Tumor board workflow challenges in preparation, presentation and documentation
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Tumor board workflow challenges
in preparation, presentation and
documentation
Executive summary
Worldwide, tumor boards share the goal of improving point of preparation. Manual processes for planning
patient care and achieving optimal treatment outcomes. and managing tumor boards can negatively affect
Those objectives have been a driving force for information-sharing during the meetings and lead to
multidisciplinary oncology care team meetings since the treatment decisions that are not fully informed and/or
early tumor board meetings reported by John C. O’Brien, documented. Subsequent group communication and
MD, in the late 1960s at Baylor Hospital, as well as the post-meeting next steps can lack clarity where these
regular breast tumor conferences at MD Anderson common workflow challenges are present, increasing
Hospital and Tumor Institute in the 1970s.1 the risk that treatment decisions might not be fully
implemented in practice.
However, many tumor boards also share a series of
inefficiencies related to workflow challenges, and many For those reasons, a well-defined, standardized process
practitioners are investigating the role and efficacy for preparation, presentation and documentation is
of tumor boards in medical systems.2 In addition to necessary for tumor boards to realize their full potential
overall inefficiency, workflow challenges can lead to for multidisciplinary decision-making, patient care and
inconsistencies and hinder the ability to deliver optimal patient outcomes. This white paper explores common
benefits of multidisciplinary collaboration. For example, tumor board workflow challenges and tumor board
collecting and organizing patient information is a experiences before, during and after meetings. Other
time-consuming task for each participant, one that is papers in this series from Roche Diagnostics Information
often not standardized among specialists and among Solutions provide analyses of tumor board benefits and
various tumor boards within the same institution, current practices.
resulting in inefficiency and/or inconsistency at theThe impact of inefficient workflow on cancer care
Described in simple terms, a tumor board is a meeting Tumor boards are commonplace but vary in size, area
of physicians and other care providers across various of focus and meeting frequency depending on the
disciplines related to individual cancer cases – a institution. Most tumor boards follow a similar workflow
platform for specialists to come together to review each (see Figure 1). Given the complexity of gathering patient
patient cancer case and reach consensus on proper data from disparate sources – and the fact that there
diagnosis and treatment plan. Attendees typically are multiple touch points in play before, during and
include oncologists (medical, surgical and radiation), after each meeting – it is easy to see how workflow
radiologists, pathologists and nurse navigators; at inefficiencies can overwhelm participants and hinder the
times, other specialists, primary care physicians and group’s ability to make and follow through on treatment
social workers are present as well. This multidisciplinary decisions.
approach supports evidence-based decision-making
and facilitates care coordination to ultimately optimize
patient care and treatment outcomes.
Typical tumor board workflow
Each participant works individually to gather all patient information while focusing
Collect Patient Data on the most relevant data related to his or her specialty to address patient-specific
concerns.
A cancer center coordinator plans the logistics of the meetings for the year,
Coordinate Logistics scheduling a time, date and place for each meeting, and inviting the appropriate
specialists.
A nurse navigator organizes the agenda and provides the list of patients to be
Prepare for Meeting
discussed at each meeting.
The specialist who requested convening on the case presents the patient-specific
issues, allowing each participant to present his or her findings with related artifacts
Conduct Tumor Board previously collected. Once all relevant data have been presented and treatment
options have been discussed, the lead oncologist of the meeting summarizes the
patient case and voices the agreed-upon, evidence-based treatment decision.
A nurse navigator or other delegate in attendance (such as a resident or medical
student on rotation) captures meeting notes, treatment decisions and next steps in
Document Decisions
patient care. In many cases, this individual enters all notes related to tumor board
discussion into the patient’s electronic medical record as well.
Figure 1: The five overarching steps in typical tumor board workflow processes include data collection, logistical
coordination, meeting preparation, meeting presentations and collaboration, and decision documentation.“ We need to look at all the different reports and integrate the information. It’s very
time-consuming, and it’s a complex process.
”
- Dr. Clara Montagut, Medical Oncologist, Hospital del Mar in Barcelona, Spain
Time-consuming preparation: The first step in experts participating in urological and gastrointestinal
preparing for a tumor board is collecting all relevant tumor boards in the UK revealed one of the key factors
clinical and diagnostic information to be presented that prevented a tumor board from reaching a decision
at the meeting. Such data may include a patient’s was the lack of a “holistic approach when discussing
medical history (including demographics, allergies and patients at the meeting.”4 Multidisciplinary oncology
medications), radiology images, test results, pathology care teams require the ability to integrate clinically
reports, tumor information, biomarkers and notes relevant patient data with evidence-based guidelines
from the patient’s electronic medical record, as well to inform clinical decisions and impact quality of care,
as applicable findings of comparable, evidence-based which underscores the universal need for clinical
cases from the larger patient population. The higher decision support software tailored for tumor board
the quality and relevance of the data being gathered, workflow optimization.
aggregated and presented – and then assessed in
conjunction with evidence-based guidelines to ensure Standardization at the point of data collection can
adherence to standards – the more effective the tumor improve consistency while decreasing time spent
board can be in making decisions collectively aimed at on preparation among meeting participants. The UK
achieving the best possible treatment outcome for every study of urological and gastrointestinal tumor boards
patient. identified the use of a standard document or form as a
way to improve tumor board preparation4; to that end,
However, physicians and other members of oncology cancer care organizations should assess and implement
care teams, already pressed for time with their clinical software technologies that enhance the ability to
responsibilities, often have little time to fully prepare standardize processes in the tumor board workflow.
for tumor boards. In fact, in a survey of British oncology
surgeons involved in breast tumor boards in the Similarly, standardization across multiple tumor boards
United Kingdom (UK), nearly one-third (29%) of survey within the same organization is key, particularly when
respondents indicated “time to prepare for meetings” it comes to data management and the potential benefit
was an area for improvement.3 With information stored decision support solutions can provide in collecting and
in numerous sources – presentation slides, handwritten populating patient information. A parallel is seen in the
notes, a hospital’s picture archiving and communication pharmaceutical industry, where companies rely on data
system (PACS), and more – collecting and entering the from clinical research to develop new drug therapies. In
data into a central location is a cumbersome task, and a 2012 article explaining data management in clinical
often a significant challenge, particularly where the research, Krishnankutty and colleagues discussed the
processes are manual and subject to variation from challenges of clinical data management (CDM):
one specialist to the next. Furthermore, manual entry of
disparate inputs from numerous sources can increase CDM…should be evaluated by means of the
the risk of errors. systems and processes being implemented
and the standards being followed. The biggest
According to a growing body of evidence, when the challenge from the regulatory perspective would
processes for preparatory data collection are arduous be the standardization of data management
and non-standardized among presenting specialists, process across organizations, and development
it can negatively affect the group’s ability to achieve of regulations to define the procedures to be
consensus on treatment decisions. Interviews of 22 followed and the data standards.5Inefficient meetings: Inadequate or incomplete that optimize meeting workflow and information-sharing
preparation for a tumor board makes meeting are evident everywhere.
management more difficult and less efficient – an
issue that is prevalent across multiple tumor boards at For tumor boards at institutions based in rural areas,
the same or different cancer care sites. For example, attendance by specialists who work remotely can pose
in an international survey by the American Society of another workflow challenge. Under these circumstances,
Clinical Oncology (ASCO), members were asked to rank virtual tumor boards offer a way for offsite physicians
suggestions for improving efficiency during tumor board to participate in multidisciplinary discussions and
meetings. The two most highly ranked suggestions exchange input with other specialists.9 However, to
were “a more effective moderator of discussions” and maximize information-sharing and the overall efficacy
“better time management at meetings.” Other highly of long-distance collaboration, technological issues
ranked suggestions included “creating criteria for inherent in such a setup (e.g., availability of video-
selecting cases” and “providing attendees with written conferencing equipment, internet speed, etc.) must be
summaries of the cases before the meetings.”6 These fully addressed. The absence of a comprehensive system
responses suggest it is important to diligently prioritize for connecting remote specialists can negatively affect
and organize cases and, where possible, share written the performance of the tumor board4 – presenting an
case summaries in advance to aid in more efficient time additional set of workflow-related challenges unique to
management of tumor board meetings. the virtual setting.
Likewise, in a Canadian study, Look Hong et al. Incomplete or inaccurate documentation: Capturing
conducted interviews with clinical specialists and the discussion and resulting decisions is another
administrators who had experience with implementing challenge associated with tumor boards. Where robust
tumor boards at three hospital sites. The authors found software tools are not in place to assist with tumor
that tumor boards “can most effectively be implemented board documentation, it is common practice for a nurse
if administrators and health professionals see value navigator or resident physician to handwrite or type
in [them], despite the time and effort required.”7 notes during the discussion with little or no means to
Furthermore, the perceived value of the tumor board fully ensure accuracy and prevent human error. In some
was influenced by how efficiently the meeting was cases, there might be no recording of decisions at all,
managed.7 The ability to convene around a centralized as noted in a 2011 review of published evidence titled,
hub of well-structured diagnostic data and evidence- “Cancer Multidisciplinary Team Meetings: Evidence,
based treatment data improves perceived and actual Challenges, and the Role of Clinical Decision Support
value by enabling fully informed, highly collaborative Technology.” In that study, Patkar et al. identified “the
decision-making for the goal of optimizing treatment consistent collection of crucial data” such as cancer
outcomes. staging and related outcomes as a challenge that
could prevent a tumor board from achieving its goals of
In some countries, time-strapped physicians are less improved decision-making and patient care.10
likely to attend tumor boards if they are not optimally
managed, which can negatively impact the treatment Uncertain next steps: Workflow inefficiencies in the
decisions made at the tumor board meetings.8 In the preparation and presentation stages of a tumor board
aforementioned Canadian study, the authors noted that can hamper the group’s work long after the meeting,
“participants were more likely to attend and participate while insufficient documentation makes it difficult for
in [tumor boards] if there was a diversity of clinical participants to follow up on treatment decisions and
specialists and patient case topics.” They went on exchange feedback.
to describe the situation at one of the hospital sites,
“where the consistent absence of a radiation oncologist In a U.S. study of tumor boards in the Veterans Affairs
and gastroenterologist resulted in more disjointed (VA) health system, researchers “observed little
discussion and fewer active treatment plans compared association of multidisciplinary tumor boards with
with the other two observed sites.”7 While tumor board measures of use, quality, or survival” but noted that
participation is mandatory in the U.S. and numerous measuring only the existence of a tumor board is
other nations, the benefits to be derived from solutions not enough to assess their impact on patient care ortreatment outcomes.11 While researchers say those Furthermore, research has shown that recommendations
findings could suggest tumor boards do not affect agreed upon during tumor boards might not actually be
quality of cancer care in the VA system, they also followed in practice and/or may not adhere to clinical
suggest that the influence of tumor boards on quality practice guidelines; possible reasons for this include
care may be subject to variation based on the “structural inadequate documentation and, in some nations, the
and functional components [of the meeting] and the absence of key specialists.2,4,10 Participants in the UK
expertise of the participants.”11 The authors emphasize study of urological and gastrointestinal tumor boards
the need for further study to assess how the structure reported that approximately 91% of cancer patients
of a tumor board can be reformatted to create the ripple discussed at a tumor board received a treatment plan as
effect of improving quality of care. An accompanying a result of that meeting; of those, only 90% were actually
editorial called for a “feedback loop” to enhance tumor implemented.4
board structure, process and outcomes.12
“ Time is the most important factor in quality of care, and it is a scarce commodity in
medicine. Time to test, time to review results, time to listen to the patients, time to consider
the best therapeutic options.
”
- Dr. Sergi Serrano, Pathologist, Hospital del Mar in Barcelona, Spain
Conclusion
When common challenges in tumor boards lead to discussion and decisions can create confusion and,
suboptimal efficiency, it is possible such inefficiencies in some cases, prevent the team from following up on
could have unintended effects on patient outcomes. decisions at the point of care. Using tools that streamline
Complex and scattered clinical data makes it difficult and standardize the entire workflow process, from
to collect all relevant information and provide a preparation to presentation and documentation, can
comprehensive view of the patient for presentation help tumor boards overcome these challenges and
at the meeting. During the meeting, inefficient achieve the primary goal of choosing and implementing
presentation impacts time management, which can the best therapeutic options to improve patient
delay or negatively affect treatment decisions. Errors outcomes.
or accidental omissions in the documentation of theReferences
1. O’Brien JC. “History of tumor site conferences at Baylor University Medical Center.” Proc (Bayl Univ Med Cent). 2006;19(2):
130-131.
2. El Saghir, Nagi S., et al. “Tumor Boards: Optimizing the Structure and Improving Efficiency of Multidisciplinary Management of
Patients with Cancer Worldwide.” Am Soc Clin Oncol Educ Book 34 (2014): e461-6.
3. Macaskill, E. J., et al. “Surgeons’ views on multi-disciplinary breast meetings.” European Journal of Cancer 42.7 (2006): 905-908.
4. Jalil, Rozh, et al. “Factors that can make an impact on decision-making and decision implementation in cancer multidisciplinary
teams: an interview study of the provider perspective.” International Journal of Surgery 11.5 (2013): 389-394.
5. Krishnankutty, Binny, et al. “Data management in clinical research: an overview.” Indian Journal of Pharmacology 44.2 (2012):
168.
6. El Saghir, Nagi S., et al. “Global Practice and Efficiency of Multidisciplinary Tumor Boards: Results of an American Society of
Clinical Oncology International Survey.” Journal of Global Oncology 1.2 (2015): 57-64.
7. Look Hong, Nicole J., et al. “Multidisciplinary Cancer Conferences: Exploring Obstacles and Facilitators to Their
Implementation.” Journal of Oncology Practice 6.2 (2010): 61-68.
8. Foster, Tianne J., et al. “Effect of Multidisciplinary Case Conferences on Physician Decision Making: Breast Diagnostic
Rounds.” Cureus 8.11 (2016).
9. McEvoy C. Get on (Tumor) Board. Advance Healthcare Network. 2009. http://health-information.advanceweb.com/article/get-
on-tumor-board.aspx. Accessed August 2017.
10. Patkar, Vivek, et al. “Cancer Multidisciplinary Team Meetings: Evidence, Challenges, and the Role of Clinical Decision Support
Technology.” International Journal of Breast Cancer 2011 (2011).
11. Keating, Nancy L., et al. “Tumor Boards and the Quality of Cancer Care.” Journal of the National Cancer Institute 105.2 (2013):
113-121.
12 Blayney, Douglas W. “Tumor Boards (Team Huddles) Aren’t Enough to Reach the Goal.” J Natl Cancer Inst. (2013): 82 -84.
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