% of orders vs. 21% of patients) and lung (10% of orders vs. 7% of patients); and Hodgkin’s lymphoma (8% of orders vs. 5% of patients). More female patients received orders than their representation among patients (62% of orders vs. 57% of patients). Conclusions: Our findings represent a first step toward improving the process by which patients experiencing financial toxicity are referred to relevant counseling and tangible financial resources. Multilevel interventions are necessary to address financial toxicity, and hospital-based EMR interventions represent progress in empowering the care team to connect patients to available resources. Categorizing the amount and type of financial help provided as a result of the EMR order is next, and efforts to proactively screen patients for financial toxicity risk are underway.