How One Institution Implemented Survivorship Care Plans in the Age of the Electronic Medical Record

October 05, 2017

By Elizabeth B. McGrath, DNP, APRN, AGACNP-BC, AOCNP®, ACHPN

More than a decade ago, the National Academy of Medicine (NAM, formerly the Institute of Medicine) first proposed that ( “all patients should be given a comprehensive summary and a clear explanation of the details of their cancer therapy as well as recommendations for necessary follow-up.”

This seemingly simple task has proved difficult to deliver in many cancer care settings. No superior model of survivorship or survivorship care planning (SCP) has emerged; however, evidence exists ( that nurse-led programs may be most successful. Research indicates that cancer survivors receiving a SCP ( have better facilitated follow-up care, including cancer screening and surveillance and management of late and long-term effects, have an overall higher satisfaction ( with survivorship care and report significantly fewer ( post-treatment emotional concerns.

Developing a Process for SCPs

At my National Cancer Institute-designated academic medical center, nurse practitioners used a quality improvement strategy to develop a standardized process to deliver SCPs to all eligible patients. The project’s primary objective was to standardize SCPs and embed them into the electronic medical record (EMR) using a templated note.

We formed a cancer SCP committee to explore approaches to expand the delivery of SCPs and standardize the SCP process. Prior to this, SCPs were completed by less than 10% of providers, only used for a few diagnoses, and used a variety of disparate templates. The first step was to define the elements of a comprehensive SCP using a literature review, and we explored available tools such as Journey Forward and American Society of Clinical Oncology (ASCO) templates to develop a customized template for SCPs to include all of the NAM’s recommendations (see sidebar).

The committee determined that the NPs embedded in each disease management group (DMG) would be best situated to generate and deliver the SCP. All patients being treated with chemotherapy or radiation therapy with curative intent would be given an SCP three to six months after completion of therapy.

We reviewed various existing templates and defined the elements that met current guidelines. From there we used ASCO guidelines to develop a generic template and explored which tools we could use in the EMR. Integration into the EMR was imperative to overcome the many barriers ( associated with successful SCP programs. Because developing each individual SCP can be a time-consuming process, we made every effort to minimize the amount of data entry and chart reviews needed by integrating the problem sheets and flow sheets.

Each oncology DMGs created flow sheets that included information about cancer presentation, pathology details, specific treatments, and treatment toxicities. The flow sheets are live documents that are found in the problem list. In addition to disease-specific flow sheets, we created templates that addressed possible late and long-term effects and management, symptoms of disease recurrence, ongoing surveillance needs, and lifestyle and wellness recommendations based on IOM recommendations. The provider (primary care versus oncology care team) expected to order and monitor ongoing surveillance and long-term follow-up is clearly documented in each SCP. Patient education templates can be uploaded into a patient’s survivor care plan and easily modified for individual patients.

Using the New SCPs

We conducted a pilot test of the flow sheets in two patient populations: prostate and breast cancer survivors. The nurse practitioner input data to the flow sheet, and the information was easily uploaded to the SCP. The data elements could be enhanced to add details in language that patients could understand as well as unique, patient-specific information (e.g., care team, contact information).

Using the disease-specific flow sheets and patient education templates, nurse practitioners can complete an SCP in less than fifteen minutes for the majority of patients.

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