Implementation of a Flowsheet in an Electronic Medical Record (EMR) to Standardize Chimeric Antigen Receptor T-Cell (CAR T-cell) Toxicity Reporting

Abstract

Topic Signficance & Study Purpose/Background/Rationale We initially conducted a quality review of patients treated with CAR-T therapies and noted inconsistencies in cytokine release syndrome (CRS) and neurotoxicity grading due to data located in various areas within our EMR and fragmented documentation between the EMR and paper record. Consistent documentation of CAR T-cell toxicity amongst providers is important for assesment and management of toxicities post-infusion in cellular therapy programs. EMR flowsheets facilitate tracking and communication within the healthcare team and ensuring proper clinical documentation. Method, Interventions, & Analysis Key members from the Informatics and Adult Stem Cell Transplant Program collaborated to develop a flowsheet to capture all elements to grade, identify symptoms and toxicities. To enhace clinical documentation, we created a tool that brings in several flowsheet enteries to the notes and to guide providers for accruate grading of CRS and neurotoxicity related to CAR T-cell infusions for the Epic® EMR. Findings & Interpretation These electronic tools were developed during the planning phase of the CAR T-cell program. Two flowsheets were used by nurses to document CRS (Figure 1) and neurotoxicity (Figure 2) based on practice guidelines established by program leaders. The flowsheet enteries were added to provider's daily documentation through “smart phrases” (Figure 3) that captured grading of toxicities and guided clinical decision making. Discussion and Implications Development of tools to standardize symptomology reporting and effectively capture data is imperative for CAR T-cell therapy programs. EMR tools can facilitate management and streamline data collection for reporting of toxicities. As more patients receive this novel immunotherapy, it will be important to have tools in place to assist with tracking patient outcomes. The future goal is to have grading auto-generated to enhance real time care delivery with alert based warnings for worsening CRS or neurotoxicity, and for these tools to reflect current standards of care, including revised consensus criteria for grading and reporting of CAR-T toxicities currently being developed by the ASBMT.