Andrew D. Zelenetz, MD
Chief, Lymphoma Service
Department of Medicine
Memorial Sloan-Kettering Cancer Center
Associate Professor of Medcine
Weill Cornell Medical College
New York, NY
Oncologists have spent years determining the proper dosing amounts of chemotherapies for patients with different types and stages of cancer, yet all of that knowledge can be derailed in an instant through illegible handwriting, incorrect calculations, and a host of other human errors that can cause higher-than-expected medication error rates and delays in getting the proper chemotherapy doses to the patients who need them.
“Inevitably, this is a human process, and people can make errors,” Andrew D. Zelenetz, MD, PhD, of Memorial Sloan-Kettering Cancer Center (MSKCC) in New York City, said in an interview.
Zelenetz and other oncology specialists decided to test the efficacy of electronic ordering, since the volume of chemotherapy doses—more than 150,000 annually by 2003— had grown to the point where the potential for errors was greater.
Before implementing an electronic system, MSKCC had developed workflow checks at every stage of chemotherapy ordering (verification, preparation, and administration), which did much to alleviate potential errors.
However, Zelenetz was tasked with helping to craft an electronic system that bore a close resemblance to the system they already had in place but that would eliminate any potential for orders to be rendered illegible or lost.
Since Zelenetz had previous experience with the chemotherapy orders, he helped implement a number of features that reflected points in chemotherapy ordering that could potentially benefit from the elimination of the paper system.
For example, the electronic system utilized built-in calculators to provide standard dosing formulas and modifiers based on height and weight. Dose modifiers can account for changes in medication due to certain toxicities. Limitations can be set on how much of a particular chemotherapy agent can be dispensed to a patient, and verification chains enable each person viewing the order online to know that the ordering physician, oncology nurse, and pharmacist have all verified the information contained in the order.
“If someone has multiplerelapsed disease, if they have an unusual toxicity and you have to eliminate a drug or change things, what the electronic form does is it allows us to enter drugs and create from scratch a new regimen,” Zelenetz said.
Such flexibility is of particular use in hematologic malignancies. More chemotherapy drugs are being approved for various forms of leukemia, lymphoma, and myeloma. The system can be revised to incorporate new drugs or drugs that have received approval for different stages and disease types without causing confusion among the treatment team.
In a study published in the Journal of Oncology Practice
earlier this year, MSKCC reported the results of the first few years of using an electronic chemotherapy ordering system (2011;7(4):213-218).
In 2010, more than 416 practitioners at the center across 8 sites placed 73,225 electronic order sets. While the center had not made a point of tracking lost or illegible orders in the past, they tracked them while implementing this electronic system. There were 197 incomplete orders in 2008, but that number dropped to 77 in 2009, and issues with delays and discord among staff have “disappeared since implementation of the online system,” according to the paper.
While the process took years to design, Zelenetz and his colleagues reported that the system works. However, while the new electronic system was successful, the authors reported that the system needs constant staff attention to remain on top of the latest chemotherapy drugs available, as well as quality improvement efforts at a hospital level, new treatment modalities and indications, and changing clinical standards.