Dr Dinesh Kapur on Value of Community Oncology, Developing AI Tools for Patient Care

The American Journal of Managed Care^® (AJMC^®) recently spoke with Dinesh Kapur, MD, of Eastern Connecticut Hematology and Oncology, also known as ECHO, an advanced community oncology conference. In this interview, we discuss the value of community oncology, the importance of clinical trials in a community setting, and how the staff at ECHO is using remote work during the pandemic to optimize the use of artificial intelligence to improve patient outcomes. Earlier this year, EHCO became the fifth community oncology practice to join OneOncology, a national network of independent oncologists. ECHO is the first practice in New England to join OneOncology.

AJMC^®: Welcome, Dr. Kapur.

Kapur: Thank you, Allison.

AJMC^®: You both lead a community practice and you are on the board of the Community Oncology Alliance—why is community oncology so important to you?

Kapur: You know, if you look at the demographics of cancer care in the United States 80% to 85% of the care has been delivered in the communities. And for many years community oncology did not have a voice or a seat at the table when it came to delivering metrics of oncology care, or even voice at the table with insurance companies, and a representation in Washington DC, showing what community oncology really does. So COA has been that voice for us in the community. And that's why it was so important for me to be part of that organization. And I've been with color now for I think, probably 14 or 15 years if not more.

AJMC^®: I read that after Yale, ECHO conducts the most clinical trials in the state of Connecticut—is that correct or no?

Kapur: I believe so. We have consistently been offering a very rich portfolio of clinical trials at ECHO. And at any given time, our clinical trial enrollment is way over any of the organizations that we work with, or in the state of Connecticut. And that has been really a hallmark of our practice, I would say for the last 25 to 30 years. And we have an independent research department, which belongs to ECHO, and we are able to get amazing clinical trials right in the beginning stages. And now what is happening is we are so far ahead in just-in-time trials, that during the COVID shutdowns and closures last week, or a week and a half ago, we enrolled 3 patients in brand-new clinical trials because we were able to open the trial so quickly. So when it comes to clinical trial monitors and organizations, they actually value that, that work is still ongoing in our practice, patients are still coming in and patients and their cancers still need to be treated. And they need to be given the most appropriate and cutting-edge care. So we've always been doing this, and we take great pride in that.

AJMC^®: Why is it important to have clinical trials moved into the community? Do you think it increases the diversity and perhaps demographics of people who wouldn't otherwise be able to get to a large city to participate in a clinical trial?

Kapur: So I have a very simple thing to say. Many years ago, I coined the term “cutting edge cancer care close to home,” and I'm changing that now. And you can actually quote me on this one, and I'm changing it to “personalized cancer care in a personal setting.” And why is that important? You have patients who come into our clinics, they know our nurses by first names. They know the front office by first name, and it actually is a great responsibility on us when we are providing this cancer care to our patients, that we are on the cutting edge of cancer care delivery. We don't want our patients to be traveling a couple of hours to Boston or New York or some other city to gain access to trials, if we can do them in our own community. Now, there are certain things we cannot do. And we don't even pretend that we can do them. Such as, you know, stem cell transplants or allogenic transplants, and we let the tertiary centers do those. But since the majority of the cancer care is delivered in the community, why not have the clinical trials also be part and parcel of cancer care delivery metrics, and in an organization like ECHO?

AJMC^®: Your practice is also part of the OCM. Where do you see value-based care in the next couple of years as the OCM transitions to the Oncology Care First model?

Kapur: So we have learned a lot from the Oncology Care Model in our practice. In fact, I think it was one of the smartest things that we did, because it changed the entire dynamic of our practice. Our nurses, our front office, our billing staff, everybody got so engrained into Oncology Care Model, that they are all looking for value and efficiency based on that model, to the point that we were one of the first practices that was cited for reducing the ER [emergency room] utilization for maximum reduction in ER utilization in the country. So we did a presentation for Medicare to, I think, 38 or 39 practices regarding the same. So the Oncology Care Model, for us, I think it brought many things to our practice. And one of the biggest things that it did was we thought we did great care at a community level, but we never had the data to prove it. And we did not have the infrastructure to prove it. So what it did for us was it we implemented a lot of infrastructure and a lot of data into our practice. And we had staff with functions dedicated to the Oncology Care Model, including the fact that we hired nurse navigators. We have we always had the chemo teaching done by our nurses and advanced practitioners. But it gave us so many things that we had not done that we implemented into our practice that brought further improvement into the practice, including putting in triage nurses, and triage to reduce ER utilization. But the biggest thing that it did for us, which will really help us in the near future, or when the Oncology Care First comes in, is that we are ready for it. We have put in so much technology infrastructure in our practice, and I can actually look at AI [artificial intelligence] as the next step for our practice. And I'm already working on [it] with our technology partner, looking at where we can make, where we could have made further difference in ER reduction, hospitalization reductions. Can we identify these patients way before and bring them into the clinics to prevent them from going to the hospital or prevent them from going to the ER? So we will be very well positioned for the Oncology Care First model. And we are actually ready for it - really, we are. For a small practice our size to put in the technology infrastructure that the OCM really helped us with. And now learning and building on that has actually been a very big, big plus for us.

AJMC^®: As a small practice, you have, I think, what, 7 physicians?

Kapur: Yeah, 7 practice physicians and we have 4 nurse practitioners.

AJMC^®: Technology was actually going to be my next question. And it's interesting that you're already looking at AI - when you expect that to roll out?

Kapur: So let me tell you… if I may, I'll share a very interesting detail about the COVID pandemic in our practice, since we broke our office into 2 teams. What we are utilizing the team at home is they're working with our technology partner in analyzing some of the data that we have currently about our last 3 years’ worth of data with OCM. And putting in AI models to predict for what patients, what chemotherapy is, what regimens, what toxicities, we can minimize, to prevent patients from going to the ER or to the hospital. Or bring the patients in sooner. So that we actually are able to predict rather than act in a retrospective manner, we work in a prospective manner in bringing the patients into the clinic. So this has been actually one thing that we've done in our practice and it did 2 things for us. One, it helped our staff stay engaged in oncology when they are working from home and two, it gives them a purpose of, you know, that they're really working in some clinical dimension with patient care. With a technology partner, yes, they're not touching the patients right there, but they are looking at the data. They're looking at the data sets. And they're looking at the technology piece of what they do. And it's good for their emotional and mental wellbeing in my mind. So that was one, one thing that we initiated. And I anticipate, to try to answer your question, when do I see some of that happening? I'm hopeful that some of the preliminary work from this project that we are doing on our own, I plan having some publications on that in the next, I would say in the next month. In fact, that is my goal, that by the end of April, early May, we at least have some preliminary draft of our research from our practice.

AJMC^®: That sounds really interesting and really incredibly useful to people right now who are at home wondering you know, are there any silver linings in this? So the fact that your staff is working that way is fantastic.

Kapur: Well, our staff has taken to it....Obviously, when when you're doing something new, everybody's apprehensive. But once they see what the mission is, our nurses have stepped up, our doctors, our APRNs [advanced practice registered nurses], everybody's stepping up in this manner.

AJMC^®: How are your patients doing right now in this uncertain time?

Kapur: So that has been the challenge. Patients who are on active treatment, we have put in so many safeguards in our practice, and the hospital as well did it. But we put in so many safeguards for our patients, that we want to provide care for them in the safest manner possible to the point that we actually rearrange our entire clinic to provide more than what was required of us in our infusion rooms, in our patient rooms. So that patient care is delivered in the safest manner possible. But on the other side, the patients are actually very thankful that we have not closed the practice or we have not cut back the hours of the practice. All that we have done is that the patients who are on active treatment or patients who need immediate office visit, they are seen without breaking a sweat. They are still on the same schedules. Nothing has changed there. And only the patients that we we felt that we can move them up a little, move them ahead by a few weeks—there appointments have been rescheduled and they've been given the option that if they did not want the appointment to be rescheduled, then we'll see them in a telemedicine format. And a lot of our patients are older. So it's actually very interesting that some of them are technologically very savvy. Some of them are not, and you have to guide them through it. But so are we. We were not technology savvy either. I mean, I was not when I started doing this telemedicine thing. And there were times that my internet didn't work or my phone crashed or my battery was not charged. But we have learned and patients have learned too. And patients are actually very thankful that we are not having them come to the office to talk to them about what we found on their lab tests and what the followup plans are. And they are really very thankful that they are engaged with us, we are engaged with them, but we are not subjecting them to a risk of of coming to the office and be exposed to other sick people. Because you have to realize we are working with a population that is extremely vulnerable. They are on active treatments. They are on chemotherapy, immunotherapy, clinical trials. And we want to really respect that as far as they are concerned.

AJMC^®: I think every physician I've spoken to so far hopes in some way, shape, or form that telemedicine continues even after the national emergency is over. Do you fall into that category as well, for these reasons [such as] why make someone come in just to hear a lab result?

Kapur: I think medicine will change and I think it should change because if we can do some of these things on a telemedicine basis, the patients don't have to leave their home too come. Some of our patients can't leave and they have to come. I think it'll go a long way in delivering better care for patients. But we have to be sure that the technology works, not just for us, but on the other side, too.

AJMC^®: Right. Is there anything else you want to say, especially looking forward to the next couple of days when the COA meeting happens virtually this year?

Kapur: I think the one thing I would say is that the mission of community oncology has always been delivering cutting edge cancer care to the patients in their own communities. And I see no reason why good, cutting-edge cancer care practices cannot deliver that care in the patients' own communities. Everybody thinks about big networks and tertiary centers, they have a role. But their role should be for doing cutting-edge surgeries, cutting-edge treatments, but their role should not be to get engaged in day-to-day cancer care that patients can receive in their communities. And as long as communities can provide that technology infrastructure and stay ahead of the curve, and keep on looking forward to bringing in more and more services for their patients—I'll give you an example. Our practice has 2 people who are dedicated to getting patients copay assistance. You know, that's all they do. They'll find, you know, patients can't afford their payments or transportation. And we are working on all those things are at our level. And so what am I looking for from a COA standpoint? I think COA has done remarkably, an amazing job, for community practices by highlighting what we do. But also by highlighting the policies that are made in Washington DC as to how they adversely impact community practices. And if we didn't have a voice at the table, we would be swept away. But because of COA we've all been able to stand strong. And we all learn so much from our COA meetings and COA colleagues, some of them are bigger than us, some of them are smaller than us, that it really reinforces the need as to how you, how you're able to learn from each other, how you're able to network from each other. And I think that's our strength, and that'll be our strength going forward. COA's working on some other initiatives that I think they'll roll out, so I can't I'm not at liberty to speak about it today. But on Wednesday, we will have some other initiatives, which will be mind blowing for community oncology and for our patients—really, it really will be for our patients. The initiatives COA has taken which will directly impact our patients in a much positive manner.

AJMC^®: Well, be sure to look forward to that; we'll be covering the conference. And we hope that you have a good rest of your week and a good, productive conference. And thank you for speaking with us today.

Kapur: Absolutely, it's a pleasure and looking forward to it.