Seeking American Society of Clinical Oncology‐Quality Oncology Practice Initiative (ASCO‐QOPI) certification in a northern New England rural health system and cancer care network

Abstract In 2006 following several years of preliminary study, the American Society of Clinical Oncology (ASCO) launched the Quality Oncology Practice Initiative (QOPI). This cancer‐focused quality initiative evolved considerably over the next decade‐and‐a‐half and is expanding globally. QOPI is undoubtedly the leading standard‐bearer for quality cancer care and contemporary medical oncology practice. The program garners attention and respect among federal programs, private insurers, and medical oncology practices across the nation. The MaineHealth Cancer Care Network (MHCCN) has undergone expansive growth since 2017. The network provides cancer care to more than 70% of the cases in Maine in a largely rural health system in Northern New England. In fall 2020, the MHCCN QOPI project leadership, following collaborative discussions with the ASCO‐QOPI team, elected to proceed with a health system–cancer network‐wide QOPI certification. Key themes emerged over the course of our two‐year journey including: (1) Developing a highly interprofessional team committed to the project; (2) Capitalizing on a single electronic medical record for data transmission to CancerLinQ; (3) Prior experience, especially policy development, in other cancer‐focused accreditation programs across the network; and (4) Building consensus through quarterly stakeholder meetings and awarding Continuing Medical Education (CME) and American Board of Medical Specialists (ABMS) Maintenance of Certification (MOC) credits to oncologists. All participants demonstrated a genuine spirit to work together to achieve certification. We report our successful journey seeking ASCO‐QOPI certification across our network, which to our knowledge is the first‐of‐its‐kind endeavor.

tion and respect among federal programs, private insurers, and medical oncology practices across the nation.The MaineHealth Cancer Care Network (MHCCN) has undergone expansive growth since 2017.The network provides cancer care to more than 70% of the cases in Maine in a largely rural health system in Northern New England.In fall 2020, the MHCCN QOPI project leadership, following collaborative discussions with the ASCO-QOPI team, elected to proceed with a health system-cancer network-wide QOPI certification.Key themes emerged over the course of our two-year journey including: (1) Developing a highly interprofessional team committed to the project; (2) Capitalizing on a single electronic medical record for data transmission to Can-cerLinQ; (3) Prior experience, especially policy development, in other cancer-focused accreditation programs across the network; and (4) Building consensus through quarterly stakeholder meetings and awarding Continuing Medical Education (CME) and American Board of Medical Specialists (ABMS) Maintenance of Certification (MOC) credits to oncologists.All participants demonstrated a genuine spirit to work together to achieve certification.We report our successful journey seeking ASCO-QOPI certification across our network, which to our knowledge is the first-of-its-kind endeavor.2][3] It is also the oldest state (median age 44.9 years). 4e current age-adjusted cancer incidence and mortality rates exceed US averages of 478.5 v. 439.8 per 100 000 and 163.7 v. 147.3, respectively. 5 This corresponds to the 10th and 11th highest incidence and mortality rate(s) in the nation. 5In 2019, 9600 cancer cases were diagnosed in Maine. 6In 2021, the MHCCN reported an analytic tumor volume of 6974 cases (Figure 1/Panel B), which represents 73% of Maine's cancer burden. 7 1999, the Institute of Medicine published a report that outlined opportunities and potential strategies to improve evidencebased cancer care nationally.8 This report preceded ASCO's efforts to define, measure, and implement a quality-based cancer program-Quality Oncology Practice Initiative (QOPI).9 Between 2003 and 2006, ASCO led a pilot program in three distinct phases involving 23 oncology practices that laid the foundation for the formative ASCO-QOPI certification.10,11 Since 2006, QOPI is now available to practices of any US-based ASCO member.10 Refinements include developing standards based on the ASCO/ Oncology Nursing Society for safe chemotherapy administration, oral oncolytic drug standards, and on-site survey(s). In fall 2020, we embarked on a feasibility discussion with ASCO seeking a health system-rural cancer network-wide QOPI certification.
We hypothesize that pursuit of QOPI certification will have salutary benefits across a rural cancer care network.Illustrative benefits are not limited to establishing quality cancer care across all our practices, once fully operational it will enable network practice leadership to identify quality trends at both the practice and individual provider levels, reduce care variation, and importantly provide documentation of quality cancer care across our network and share with third-party payers, many of whom identify and/or use QOPI metrics as state-of-the-art for contemporary cancer care.We report our experience spanning more than 2 years seeking accreditation across eight member practices.These included an academic practice, three smaller community practices, and four practices at critical care access hospitals providing cancer care in six rural locations (Figure 1/Panel B) in Northern New England.

| Background
By 2016, all 11 MHCCN hospitals were integrated into a centralized Network Tumor Registry, which provided an excellent departure point for reporting numerous quality cancer measures.
MaineGeneral successfully renewed their QOPI certification in 2022.Their oncologists provide cancer care for patients at Franklin Memorial Hospital in Farmington and accordingly measurement data are not reported from this MH member practice.This arrangement is geographically expedient for rural cancer care in our health system and has been operational for 7 years.The Franklin practice, however, follows all MHCCN (QOPI) policies.
MaineGeneral provided valuable mentorship to the MHCCN team over this journey.By January 2021, all MH member oncology practices operated under a single electronic medical record (EMR)-Epic Systems (Verona, WI).This arrangement facilitated the decision to electronically report measurement data to Cancer-LinQ. 15,16St. Mary's Regional Medical Center utilizes a separate instance of Epic hosted on their premises and managed by their organization.The MHCCN team does not have access to data within St. Mary's Epic instance.Given this, including St. Mary's Epic data would have required a separate Business Associate Agreement (BAA), dedicated IT resources, and an inventory of their workflows and Epic configuration items.We elected to defer including St. Mary's for these reasons.In collaboration with the ASCO-QOPI administrative team, mutually agreeable accommodations for these three sites were made.
With this backdrop, the MHCCN team reviewed published ASCO-QOPI Standards Manual and QOPI Certification Track 2021 Measures Summary (Table 1). 17

| Stakeholder meetings
In December 2021, the QOPI leadership team assembled our first stakeholder group meeting.The group is comprised of all MHCCN oncology providers, pharmacists, select Advance Practice Professionals (APPs), and practice managers, and our informatics team is devoted to the project.These forums were convened quarterly, chaired by our leadership team with an agenda distributed in advance, and minutes kept.Physicians were required to complete a postmeeting survey.A monthly electronic newsletter was distributed that reported progress to date.

| Phase V-Survey preparation
Leading up to survey the leadership team and stakeholder group convened several ad hoc meetings to review final preparations.We worked closely with the ASCO-QOPI surveyor conveying policies, answering queries, assisting with organizing the on-site review, and selecting two sites for survey.

| QOPI pre-certification Phase I
In January 2022, we achieved an initial Round 1 passing score of 67.61% (target ≥55%) required for the QOPI Pre-Certification Track.
With cumulative reporting of CancerLinq data, our original January 2022 submission score is now 74.23%, which improved to 75.61% as of December 2023 (see Figure 2, Panel B).Our manual abstraction observed nearly 90-100% compliance on the majority of measures (Table 2).While several measures were documented in the EMR, they were not in discrete "searchable" fields for electronic transfer.Six QOPI measures/standards are worthy of comment (Table 1).
Staging documentation (Core 2) and Performance Status (PS) were nearly uniformly entered in EMR office notes, though not in searchable fields.Our lung cancer PS score (NSCL84) was our lowest at 5.19 (4/77).Chemotherapy intent, curative versus non-curative (Core 10), while a defined and required element in our informed consent form for treatment, which is scanned into the EMR, is also not searchable.Use of G-CSF (QOPI15) in patients receiving chemotherapy for metastatic cancer (lower score is better) at 20.95 (44/210) was judged to be slightly higher than it should be.As we approached survey an admitted gap was to develop a consistent approach for pregnancy testing in women of childbearing potential (QOPI Standard 1.2.4), who are about to receive chemotherapy.These issues were addressed at the stakeholder meetings.When using CancerLinQ for automated abstraction, a passing QCP score of ≥55% is required.
Antiemetic therapy for high-risk antineoplastic agents proved challenging.Our Round 1 score (SMT28/28a) was among the lowest at 12.34 (10/81).This measure requires use of an NK1 receptor antagonist and olanzapine.We reviewed our guidelines and discussed this with our providers and pharmacy teams.First, this was not judged a clinical problem from our patient experience and interdisciplinary discussion among providers, pharmacists, and chemotherapy nurses.
Manual abstraction revealed that neither drug was administered nor one of the two agents in the majority of instances.We elected not to aggressively pursue this measure and shared this recommendation with the stakeholder group.Rationale was based on an unsubstantiated problem for our patients, would entail new purchasing arrangements, and potential for polypharmacy and introducing new drug interactions and side effects.Our current practice administers a combination of palonosetron (5-HT3 antagonist), fosaprepitant (NK1 antagonist), and dexamethasone in this setting with excellent results.
We reached out to ASCO-QOPI to share our concerns about this measure and learned this has been previously raised by other practices.On balance, we thought it prudent to defer managing up on this particular measure.

| Phases II/III
The largest barrier to technical implementation proved to be a lack of standardization in documentation across facilities and providers, in addition to limited structured data (e.g., cancer staging).For instance, due to Epic build incompleteness, a range of PS scores were not being transferred into the reporting environment.This significantly contributed to score reductions.

| Stakeholder meetings and CME/MOC credits
Participation by providers, other healthcare team members, and our QOPI leadership was robust.Physicians valued participation as well as their input on addressing ways forward.The meetings were free of commercial bias or other interests.We successfully applied for continuation of this activity for 2023 and 2024.
The Stakeholder meetings provided an interprofessional forum to discuss improvement approaches.A fundamental principle when making revisions to EMR workflows was to develop strategies that were efficient, reduced redundancies, and limited the number of "clicks" to help physicians.At the outset, G-CSF utilization was reviewed in patients receiving chemotherapy for metastatic disease and it was deemed best to permit clinical discretion for use based on acceptable guidelines (e.g., age, comorbidities, myelotoxic risk of regimen among others) rather than prescribe this.The group was also apprised of foregoing major modifications in our approach to antiemetic support for patients receiving highly emetogenic chemotherapy.These recommendations were valued.
Accordingly, following physician consensus (post-meeting survey responses) and working closely with our informatics team, we built a chemotherapy intent "hard-stop" in our electronic order sets in To our knowledge, the QOPI accreditation journey reported herein is the first-ever successfully executed across a health system in an essentially rural cancer care network.Several themes emerged from the start.Foremost, this endeavor involved a highly interactive and engaged interprofessional leadership team of oncologists, nurses, pharmacists, informatics analysts, and quality improvement experts over the course of our journey.This approach is of paramount importance.The team was committed to the project, demanded discipline, and met routinely to monitor progress over the two-year course seeking QOPI certification.Secondly, strong institutional and informatics support to realize this goal was vital.Without the electronic linkages in our health system, the collective effort of single site-by-site, manual abstraction of data across a healthcare system is highly impractical.The difference between achieving a pre-certification score of >75% for manual abstraction versus ≥55% for electronic transfer must be carefully considered.While a lower benchmark for the latter, the time and effort required at the outset for manual abstraction is comparable to expended effort to track and report data electronically.Now that we have operationalized Can-cerLinQ electronic data reporting enormous efficiencies in time and effort are realized for each successor accreditation period.We feel this is a justifiable and worthwhile approach that spanned more than 2 years.Attention to identifying EMR searchable fields became readily apparent and the need for a strong informatics team to accommodate and build the changes that are required cannot be understated.This was undoubtedly a much more cost-effective manner in which to proceed and once built, tees up future activities and engagements.This venue provided opportunities to define more optimal workflows, especially electronic, and allow physician-driven input on clinical decision-making.Offering professional educational and certification credits placed value on physicians' time and participation.
There are opportunities to provide better care to patients and improve documentation.Cancer staging is an illustrative example.Clinical staging presents challenges across the nation and improvements in our EMR documentation were needed, despite frequent documentation in individual office visit notes. 42Access to traceable staging data in the EMR facilitates participation in treatment pathways given the complexities and expense of contemporary cancer treatment, and referral of advanced stage patients for palliative care.Our care teams appreciated the need to develop strategies to protect women of childbearing potential and the adopted approach will clearly benefit patients and providers.The efficiencies we are building into our EMR and the power of the CancerLinQ platform will be realized by our practices in the coming years. 43This is nicely illustrated by our recent progress on the Epic TNM staging initiative.
[46] Contemporary cancer care is complex and exorbitantly expensive with numerous alternative payment models and value-based care initiatives.Accordingly, quality measurement in oncology is rapidly advancing. 479][50] What is clear-physicians genuinely want what is best for their patients, sensitivity to federal and private reimbursement approaches are increasingly tethered to quality initiatives, and strategies that embrace physician input and clinical discretion are likely to be more successful. 50Given this, ASCO-QOPI is a physician-driven, peerreviewed process that our organization embraced and for this reason set upon this journey.The MHCCN is better for this achievement.

| CONCLUSIONS
We report a successful two-year journey to seek ASCO-QOPI certification in a rural cancer network.Keys to our success included a robust interprofessional team devoted to the work, a single EMR across our health system and participation by our informatics team, extensive experience with other cancer-focused accreditations, and willingness to embrace and value physician input and clinical discretion capitalizing upon an innovative approach with our Stakeholder group.In the end, this effort was simply the "right-thing-to-do" for our patients, their families, and our providers.By sharing our approach we are hopeful this can guide other rural health system cancer care practices and networks.

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E Y W O R D S accreditation, ASCO-QOPI, cancer network, oncology, quality improvement 1 | INTRODUCTION In June 2017, MaineHealth (MH), a leading integrated health system in the nation announced a $10 million, 5-year grant from the Harold Alfond Foundation supporting The Development of an Integrated Patient-Centered Oncology Service Line for Maine.The award formally launched the MaineHealth Cancer Care Network (MHCCN), which is comprised of nine MH member organizations and two affiliates at MaineGeneral Medical Center-Harold Alfond Center for Cancer Care in Augusta and St. Mary's Regional Medical Center in Lewiston.In 2023, MH was divided into three regions-Southern, Coastal, and Mountain (Figure 1/Panel A).MaineHealth provides healthcare services to 1.1 million people in 11 of 16 counties in south-central Maine and Carroll County in eastern New Hampshire.Since December 2018, the MHCCN has undergone expansive growth substantiated by rapid evolution of a network-wide employed medical oncology group.In August 2019, MHCCN was competitively awarded entry into the NCI Community Oncology Research Program.The Portland practice in October 2020, assumed a major teaching role in the Maine Track Program-Tufts University School of Medicine undergraduate medical education for the second-year hematology-oncology course (last 3 years taught in Maine); and in July 2023, launched a 3-year combined Hematology-Oncology Fellowship focusing on rural cancer care.

, 18 2
.2 | QOPI pre-certification Phase I-Preliminary work We initially sought an IRB-approved research exemption to consider the project quality improvement (Figure 2/Panel A).Thereafter, a BAA and registration to gain access to the Quality Initiative dashboard was executed with ASCO-QOPI.Our team worked with our Information Technology Department for feasibility assessment for electronic data transfer.This required a project charter and led to another BAA with CancerLinQ.During the onboarding process, CancerLinQ provided the Panel A. MH regions and organization entities.(Note: MaineGeneral Health/Harold Alfond Center for Cancer Care staffs and provides oncology care at Franklin Community Health Network and St. Mary's Regional Medical Center were excluded (see Methods for discussion.)Panel B. MHCCN Network Tumor Registry analytic tumor volume.(Note: sites that did not participate -*care provided by MGMC/HACCC oncologists; **separate QOPI program and re-certified in 2022; and ***operates under different EMR.)

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Preliminary discussions with ASCO-QOPI team for health system certification -Go / (No Go) feasibility assessment Fall 2020 IRB submission to determine quality-based project (i.e., requested research exemption -granted) IRB-Institutional Review Board; EMR-Electronic Medical Record; CY-Calendar Year; KPI-Key Performance Indicator.Graph depicting MHCCN CancerLinQ scores since completion of Pre-Certification Phase (Round 1) in January 2022 and updated through December 2023.
F I G U R E 1 MaineHealth's (MH) three regions with member/affiliate organizations (Panel A); and MaineHealth Cancer Care Network (MHCCN) analytic tumor volume by member site (Panel B).MHCCN team with SQL code to extract data elements they required from Epic.This code targeted Epic's Clarity reporting environment, which is updated nightly with changes from Epic's Hyperspace (frontend interface).The MHCCN team worked with CancerLinQ to develop code to target the Medical Oncology population from Epic, and to isolate specific Epic configuration items that were needed for measure calculations, including Flowsheets, Note Types, and SmartData Elements.In total, 19 SQL extracts were executed weekly to pull the previous week's data.The MH Integration team established secure delivery to CancerLinQ through the Secure File Transfer Protocol (SFTP).During this period, the team also began to socialize the QOPI initiative across all MHCCN sites and assemble a stakeholder group.Taking advantage of our Network Tumor Registry we embarked upon manual abstracting 2020 QOPI Pre-Certification measures from up to 10 (randomly T A B L E 1 Quality Oncology Practice Initiative certification measures and policies.SmartLinQ QOPI ® Certification Track 2021 Measures Summary for electronic reporting Module Measure Measure title Core 2 Staging documented within 1 month of first office visit.Core 4a Pain quantification score during first two encounters.Core 10 Chemotherapy intent (curative vs. non-curative) documented before or within 2 weeks after administration.CRC 68 Adjuvant chemotherapy received within 4 months of diagnosis by patients with stage III colon cancer.GynOnc 94 Platin and/or taxane administered within 42 days of staging for ovarian, fallopian tube, or peritoneal cancer.Lung 84 Percentage of patients with initial AJCC stage IV or distant metastatic lung cancer whose performance status is documented.selected)chartsacrossrepresentativetumortypes including breast, colorectal, and non-small cell lung cancer cases.This was undertaken at all eight participating member sites to determine baseline assessment, identify gaps, and to help with electronic data transfer (see Table2).Following review of the manually abstracted data our QOPI team convened once or twice a month via Zoom.Panel A. -Project timeline of key MHCCN QOPI events.Panel B. F I G U R E 2 Project timeline (Panel A) and graph depicting MaineHealth Cancer Care Network (MHCCN) CancerLinQ scores over course of project (Panel B).2.3 | Phases II and III-Electronic data transfer to CancerLinQ An illustrative example of the impact of our QOPI accreditation immediately followed our pilot staging quality improvement workflow process that is now going live across our network.We are now able to track this work at the individual practice or provider level.Effective Thirdly, prior extensive experience across a variety of cancer-focused CoC accreditations (especially for tumor registration, breast and rectal cancer) and American College of Radiology for radiation oncology practice proved valuable.Our robust Network Tumor Registry provided strong leadership for this undertaking and readily identified gaps and helped frame ways forward in the EMR.Finally, creating a Stakeholder group and offering CME/MOC credits was prescient and valued by physicians.