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True integration of cutting-edge care and timely translation of information from the bench to bedside requires an oncology practice to have knowledgeable physicians and a "toolbox of technology."
True integration of cutting-edge care and timely translation of information from the bench to bedside requires an oncology practice to have knowledgeable physicians and a “toolbox of technology.” EMRs and algorithms for understanding risks of recurrence and benefits of therapy are examples of two such tools.
Although many clinicians view implementing technology as a significant challenge, it is also an opportunity to enhance ease of care and safety, while also capturing a wealth of data for quality-of-care and billing analysis. Electronic records enhance efficiency by eliminating the need to search through paper charts. Each patient’s complete medication information is available with the click of a mouse. Oncologists can update the medication history and then check for allergies when ordering the next round of chemotherapy.
The clinician’s time and the patient’s journey should be the key drivers for developing and implementing a truly patient-centered, meaningful IT application. The goals of health IT must be to enhance efficient patient care through better documentation, clinical research, ease of retractable information for reporting outcomes, or other needs for data extraction as a byproduct of workflow.
IT needs must be driven by processes rather than product availability. The “big picture” of the patient journey and IT skills of all staff involved are also important variables; focusing on them as well as on physicians to drive technology adoption will help ensure success. A proactive implementation team that trains staff is another key to ensuring a smooth implementation.
There are many schools of thought regarding implementation (eg, “big bang” vs. a phased approach). With the big bang, you feel the “pain” all at once, but at least everyone is on the same platform and all the information is now in the same place. This approach helps you avoid the trap of having some areas of a practice relying on paper records while others are forced to use incomplete electronic records. Process-based, stepwise, phased implementation can be a less overwhelming approach. But this “stuck in two worlds” approach means you are never sure if all of a patient’s information is included in the electronic record—was it missed, or was it put on paper, or did someone mean to enter it in the computer and just forget? This complicated process requires an effective plan for implementing equipment and coordinating staff training. The plan must also include a timeline that specifies how long you want each phase to run before the next phase goes live.
For both approaches, you need to plan very carefully on how you will train each area of the practice. “Super users” who train and support the rest of the staff are very helpful. You will need to have a project manager who coordinates the project and decides what and how many servers are needed, what type of hardware to order, and go-live timelines with testing and training included. Clinical informatics and technical support are keys to this process. IT support must include hardware support (if someone cannot turn on the computer, does not have access to the correct drive, needs Internet access, needs a printer installed, cannot print, etc) and clinical support (if someone cannot log into the clinical application, cannot access the correct screens, or does not have the correct screens).
Inadequate training—both prior to “going live” and post implementation—can result in frustration. The staff will naturally be nervous about using a new electronic record—whether they are proficient with computers or not— and if they cannot access the appropriate applications or screens, their frustration level will skyrocket. Simple things like not being able to print or find the weight field on a screen will send them into overdrive.
Improving efficiency and quality with CPOE
Once implemented, these tools can help deliver safer care and improve practice efficiency. Many EMR vendors assist healthcare providers with well-constructed clinical screens and safety alerts, such as best practice alerts (BPAs). BPAs appear on the screen to remind providers to order the appropriate medications or place the patient on the appropriate protocol. Electronic systems (including CPOE) also provide soft and hard stops for patient assessments or incomplete billing orders. The stops will not allow users to move to the next screen unless the fields are populated.
The Centers for Medicaid and Medicare (CMS) has released the latest set of Physician Quality Reporting Initiative (PQRI) measures that require physicians who have opted to participate to report specialty-specific performance measures to receive incentive bonuses. These measures are pre-defined and captured on the patient’s bill, and must therefore be clearly indicated on the patient’s record and in the final diagnosis and coding. The electronic record allows providers to consistently document the patient’s condition, diagnosis, and treatment plan, along with any necessary measures and codes needed for PQR that can be entered during the patient’s visit.
Computerized physician order entry (CPOE) allows for consistency in ordering when order sets and physician “favorites” are developed. These two items can customize treatment plans, physician practice methodologies, patient reactions to chemotherapy regimens, and evidence-based treatment protocols.
In the world of paper records, being on-call means assessing the patient over the phone, gathering their history, and treating them without having the patient’s record in front of you. With an electronic record, you can go to your computer at home—or even with some vendors, pull the record up on your wireless phone/PDA—and review the patient’s chart to make an accurate assessment. You can then send a prescription to the patient’s pharmacy, ensuring the patient receives treatment much more efficiently. Electronically prescribing medications is clearly the direction our government is pointing us toward.
Using electronic records with hospitalized patients means documents can be viewed remotely, improving time-efficiency at the bedside and potentially enhancing care for patients. Faster communication channels among a multidisciplinary physician team is possible with optimal, common, shared IT platforms, and they provide great customer service and satisfaction to the patient. Today’s patients expect their team of doctors to be on the same page. The ability to teleconference and host virtual group meetings is quickly catching on as an alternative to multidisciplinary tumor conferences that facilitate treatment planning.
Embedded artificial intelligence tools, such as adjuvant online and electronic cross-verification of patients on available clinical trial databases, are a step toward personalized medicine and are fast becoming a reality in modern oncology practice. The practical application of bioinformatics is another innovative technology that will form the backbone of the hottest fields of oncology: genomic and proteomic medicine.
Pattern recognition can potentially be of immense value in individualizing care. Identifying patterns in data clusters and other information can help clinicians to segregate distinct biological sub-types of cancer within the same subset of previously lumped tumors based on morphology alone, and thereby help in understanding prognosis and selecting individualized treatments. Th is might also help identify potential responders and resistant patients, helping to tailor toxic therapies to patients more likely to benefit, while saving others from toxicities.
Tools such as Genomic Health’s Oncotype DX assay, which is used with breast cancer patients, select tumor gene profiles to better define individual patient prognosis, and determine potential benefits of treatments such as chemotherapy and endocrine therapy. Better therapy selection could help avoid potential lethal toxicities and improve economic efficiencies of the healthcare system as well. Selecting therapies based on individual tumor genomic profile rather than population or general pathology-based criteria is already common with many tumor types, and breast cancer has become the poster child for excellent outcomes.
Providing cutting-edge care also means offering oncology-specific clinical trials. According to the Coalition of Cancer Cooperative Groups, just 3—5% of adult cancer patients diagnosed in 2008 will participate in a cancer clinical trial in 2008. There are several explanations for this poor accrual: inefficiency and time constraints of matching a patient with a trial; inability to inform a patient about the right trial at the right time; overhead expenses to cover screening costs and personnel; and time spent in extensive counseling that is often poorly reimbursed under the current system. Electronic databases of all the available trials can now be created with inclusion and exclusion criteria as rules, allowing physicians to crosscheck multiple research trials against patients at any given time. Such a system facilitates finding the right patient for the right trial based on set system rules.
Continuing education is essential to communicate these new innovations and possibilities. It is an ongoing challenge for practicing oncologists to stay current without technology in their practice. Navigating and finding the most up-to-date information is a skill just as necessary as the intricate memorized knowledge acquired as one learns and practices medicine. National meetings for organizations like ASCO and NCCN try to provide rapid dissemination of such information. However, due to practice demands and schedule constraints, most practicing oncologists are unable to take advantage of these opportunities. CME provided via podcasts and archived online presentations are other options that provide necessary updates on health IT.
When used optimally, the various technologies described here have the potential to enhance practice efficiency and enable physicians to keep up with their rapidly advancing feld. Next-generation cancer practitioners must embrace the right technology and tools, such as EMRs, research and treatment algorithms, and adjuvant online models and databases of tumor genomics, in order to provide high-quality, individualized treatment. Working off an electronic system with an EMR, using a computer with high-speed Internet access, and taking advantage of data storage and filing capabilities are tasks that can be performed hand-in-hand within the day-to-day practice of oncology. But for this to happen, oncologists must be proactive in incorporating these into their practice.
Dr. Juturis the chief medical officer for NexGen Oncology (www.nexgenoncology.com), and the chief of Hematology/Oncology at Presbyterian Hospital of Dallas, Dallas, TX.