Utilizing Technology to Identify Patient Co-Morbidities and Reduce Hospital and ED Admissions

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Utilizing Technology to Identify Patient Co-Morbidities and Reduce Hospital and ED Admissions

ACCC 37th National Oncology Conference 

This educational activity is jointly provided by AXIS Medical Education and ACCC

This activity is supported by educational grants from Abbvie,  AstraZeneca, GlaxoSmithKline, Lilly and Pfizer, Inc.

Release Date: 10/16/2020

Expire Date: 10/15/2021

Estimated Time to Complete: 75 minutes

Target audience: Nurses, APPs, cancer program administrators, practice administrators, case managers and care coordinators, finance and HIT leaders

Overview: After analysis of Oncology Care Model data identified three comorbid illnesses that led to significantly higher rates of unplanned emergency department (ED) visits and hospitalizations—COPD, congestive heart failure, and diabetes mellitus—Tennessee Oncology developed targeted management algorithms that proactively addressed these conditions. Today care coordinators use these algorithms to screen, identify, and help manage at-risk patients via the care management platform, either by patient-initiated contact, such as telephone triage, or through a patient health portal, depending on the patient’s access and comfort with this technology. For patients admitted to the ED or hospital, admission software provides real-time data to the practice to improve patient management and reduce length of stay and readmissions.

Learning Objectives:

At the end of this educational activity, participants should be able to:

  • Explain how access to real-time data can be used to develop targeted patient management algorithms.
  • Use these algorithms to identify patients at risk for ED visits and hospitalizations and then develop workflows to improve patient management, reduce ED visits, and decrease hospitalizations.
  • Demonstrate the use of these algorithms to become adept at identifying patients with co-morbidities and developing better management strategies to address them.


Larry Bilbrey, Care Data Systems Manager
Care Data Systems Manager
Tennessee Oncology

Jonetta Blakely, MD, MS, MMHC
Executive Director, Health and Economic and Outcome Research and
Chairwoman, Performance Improvement Committee

Tom Gallo, MS, MDA
Executive Director
Virginia Cancer Institute


Accreditation Statement


In support of improving patient care, this activity has been planned and implemented by AXIS Medical Education and ACCC.  AXIS Medical Education is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Credit Designation for Nursing
AXIS Medical Education designates this continuing nursing education activity for 1.25 contact hours.
Learners are advised that accredited status does not imply endorsement by the provider or ANCC of any commercial products displayed in conjunction with an activity.

Healthcare Executives
ACHE Qualified Education credit must be related to healthcare management (i.e., it cannot be clinical, inspirational, or specific to the sponsoring organization). It can be earned through educational programs conducted or sponsored by any organization qualified to provide education programming in healthcare management. Programs may be sponsored by ACHE, chapters, or other qualified sources, whether the programming is face-to-face or distance offerings (webinars, online seminars, self-study courses, etc.). You will receive a certificate of completion for 1.25 hours.

AXIS Contact Information

For information about the accreditation of this program please contact AXIS at info@axismeded.org.

Disclosure of Conflicts of Interest
AXIS Medical Education requires instructors, planners, managers and other individuals and their spouse/life partner who are in a position to control the content of this activity to disclose any real or apparent conflict of interest they may have as related to the content of this activity. All identified conflicts of interest are thoroughly vetted by AXIS for fair balance, scientific objectivity of studies mentioned in the materials or used as the basis for content, and appropriateness of patient care recommendations.

The faculty reported the following financial relationships or relationships they or their spouse/life partner have with commercial interests related to the content of this continuing education activity:

Name of Faculty or Presenter/Planner

Reported Financial Relationship

Larry Bilbrey

Received income from: Tennessee Oncology, PLLC-Self

Ownership interest: Hospital Corporation of America-Spouse

Jonetta Blakely, MD, MS, MMHC 

Contracted Research: Bristol Myers Squibb

Tom Gallo,MS, MDA

Nothing to disclose

The planners and managers reported the following financial relationships or relationships they or their spouse/life partner have with commercial interests related to the content of this continuing education activity: 

Name of Planner/Manager/Reviewer

Reported Financial Relationship

Leigh Boehmer, PharmD, BCOP

Nothing to disclose

Christina Fuller, BSW

Nothing to disclose

Tom A. Gallo, MS, MDA

Nothing to disclose

Marilyn L. Haas-Haseman, PhD, RN, CNS, ANP-BC

Nothing to disclose

Monique J. Marino

Nothing to disclose

Rebecca McMahon

Nothing to disclose

Dee Morgillo, MEd., MT(ASCP), CHCP

Nothing to disclose

Kerri Michalik, MHA, BSN

Nothing to disclose

Barbara Schmidtman, PhD

Nothing to disclose


Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed in this activity should not be used by clinicians without evaluation of patient conditions and possible contraindications on dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities. 

Method of Participation and Request for Credit    

  • Attend/participate in the educational activity and review all course materials. 

To receive credit for this activity, participants must review the activity information including learning objectives and faculty/planner disclosures and actively participate in the educational activity. Upon successfully completing the post-test with a score of 75% or better and the post-activity evaluation, your certificate will be made available immediately.

Larry Bilbrey

Care Data Systems Manager

Larry Bilbrey is the Care Data Systems Manager for Tennessee Oncology, where he is responsible for value-based care reporting to multiple government and commercial payers.

Larry began his career at Tennessee Oncology almost 15 years ago. He has spent the majority of his time with Tennessee Oncology in operations. Prior to becoming the Care Data Systems Manager, Larry was a Regional Operations Manager for 7 years, and, prior to that, an Operations Manager. 

There have been multiple projects that Larry has been involved in with Tennessee Oncology over the years. He has been a part of the Value Based Care project(s) at Tennessee Oncology since its origination in 2014. He has developed many aspects of Tennessee Oncology’s Value Based Care initiatives including navigation/care coordination and central triage. Larry has played an integral part in the original Medical Home pilot. This comprises of being the designer and product owner/administrator of Tennessee Oncology’s original proprietary telephone triage management tool.

Johnetta Blakely

Executive Director of Health Economics and Outcome Research ; Chairwoman, Performance Improvement Committee

Johnetta Blakely holds the position of Executive Director of Health Economics and Outcomes Research for Tennessee Oncology, PLLC, one of the nation's largest community-based oncology practices. In her role she provides oversight for all outcomes research projects within Tennessee Oncology. She is responsible for direct oversight of protocol development, budgeting, data analysis, abstracting and presentation of data. She collaborates closely with technology vendors, pharma and other organizations to collaborate in these projects. She also provides suggestions and guides improvement based on the data from health outcomes projects. She also serves as the chair of the Performance Improvement committee for Tennessee Oncology which allows implementation of process improvement guided from outcomes.  She has maintained an active Hematology-Oncology practice for the past 15 years with an interest in breast cancer and lung cancer. 

A diplomate of the American Board of Internal Medicine, she holds certification for Medical Oncology. She participates in clinical research and is published in leading medical journals. She maintains associations with professional organizations including the American Society of Clinical Oncology, American College of Physicians, Community Oncology Alliance, and Tennessee Medical Association.

She earned her medical degree at the University of Tennessee, Memphis. She completed her Internal Medicine residency at the University of Texas, Houston, and her Medical Oncology fellowship at the University of Texas M.D. Anderson Cancer Center. She earned a master’s degree in Clinical Research from the University of Texas Health Science Center in Houston and a Masters in Management in Health Care from Vanderbilt University.


4 Questions  |  1 attempt  |  0/4 points to pass
4 Questions  |  1 attempt  |  0/4 points to pass
Session Recording
Open to view video.
Open to view video.
4 Questions  |  3 attempts  |  3/4 points to pass
4 Questions  |  3 attempts  |  3/4 points to pass
10 Questions
CE Certificate
Up to 1.25 medical credits available  |  Certificate available
Up to 1.25 medical credits available  |  Certificate available