A Road Map for Creating a CPRS Template for a Cancer Survivorship Treatment Summary and Care Plan
The template was designed to be relatively simple for a provider to create, using check boxes that would populate the template with disease-specific care plans based on NCCN guidelines.
Review Process
The VACHS team’s original goal was to provide the first treatment summary to a patient on January 1, 2013, 10 weeks after the initial meeting with the CAC. This turned out to be overly optimistic. The VACHS Forms Committee meets once a month at VACHS. There is a formal review process for CPRS templates and all the decision makers must be present (Review Process Time Line).
The changes requested by the VACHS Forms Committee included taking out medications/appointments sections; spelling out all abbreviations; asking the educational coordinator to review educational portion of the template to make sure it complies with guidelines and reading level; and adding fields next to date of diagnosis field and, in every instance of treatment, dates for author to indicate where the diagnosis was made and where the treatment occurred.
Implementation
Starting with the list originally generated by the tumor registrar, the VACHS team set a goal of about 100 patients to be followed in an APRN survivorship clinic to focus on stage I lung cancer, stage I and II colorectal cancer, and stage I melanoma patients. As appropriate, patients were transitioned from being followed by a fellow or attending MD at the VACHS hematology/oncology clinic to the APRN survivorship clinic. As patients were seen in clinic for scheduled surveillance visits, the APRN survivorship clinic provider reviewed the process of creating a treatment summary with each patient and family as appropriate and reviewed their history with them in person to make sure that any complications related to treatment were identified. During each survivorship clinic visit, the provider verbally reviewed the plan for surveillance and signs and symptoms of recurrence to report to their clinician before providing the SCP to the patient. 
Over the past 3 years, the VACHS Cancer Center has incorporated a hematology/oncology dietician, a health psychologist, a social worker, and a physical therapist into the outpatient clinic; all are usually available for sameday referrals. During regular survivorship visits, the survivorship APRN reviews any needs the veteran has and makes appropriate referrals. Palliative care personnel also are available in the cancer center during outpatient clinics for same-day consults. Survivorship patients are not automatically scheduled to see members of the team; rather, appropriate referrals are made via consults in CPRS after meeting with patients and assessing their needs.
In the past 3 years, 2 support groups were created, one for VACHS cancer center patients and one for caregivers. These groups are well attended by oncology and survivorship patients.
As part of the patient’s initial visit, the survivorship APRN reviews the patient’s information in CPRS and systematically reviews the original pathology, surgery, and tumor board notes as well as any notes related to treatments both within the VA system and in the community and creates the treatment summary CPRS note. In cases in which the patient had treatment at an outside facility, the patient signs a release of information form and original documentation of that treatment is requested. The completion of the SCP depends on the timing of when all appropriate information is available to be reviewed. As with all templates, minor editing is done to create the final note.
Once the survivorship APRN completes and signs the SCP, the patient’s primary care provider is added as a cosigner to the note. The patient receives the signed SCP at the visit. The January 2016 CoC Standard 3.3 update specifies that the SCP must be provided to the patient at an in-person visit and not mailed. As the SCP is a signed note in CPRS, it is easy to keep track of the date on which the information was reviewed and documented. If there are changes, such as a new cancer diagnoses or subsequent treatments, it is clear when the original information was documented. After providing the SCP to the patient and reviewing the document at an in-person meeting with the patient, the survivorship APRN documents the date that the SCP was provided to the patient in the progress note in CPRS. Once signed, the SCP is available to all providers within VACHS and able to be printed.
To date, 210 treatment summaries have been created for and provided to patients. Only 1 provider, the cancer care coordinator, is currently using the template, but use is not restricted. Patient feedback has been favorable: Patients state that the list of symptoms included in the treatment summary is useful. Patients report sharing the document with outside providers. The treatment summary also provides patients and families with a predictable plan for surveillance and regular in-person follow-up.
Patient Satsfaction Survey
In March 2015, VACHS conducted a patient satisfaction survey of 98 patients who had been provided with treatment summaries to better understand the impact on patients. This survey assessed quality measures, including patient’s confidence in their understanding of their cancer diagnosis, stage, treatment history, and plan for surveillance. Patient satisfaction with the resources available to them for healthy living also was measured, as was patient satisfaction with their survivorship and oncology providers and awareness that they had received a care plan. 
Surveys were mailed to all VACHS survivorship patients for whom the treatment summaries were created who were still living and had not experienced a recurrence. The list of survey recipients was generated by searching VistA for the unique note title: Cancer Survivor Treatment Summary.
Sixty-six patients responded, a 67% response rate. The primary cancer diagnoses of the 66 study participants were lung (62.5%), colorectal (21.9%), melanoma (7.8%), head and neck (3.1%), and more than 1 malignancy (15.6%). Of the 66 respondents, 36.5% acknowledged receiving a treatment summary (23 patients).
Of those who acknowledge receiving a treatment summary, two-thirds stated that they have referred to the treatment summary for details about their diagnosis, treatment, plan for surveillance, and symptoms to report to practitioner. Between 73% and 76% were highly confident and between 22% and 25% were somewhat confident in their knowledge of their type of cancer, stage, treatment history and surveillance plan (> 90% positive response). The majority (66%) of patients were highly confident, and 32% were somewhat confident that there are resources available at VA to support their healthy lifestyle (98% positive response).
The survey also noted that 86% report being highly satisfied with care, and 92.4% are highly confident that their caregiver will provide compassionate care. Participants state that they have used the nutrition consults (38.5%), physical therapy (23%), health psychology (15.5%), smoking cessation (15.3%), and social work (10%). Of note, almost all those patients who reported using these services responded that they would recommend them.
Challenges
Despite the progress made at VACHS, there are significant challenges to meeting the CoC revised standard 3.3, which requires that 25% of patients treated with a stage I, II, or III cancer receive a Cancer Survivor Treatment Summary at an in-person visit in 2016. These relate primarily to multiple competing demands on provider time. In addition, 63.5% of patients who had been provided with a SCP at an in-person visit and responded to a satisfaction survey said they had not received the SCP. More research is needed to inform practice changes to optimize ongoing education and post-treatment care for veterans who are cancer survivors.
Conclusion
VA cancer centers seeking to ACoS CoC accreditation are required to provide a written summary of cancer treatment and plan for survivorship care to patients
diagnosed with at stage I, II, or III malignancy and treated at their facility. This requirement necessitates a significant ongoing investment in clinician and administrative workload to comply with the standard. The Comprehensive Cancer Center at VACHS, building on work by the SSIG, developed a concise note template in CPRS that enables oncology clinicians to create a treatment summary for each patient who meets criteria. During this process, VACHS has developed resources that may be useful to other VA cancer centers who are working to create this process. Clinicians interested in trialing the VACHS Cancer Survivor Treatment Summary template are encouraged to contact the author for additional information.
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Author disclosures
The author reports no actual or potential conflicts of interest with regard to this article.
Disclaimer
The opinions expressed herein are those of the author and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies.
Acknowledgments
This project was a team effort. The author thanks the following VACHS colleagues for their input and support for this project: Michal Rose, MD, cancer center director; Donna Connery, tumor registrar; Renee Midgett, former clinical applications coordinator; Robert Troy Nall, health systems specialist; Forms Committee; Clarice Grens, APRN; and Jessica Barber, PhD, clinical psychologist as well as Members of VA Survivorship special interest group.
