And So the Search Begins …

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When patients reach out directly or are referred to navigators, the navigator must piece together the patient’s case. The navigator starts by looking for the all-important pathology reports that describe initial tumor details. These may be in the navigator’s hospital EHR, if they are lucky. Abnormal imaging reports or consults describing symptoms are also useful to have. 

Then, patient records need to be gathered from the specialty physicians (surgeon, medical oncologist, radiation oncologist, etc) to whom the patient has been referred and who might be part of the treatment care team. By this time, the navigator has likely looked in at least 2 information systems, called 4 people, and maybe created documentation for the patient in the EHR and her own navigation system — if she is lucky enough to have one.

The Disconnected Care Team

The fragmented information and technology landscape often reflects the fact that navigators are operating within disconnected care teams. Care team members often use different systems, each designed for their own narrowly defined needs. The result is that no one has complete patient information, although they should if they are to do their jobs optimally.

For example, navigators’ notes can be a gold mine for others on the care team. But if captured in a care coordination system, other care team members may not have access to those notes, preventing them from seeing the big picture. Thus other members of the care team frequently reach out to the nurse navigator for a fuller view of the patient, often seeking information about distress levels, access issues, or other matters that may affect care adherence or a patient’s understanding of their treatment plans.

As the oncology care clinicians struggle with new standards and requirements for value-based care, including patient satisfaction and access, they are turning to navigators. Navigators’ phones are ringing more than ever. An unbiased, patient-centered system for aggregated data could solve this and other pressing problems. All care team members could log in and look at a full patient record, including all past and planned treatment events, comorbidity and symptom information, distress levels, adherence issues, etc. Even better: a care coordination system could proactively send valuable (and relevant) information to all stakeholder care team members.