Despite major advancements in cancer therapy, delays in accessing oncology services remain common and consequential. The early period between initial suspicion and formal consultation is particularly vulnerable to breakdowns in communication, referral logistics, and scheduling inefficiencies. These delays not only affect prognosis, particularly in aggressive cancers, but also intensify psychological distress for patients and families.
Recognizing the complexity of this challenge, institutions across the country are rethinking how patients enter the cancer care continuum. The Duke Cancer Institute (DCI) and University of California San Francisco (UCSF) Helen Diller Family Comprehensive Cancer Center have each developed distinct yet complementary approaches that leverage clinical expertise, digital tools, and coordinated workflows to improve access and responsiveness. These approaches were summarized at the NCCN 2025 Annual Conference by Susan Blackwell-Crawford, MHS, PA-C, Associate Director of Advanced Practice, and Thoracic Medical Oncology PA for Clinical Operations and Access, DCI, and Laurel Bray-Hanin, MA, Vice President, and Chief Operating Officer, Cancer Services, UCSF Health.
DCI: Advanced Practice Provider–Led Diagnostic E-Consults
DCI’s e-consult strategy was developed to address a specific challenge: patients with findings suspicious for malignancy but without a definitive diagnosis. These patients, who are frequently identified through incidental imaging or vague symptom presentations, often fall between the cracks of traditional referral systems. “And we know that delay in access for oncology patients leads to poor outcomes and even decreased survival,” said Ms. Blackwell-Crawford.
Launched in 2021, the initiative centered on an Epic-integrated consult pathway, referred to internally as “E-Comm,” and it is managed by experienced oncology advanced practice providers (APPs). “We knew we had experienced oncology APPs who could receive these e-consults, review the patient’s chart, and help facilitate earlier access to the appropriate oncology team. In addition, the APPs could begin ordering diagnostic tests and could even set up in-person urgent evaluations as needed,” Ms. Blackwell-Crawford explained. “And all of this we wanted to be done in less than 24 hours—as far as answering the e-consult.”
The E-Comm system enables referring providers in primary care or emergency medicine to submit a consult request for patients with a suspected malignancy. Each submission requires patient consent, and providers are given a script to help explain to the patient why the e-consult is necessary, how it may be a better option than a referral, and what the patient can expect once the e-consult is initiated. Providers are also instructed to explain that a small copay may apply, although most commercial and public insurers fully cover the service.
APPs reviewing E-Comm consults assess whether the clinical findings suggest a potential malignancy that requires oncology evaluation. They use a standardized documentation template in Epic (smart phrase: .ECOMMDDC) to record the chart review, clinical impression, and triage decision. If appropriate, they also initiate next steps, such as ordering diagnostic imaging, laboratory tests, or referrals to other specialists. If the concern does not meet criteria for urgent oncology evaluation, the APP provides structured guidance back to the primary care team for appropriate surveillance or further diagnostic workup.
Between August 2023 and August 2024, DCI completed 900 e-consults, addressing thoracic (n=252), abdominal (n=214), lymphadenopathy (n=120), renal (n=87), and other concerns (Figure 1). The majority of consults originated from primary care (63%) and emergency departments (28%) (Figure 2).
E-Comms completed in 2024 (N=900).
Citation: Journal of the National Comprehensive Cancer Network 23, Supplement; 10.6004/jnccn.2025.5004
E-Comm volume by referring teams.
Abbreviations: dept, department; ED, emergency department.
Citation: Journal of the National Comprehensive Cancer Network 23, Supplement; 10.6004/jnccn.2025.5004
The team at DCI met their goal of answering E-Comms in <24 hours. During the same 12-month period, the mean completion time for answering an E-Comm was 20.5 hours. In addition, approximately 70% of cases were ultimately referred for oncology consultation, validating the triage function of the program.
One of the most meaningful outcomes was a reduction in time to specialty care. In July and August 2024, the average time to first oncology visit decreased to 10.5 days, representing a significant improvement over historical baselines. This acceleration in access was achieved without compromising the consult quality or clinical appropriateness, Ms. Blackwell-Crawford noted.
As the E-Comm volume increased, the team at DCI implemented additional safeguards and adaptations. Recognizing that many patients from the emergency department lacked established primary care, the team developed a hospital follow-up clinic embedded within its primary care clinic to serve as a bridge for patients not yet formally in the system. For complex findings such as possible brain or spine metastases, a partnership with neurosurgery ensured review prior to discharge, further improving patient safety.
Billing practices were also refined to reflect the clinical outcome of each e-consult. When the APP determines that a finding is unlikely to represent malignancy and provides follow-up recommendations to the primary care provider—such as additional imaging or observation—the consult is billable, as it delivers clinical guidance outside the scope of oncology. However, when the APP concludes that the patient should be evaluated by an oncology specialist and initiates that referral, the e-consult is not billed. This approach reinforces the e-consult’s role as a triage tool designed to streamline appropriate entry into oncology care. APPs completing the consults receive 0.7 work relative value units, ensuring recognition of clinical effort.
DCI’s model underscores the power of interdisciplinary collaboration, digital efficiency, and structured documentation to close access gaps. With Epic integration, clear expectations, and real-time routing capabilities, the program has become a cornerstone of early oncology care triage at DCI.
UCSF: Patient Empowerment Through Web-Based Self-Scheduling
At UCSF, the focus shifted from provider-facing triage to patient-facing access innovation. In the early months of the COVID-19 pandemic, cancer screening rates across the United States declined dramatically—by 37% for breast, 89% for colon, and 90% for cervical cancer.1 These declines translated to significant reductions in new patient referrals at UCSF and raised urgent concerns about delayed diagnoses. In response, the cancer center explored ways to eliminate traditional scheduling barriers and empower patients to initiate their own care journey.
“We wondered, is it possible for a new patient with cancer to accurately self-schedule their first appointment?” said Ms. Bray-Hanin. “We asked, are clinicians willing to take some risk with us and try something novel?”
The resulting platform enabled new patients to book oncology appointments directly via a UCSF website. The system offered 2 primary pathways: the first—navigator scheduling—allowed patients to book a phone intake appointment with a trained coordinator, usually within 24 hours. During the call, the navigator gathered relevant medical records, confirmed insurance coverage, and determined the appropriate specialty or provider.
The second option—direct-to-clinician scheduling—offered patients the ability to select a provider (an APP or physician) and appointment time through a guided, lay-language, diagnosis-specific decision tree. Patients could choose between in-person and telehealth visits (limited to California residents), select location preferences, and proceed with scheduling as a guest without needing a MyChart account (they were given an opportunity to sign up later).
“This made patients feel satisfied and empowered, knowing who they were seeing and when they were going to be seen,” she noted.
Behind the scenes, each scheduled visit generated a new patient referral, triggered automated insurance workflows, and routed information to care teams through Epic. To support record collection, patients could upload documentation via a secure link or indicate where they had received prior care. Appointments could be confirmed or canceled online, and post-booking surveys captured real-time patient feedback. Between July 2021 and January 2025, the share of appointments booked directly with clinicians increased from 13% to 49%, as comfort with the tool and system capacity grew, noted Ms. Bray-Hanin (Figure 3).
Results of scheduling practices. As direct clinician scheduling expanded to more practices, it became almost as prevalent as scheduling through an intake navigator.
Citation: Journal of the National Comprehensive Cancer Network 23, Supplement; 10.6004/jnccn.2025.5004
Patients rated the platform highly: 94% found it easy to use, and 96% needed no external assistance. Additionally, nearly 45% of bookings occurred outside normal business hours, demonstrating its value in expanding access beyond traditional call center workflows.
Use of the platform tended to skew younger, with patients between the ages of 25 and 64 years comprising the bulk of users, and older adults aged ≥65 years participating less frequently. This pattern suggests that hybrid models remain necessary to meet the needs of all populations. Of note, patients booking through the open scheduling platform were more likely to be commercially insured (58%) than those entering through other access points (39%). When the initiative began, the majority of self-scheduling was done through a navigator. However, as direct clinician scheduling expanded to more practices, it became almost as prevalent as scheduling through an intake navigator, she noted.
Accuracy with the platform was high. Between 90% and 95% of patients selected the appropriate specialty and visit type. For the small percentage who scheduled incorrectly, intake staff followed up to adjust bookings as needed. The most common friction points involved limited availability for high-demand providers, insurance issues (particularly acquiring required insurance Letters of Agreement), and challenges retrieving records from systems not integrated with Epic.
Ms. Bray-Hanin noted that staff have been excited to use this tool, as it reduces the back-and-forth and “playing phone tag” with patients during the appointment scheduling process. The program was also supported by a small, dedicated agile scrum team representing clinical operations, IT, marketing, and patient access. Daily huddles allowed the team to make necessary adjustments based on patient feedback, improve decision-tree logic, and optimize language clarity.
Conclusions
As demonstrated through the experiences at both institutions, timely access to oncology care is both achievable and sustainable when infrastructure and innovation align. DCI’s e-consult model leverages clinical judgment and interdisciplinary coordination to reduce ambiguity in the referral process. UCSF’s digital scheduling tool eliminates barriers for patients navigating their first cancer consultation, reinforcing transparency and patient autonomy. Together, these models reflect a broader transformation in oncology access strategy—one grounded in efficiency, inclusivity, and responsiveness to the needs of both patients and providers.
Reference
MacKenzie M, Potugari B, Bzeih R, et al. Cancer screening during the COVID-19 pandemic: a systematic review and meta-analysis. Mayo Clin Proc Innov Qual Outcomes 2021;5:1109–1117.
