Electronic Tools Enhance Documentation of Patients on CAR T-Cell Therapy

Dylan Essner

CAR T-cell therapy has become one of the most promising therapeutic modalities in hematologic malignancies, said Dylan Essner, an Epic Beacon Analyst at Washington University in St. Louis. However, more refined tools are needed to efficiently track patients receiving the therapy.

To that end, novel electronic documentation tools developed by technicians at Epic Beacon utilize flowsheets and smart links to allow healthcare providers and nurses to input patient data with ease.

At Epic Beacon, Essner developed an electronic tool that consolidates flowsheets for documentation of cytokine release syndrome (CRS), immune effector cell-associated neurotoxicity syndrome (ICANS), and immune effector cell-associated encephalopathy (ICE) into 1 document for reference.

"[The value in implementing these tools] is to get better data," said Essner. "We know that these reporting tools and these building blocks we have developed can lead to better documentation. We are going to be able to query that information easier and look into the system to calculate how many patients we have on CAR T-cell therapy."

There are currently 2 CAR T-cell therapies that are approved in the United States. In August 2017, tisagenlecleucel (Kymriah) became the first CAR T-cell therapy to receive regulatory approval when the agency authorized the treatment’s use for patients ≤25 years of age with B-cell precursor acute lymphoblastic leukemia that is refractory or in second or later relapse.

In 2018, the indication was expanded for use in adult patients with relapsed/refractory large B-cell lymphoma—including diffuse large B-cell lymphoma (DLBCL), high-grade B-cell lymphoma, and DLBCL arising from follicular lymphoma—after ≥2 lines of systemic therapy.

In October 2017, the FDA approved the CD19-directed CAR T-cell therapy axicabtagene ciloleucel (axi-cel; Yescarta) as a treatment for adults with relapsed/refractory non-Hodgkin lymphoma.

In an interview with OncLive, Essner discussed the utility of these tools, among others, in the documentation, grading, and treatment of patients receiving CAR T-cell therapy.

OncLive: What electronic tools have you helped develop to track patients on CAR T-cell therapy?

Essner: Within the CAR T-cell therapy build at Epic Beacon, I mainly help develop the documentation tools for flowsheets. I built the CRS, ICANS, and ICE flowsheets and then included them in 1 flowsheet template. In turn, providers and nurses can document their patients’ CRS, ICANS, and ICE.

Some of those—particularly the ICANS and ICE flowsheets—have a built-in formula that allows the flowsheet to autopopulate the grade and score of the [occurrence]. The healthcare provider or nurse can insert the different data points for each flowsheet. Then a row at the bottom autocalculates the grade for each patient so the provider or nurse does not have to.

For CRS, the provider or nurse can access [the flowsheet], which provides an informational chart [for them to reference]. From there, they can grade each patient on the bottom row.

With those flowsheet data, we also built smart links that pull the data and automatically populate them into the progress notes to make documentation much easier for healthcare providers.

What other tools are currently in development?

We have some other tools we have developed regarding best practice alerts (BPAs). For example, if a patient is receiving CAR T-cell therapy and the provider orders steroids for them, [the system] will alert [the provider] that the patient is on CAR T-cell therapy and, therefore should probably not receive steroids.

We are currently working on a new BPA that will alert [providers] in the emergency room that a patient receiving CAR T-cell therapy is coming in, so they can contact the on-call oncologist.

Additionally, we are working on some reports that can query information based on the different building blocks [I highlighted]. We built some electronic prescribing records for the CAR T-cell orders that allow [us] to identify which patients had [been prescribed] CAR T-cell therapy. From there, we can query how many patients we currently have on CAR T-cell therapy.

How could this technology impact future practice in oncology?

As we implement these building blocks for reporting, we can get more information and better documentation moving forward.

Thorough documentation and making sure that everything is entered into the system correctly [is critical] because the better the information is put in, the better we can use it for reporting.