Enhancing patient clinical streamlining (EPACS) pilot in the breast medicine service at memorial sloan kettering cancer center.
Authors: Amel Riazat-Kesh Yosef Joseph Rene , Miceli Madeline Rose , Smith Andrea , Keenan Kathleen , Morrison Jashane , Magnoli Rocco , Strong Vivian E. , Traina Tiffany A. , Sanford Rachel Ann 
Published: June 2023

e18759 Background: Breast cancer patients at specialty cancer hospitals have a 10% lower risk of death in the first year vs those at community hospitals, where 77% of cancer patients are treated. However, there are barriers to seeking and following up care at the former. One intervention shown to favor continuity and reduce time to treatment has been ‘enhancing patient clinical streamlining’ (EPACS), which coordinates patient record-collection, care, expectations and therapy from initial contact. Methods: In this quality improvement project, we implemented EPACS in the breast outpatient service at a specialty cancer hospital. In lieu of the traditional sequence of nursing then doctors' visit followed by coordination of workup and subsequent therapy, EPACS involved an initial nursing visit followed by a telephone call from a provider (registered nurse, RN or advanced practitioner, APP) used to collect medical records/data, clarify patient expectations, and coordinate workup. Patients were then reviewed by MDs and treatment decisions were made. Phone calls were made to a subgroup of patients to assess satisfaction; and participating providers completed questionnaires regarding their experience of the pathway implementation. Results: The EPACS pilot was run at 8 clinics in parallel. In total 156 of 377 eligible patients (41.4%) were telephoned in a 6 month period. RN telephone calls lasted 15-60 minutes; while 82% of APP calls lasted > 60 minutes. 66 of these 156 (42.3%) were questioned on a separate phone call on their experience. Patient and MD satisfaction with EPACS was universally high: patients consistently reported that they felt better prepared and connected to their team after the calls. The majority of MDs felt that EPACS saved them time and increased overall efficiency. RN and APP responses were more mixed, with some feeling that calls were lengthy and overly broad in scope. Notably, only 19% of eligible patients were contacted prior to RN and practice-associated APP visits; vs 74% by per-diem APPs; hinting at time limitations. Cancellation and no-show rates were unchanged vs pre-EPACS, as were patient time in clinic; and time to first chemotherapy from first visit. There was no objective harm to patients with EPACS vs without. Conclusions: Although EPACS implementation in a busy breast outpatient service did not replicate prior findings of increased patient retention or reduced time to treatment; it did result in objective significant improvement in patient experience as judged by patient-reported metrics. Patients felt prepared, involved, and heard, though partially at the cost of staff time and workflow. Future work might aim to lighten the data-gathering aspects of the EPACS framework and focus instead on patient ideas, concerns and expectations, capitalizing on the observed benefits while limiting negative impact on time management experienced by some providers.