Design and implementation of a patient management system for coordination of theranostics care at a major referral center

1. Introduction

The past decade has seen extensive growth of clinical Theranostics services across Nuclear Medicine Departments in the United States. The Food and Drug Administration (FDA) approval of multiple new radio-pharmaceutical therapies (RPTs), especially directed at prostate-specific membrane antigen (PSMA) for prostate cancer and somatostatin-expressing neuroendocrine cancers, has significantly increased the number of RPT patients requiring daily coordination.^1,2 As new RPTs become clinically approved and indications expand for existing RPTs, clinical volumes are expected to increase significantly.³ This increase in clinical volume, anticipated extension of RPTs beyond major academic centers into community sites, and the general workplace demands placed on all staff necessitate a paradigm shift in how the clinical workflow for Theranostics care is practically managed.

Commensurate with most Nuclear Medicine Departments across the United States, the Theranostics service at our institution has experienced substantially increased demand over the past several years to encompass several hundred patients. There are multiple FDA-approved RPTs offered at our center: Lu-177 vipivotide tetraxetan (Pluvicto^®), Lu-177 dotatate (Lutathera^®), Ra-223 dichloride (Xofigo^®), and Sodium Iodide I-131, in addition to therapeutic medical devices such as Y-90 radio-embolization. As a major referral center, our institution receives new patient referrals daily from multiple states across New England. Traditionally, out-of-institution referring medical oncology providers would independently refer to an affiliated provider, who would then manually assist in the coordination of eligibility screening and further engagement of our Theranostics team. However, with sharply rising patient referral numbers, this becomes unsustainable. Further, the lack of a standardized workflow across different institutions within and external to our medical enterprise network can result in significant resources directed towards manually coordinating the transfer of outside records, reviewing RPT eligibility, coordinating radiation safety assessments, and initiating patient scheduling and multidisciplinary follow-up care.

Due to these challenges, there was a clinical need to develop a streamlined approach. The ideal system would handle referrals arriving from multiple external centers, expedite the eligibility assessment, provide a robust framework to coordinate internal patient scheduling and unique RPT protocols, and ease communication between a large and expanding Theranostics team. Here we report the development and implementation of a comprehensive patient intake and management system for our Theranostics service, outline its key functionality, compare it to traditional models, and evaluate its utility through a survey and interview of stakeholders.

2. Methods

The key stakeholders involved in the administration of RPT care and their complex interdisciplinary interactions were first identified (Fig. 1). Traditionally, communications regarding RPT are performed on an individual provider-to-provider level, with tumor boards utilized in cases where complex treatment planning is required.⁴ However, due to the many multidisciplinary care team members involved in planning and organizing RPTs, the volume of patients, and the fact that our Theranostics Service spans multiple sites servicing multiple states in New England, we assessed different software environments to complement this model to develop a patient management system allowing real-time clinical and logistical management of patients. The Microsoft 365 software suite, comprising Office, Forms, Teams, Power Automate, and Outlook, was ultimately chosen to implement this design due to its ease of use, wide accessibility, ability to handle complex tasks and interactions, and its compliance with The Health Insurance Portability and Accountability Act (HIPAA) at our institution. Initial software development and pilot testing were performed in the summer of 2023 and implemented clinically in the Fall of 2023. Workflow integration was achieved through the development of a custom Microsoft Power Automate Application Programming Interface (API) to automate the multi-software system (Appendix A). An anonymous quality improvement/assessment survey of the utility of this system was conducted in the summer of 2024, approximately six months after launch, and administered to all clinical stakeholders and users across Medical Oncology and the Theranostics team (Appendix B).

Fig. 1.

Key stakeholders involved in RPT at our institution and their complex dynamic interactions. Note that this may differ across institutions. Created in BioRender.

3. Results

The overall design principles of the management system center around a standardized patient intake process, which begins with a set of HIPAA-compliant forms accessible to all referring providers (Fig. 2). A unique form is available for each RPT offered at our institution. These forms provide referring providers with pertinent information on the respective RPT, including package inserts, brief eligibility guidelines, and links to patient payment assistance programs. The form next solicits pertinent provider and patient medical record information for review; for external providers, a link to the Nuance PowerShare streamlined medical record and imaging upload system is provided. A section sub-sequently records the referring provider’s assessment of patient eligibility for the respective therapy as well as any active clinical concerns. A free response box is also provided for the referring provider to highlight any specific concerns or barriers to therapy. A sample summary of the questions asked on the intake form is provided in Fig. 3.

Fig. 2.

Initial intake form for referring providers. Identical forms exist for other RPTs offered at our institution.

Fig. 3.

Overall design principles of our patient intake and management system (Example for Lu-177 vipivotide tetraxetan (Pluvicto^®)). Created in BioRender. MRN: Medical Record Number, EMR: Electronic Medical Record, ARPI: Androgen Receptor Pathway Inhibitors, RPT: Radiopharmaceutical Therapy, PSMA: Prostate-Specific Membrane Antigen, PET/CT: Positron Emission Tomography/Computed Tomography, APP: Advanced Practice Provider.

Upon form submission, Power Automate instantiates the patient into an approval queue for review of treatment eligibility (Fig. 3). The system notifies all stakeholders of the new submission. Working asynchronously, providers in the department can then review the newly referred patient in a dedicated multidisciplinary communication channel on Microsoft Teams (including attending and trainee nuclear medicine physicians, Theranostics advanced practice providers (APPs), radiation safety officers, nuclear pharmacists, and nuclear medicine technologists). A brief clinical synopsis consisting of relevant past medical and oncologic history, labs, and social history is created using the information provided by the referring provider. Pertinent clinical and imaging findings for each patient are initially evaluated by physician trainees, who are encouraged to assess the patient’s suitability for RPT. Final assessments are then conducted by attending physicians and Theranostics APPs.

Upon initial departmental consensus, the patient approval form is updated accordingly, and an in-person patient consultation and consent appointment is scheduled with the physicians and APPs of the Theranostics Service, the radiation safety officer, and the patient. Power Automate then activates a notification system to alert the referring team of the approval decision. Additional discussion with each patient’s treatment team can be pursued if the in-person consultation raises additional issues. However, for most patients, this streamlined workflow provides a two-business-day approval decision turnaround time.

Patient approval automatically creates a virtual patient instance in the main Microsoft Teams-based workspace of the respective RPT. This workspace is used to comprehensively manage the patient’s specific treatment protocol and to facilitate communication with members of the patient’s clinical care team. Crucial to the main workspace is the centralized patient trackboard, which allows for easy management of all appointments and adherence to scheduled lab draws, infusions, and multidisciplinary follow-up care during the patient’s RPT course. This list is continually reviewed and updated by the Theranostics APPs. Each patient event on the trackboard can be flagged, prioritized, and assigned to departmental team members. Importantly, this information is always accessible to all Theranostics team members, allowing for easy coordination and built-in redundancy of workload, thereby removing reliance on any single individual.

Specific channels for communication are built into the main workspace of each RPT. These communication channels allow for discussion of clinical management with individual providers in a convenient, organized, and timely manner, facilitating expert and consensus discussion as needed, including with the medical oncology team. A centralized daily sign-out, including the most up-to-date information and notable outstanding tasks for all patients across all RPTs, is built using this main trackboard. Last, patient information is comprehensively transferred into a secure, Institutional Review Board (IRB) approved database, which stores all relevant patient conditions, treatment data, lab data, and outcomes. This database is regularly updated by an experienced member of the Theranostics team for future research, quality assurance, and improvement efforts.

The potential benefit of our system has been assessed specifically for our Pluvicto service. Since launch (8/2023–9/2025), 144 patient referrals for Pluvicto have been managed with this system, with 136 patients approved for consultation. Time from patient consultation to first treatment decreased from 34 ± 18 days (median ± inter-quartile range, IQR, data obtained from n = 28 available patients) pre-system to 23 ± 9 days post-system implementation (Kruskal-Wallis test, p < 0.04). Time from referral to the in-person consultation using this system to date is 7 ± 8 days. Results of an anonymous quality assessment survey on the utility of this system, administered to all clinical stakeholders and users involved with RPTs (4 Theranostics MDs, 9 medical oncologists, 2 Theranostics APPs, 5 oncology APP/RNs, 3 Technologists, 1 Radiation Safety Officer and 2 scheduling staff) showed overall positive feedback for this system (n = 10/26, response rate 38 %). When asked if the current system works well for day-to-day patient management, 80 % of respondents answered “Yes” and 20 % answered “Maybe.” Most responders (90 %) wanted a complementary tumor-board conference to this system for complex cases, albeit at 1–2-month intervals. Analysis of free-form comments on the impact of this system highlighted the following merits: ease of organization and collaboration, increased system-wide efficiency, consistency in care delivery, operational accountability, and support for onboarding new staff in a growing department.

4. Discussion

Demand for RPTs is increasing across the United States. Meeting this demand without critical strain on the Nuclear Medicine departmental staff requires the innovation of new comprehensive patient management systems. Here we show the design and implementation of a HIPAA-compliant patient intake, approval, and treatment management plat-form that successfully coordinates care at our major Theranostics referral center. Several commercial options exist and are in development for automated patient intake and management. However, to the best of our knowledge, no currently available commercial solution incorporates all the functionalities described in our implementation. Additionally, available commercial options can require substantial upfront costs and training. Our system is built on enterprise-grade tools already owned by most hospital systems. The initial intake form is widely available to all internal and external referring providers and prioritizes ease of communication across all stakeholders to avoid delays in care.

While traditional tumor board models and one-on-one communication work well for highly complex patients where real-time decision-making and collaboration are required, they are resource-intensive by design. Additionally, traditional tumor boards require a set time and set (small) number of patients to be determined a priori, which can introduce added scheduling and workflow constraints. Our system works as an adjunct to traditional tumor boards to decouple the initial patient review (with concerns from medical oncology teams raised on the intake form) and allow for earlier multidisciplinary input across the Theranostics service while accommodating a variety of unique schedules. Should a patient require more intensive real-time collaboration, as determined by any reviewing member, they can quickly be escalated to a regularly scheduled traditional tumor board and/or the broader care team. Expansion of the multidisciplinary team (e.g., Radiation oncology or interventional radiology) can also be accommodated easily within our system.

The initial motivation for our design was to streamline the clinical Theranostics service. We believe that this system also provides benefits for trainee education. Rising clinical volume across all aspects of nuclear medicine limits the time that physicians and APPs can regularly dedicate to in-person case discussion.⁵ Our asynchronous review process facilitates continued multidisciplinary discussions while ensuring each trainee is exposed to the full spectrum of patient cases encountered by our service, both on initial presentation and during an RPT treatment course. It is also important to note that trainee participation in this system does not replace the in-person consultation experience and attendance at individual RPT treatment appointments, which are essential components of the training required for board eligibility. Continued adjustment of how trainees interact with this system will be required as Theranostics training pathways evolve.⁶

An anonymous survey of key stakeholders revealed that this system was largely effective in its implementation and ongoing operations, with most respondents supporting the current framework. The system may also streamline accessibility to RPT, as defined by time from referral to in-person consultation.

There are limitations to this framework to consider. First, the system is currently not completely automated. Manual oversight at key steps was deemed crucial for quality control of patient information transfer. Manual action is required during initial trackboard schedule creation due to unique patient treatment protocols, as well as for database creation and subsequent updates. Future work will incorporate additional APIs for full automation and integration with the EMR. Currently, the system is not specifically reimbursed; we are hopeful that we can ultimately transition this system into an e-consult platform, enhancing access for providers while also enabling billing for our services to support coordinated, complex care. Similar models have been successfully implemented across various specialties, allowing for effective billing and care coordination.^7,8 Initial analysis suggests that our system positively impacts operational efficiency for multiple experienced stakeholders involved with Theranostics at our hospital. Further work is needed to technically improve our system and to quantitatively assess the impact on care quality, cost, and efficiency.

5. Conclusion

We report the design and successful implementation of a patient intake and management system for Theranostics care using widely available software across most medical centers. As Theranostics care continues to grow and clinical volume and complexity of managing RPT patients increase, the functionality demonstrated by this system will become increasingly important as a complement to more traditional models of tumor boards and patient management. Future development of similar systems will require consideration of the issues considered herein to improve Theranostics care quality, efficiency, and patient outcomes.

Appendix A. Automated patient intake workflow system pseudocode overview

Microsoft Office tools with Power Automate coordinate referral, approval, and task management.

Workflow Sequence:

• Form Submission (Microsoft Forms): Provider completes patient intake questionnaire

• Response Retrieval (Microsoft Forms): Capture all form data

• Review Initialization (Power Automate): Uses patient information to create a new review instantiation

• Approval Request (Power Automate): Route to Microsoft Teams channel for eligibility screening and consensus approval from multimember Theranostics team (including trainees).

• Conditional Branch (Power Automate): Executes based on approval decision, after case discussion

If Approved:

• Email approval confirmation to oncology and scheduling team (Outlook)

• Post notification on the common Teams channel (Microsoft Teams)

• Instantiate patient object (Power Automate)

• Populate pre-defined tasks relevant to each patient within the patient object. (Excel/SharePoint): Tasks include scheduling information for imaging, treatment dates, pre-lab checks, consent forms, and provider assignments (Power Automate)

• Update tasks upon user completion/interaction (Power Automate)

If Declined:

• Email declined notification (Outlook)

• Post to Teams channel (Microsoft Teams)

Appendix B. Survey questions

1. Do we need/want a Pluvicto^®/Xofigo^® conference?

   1. Yes, every month
   2. Yes, every 2 months
   3. No
2. What DAY would you realistically be able to attend a Pluvicto^®/Xofigo^® conference? Ranked options provided.

   1. Monday
   2. Tuesday
   3. Wednesday
   4. Thursday
   5. Friday
3. What TIME would you realistically be able to attend a Pluvicto^®/Xofigo^® conference? Ranked options provided.

   1. 7 am–8 am
   2. 12 pm–1 pm
   3. other
4. Overall, does the current Teams/Email coordination work for day-to-day patient management?

   1. Yes
   2. No
   3. Maybe

5. Please provide additional feedback/comments that may help improve the Theranostics Service for all.

6. Which Department are you mostly affiliated with?

   1. Nuclear Medicine
   2. Medical Oncology
   3. Other