Technology: Can Oncology EMRs Improve Quality?

“So far, it’s been impossible to take a general EMR from a major vendor and apply it successfully to oncology,” notes oncologist Bill Jordan, president and CEO of the Center for Cancer and Blood Disorders in Forth Worth, Texas.

The trouble isn’t EMRs, it’s a lack of specificity in some products. “Oncology is a complex specialty with high risks in terms of chemo­therapy dosing, and small mistakes can have huge consequences,” Jordan explains. Oncologists need an electronic medical record that can not only house patient information, but also helps in the management of the patient, dose calculation, protocol management, and alerts.

There are reasons why the major EMR?players have been slow to develop products for oncologists. For one thing, the oncology market is small compared to that of most other specialties. Also, the lingo is different - think of cancer staging and the cycles of chemotherapy - and the work flow is unique.

Fortunately, some specialized vendors have stepped into the breach, which is why Jordan’s group has been able to use an EMR for the past 10 years.

Oncology leaders

According to some physicians and experts, players in oncology-specific EMRs include Palo Alto, Calif.-based Varian Medical Systems and Sunnyvale, Calif.-based Impac Medical Systems - neither of which is a big health IT vendor. Another product that has garnered notice among oncologists, IntelliDose from IntrinsiQ in Waltham, Mass., is not a complete EMR but specializes in the ordering and administration of chemotherapy drugs.

Automation of chemotherapy is a key safety feature in all oncology health IT products and it can get big results even without a complete EMR. It’s a good place to start.

Simple solutions

For example, when physicians wrote paper orders at Lifebridge Health Cancer Institute in Baltimore, they were faxed to the pharmacies at the two hospitals that own the institute, notes Linda Rogers, its administrative director. Some therapeutic regimens were printed on “generic templates,” she says, “but they were all over the place. With so many practitioners and practices, it was challenging to keep track of them. There was a large burden placed on the pharmacy and the infusion nurses for double-checking calculations, interpreting handwriting, and so on. That was the primary reason we got an automated system. We really focused on the order entry and on documenting the administration of those medications.”

IntelliDose has improved patient safety at Lifebridge, not only by automating the ordering process, but also by providing a central repository for tracking medications that have been administered to each patient, Rogers says.

IntelliDose doesn’t enable physicians to document their notes in discrete data categories, but it can be used with voice recognition software for dictation. It can also be interfaced with hospital EMRs, labs, and pharmacies. The software verifies lab results, checks for drug interactions, calculates drug dosages, supports nurse charting, and allows physicians to write take-home prescriptions. IntelliDose doesn’t include a billing or a scheduling module, but it offers a charge capture feature and pulls demographic data from hospital- and office-based administrative systems.

In addition, Rogers points out, IntelliDose has been helpful in meeting CMS’s Byzantine requirements for documenting erythropoiesis stimulating agent (ESA) administration. “We’re able to run ESA reports and use those reports,” she says. “The pharmacy just put in a process for ESA monitoring, and it includes the use of IntelliDose reports.”

Templates can be customized

Varian’s Aria system, which Bill Jordan’s group uses, is a full EMR with all the features needed to document patient care. It can be directly interfaced with the GE Centricity practice management system and communicates with other practice management systems via HL7 messaging. The system accommodates the needs of medical oncology, radiation oncology, and other oncology subfields, while enabling physicians to document a patient’s comorbidities and non-oncology treatments.

Using national guidelines, Varian has created 300 cancer treatment regimens that physician practices can customize, notes Maureen Thompson, senior director of oncology information systems for the company. While physicians can’t change these protocols without group authorization, they can vary them for individual patients, but only with a written explanation.

“If I order a drug and I want to change the dose, it asks me why,” explains Jordan. Another safety feature in Aria, he says, is the link between lab results and ordering. “Take a dose calculation for a drug like carboplatin that requires data on the renal function of a patient. The computer actually asks us to input that.” This is easy for his group, he notes, because its EMR has an interface with LabCorp, which is located in the cancer center’s main office.

Jordan and other oncologists who use EMRs admit that no computerized order entry system is perfect. Pharmacists still check his orders, and nurses check each drug and dosage before they administer it to patients. He also scrutinizes medications himself before handing them to his nurses.

Using a single EMR in the practice’s eight sites also helps avoid medical errors, Jordan notes. “For instance, I’ll see a patient who sees a second doctor and then a third doctor for different reasons. If we didn’t have an EMR, that patient might be put on three different types of medication for, say, high blood pressure.”

Aside from increasing safety and efficiency, Jordan observes, the biggest benefit of having an EMR is the ability to improve care by using data to change physician behavior. In fact, he says, the main reason his group acquired the Aria EMR was to collect information on outcomes. “We selected Aria because almost all the information is codified and is retrievable.” Working with a “knowledge-sharing network” called Oncology Metrics, “we can now benchmark our practice against other oncology practices across the country,” he says.

Is a homegrown EMR the cure?

Oncologist Bruce Feinberg, president and CEO of Georgia Cancer Specialists, a 40-doctor group in Atlanta, declares that no EMR currently on the market is adequate for the unique needs of oncology. When the group shopped for an EMR, he says, “Our feeling was that all of the oncology EMRs were significantly deficient because they weren’t built by oncologists. They also didn’t take advantage of the potential for artificial intelligence, which is what enhances the efficiency of an EMR. If you don’t attain the efficiency, you don’t garner the usage, and if you don’t do that, you can’t accomplish the goals of decreasing risk and physician liability and increasing quality of care.”

Despite these reservations, Georgia Cancer Specialists has been using EMRs for 13 years. The company that made the group’s first EMR went out of business in 2000, leaving it with an unsupported, obsolete product. So the practice put out an RFP to 15 vendors. The winner was NextGen, which, at the time, had no oncology edition. That was OK with Feinberg’s group, he says, because NextGen had the best billing and scheduling systems, and it had the best toolkit to help the practice build its own EMR. NextGen agreed to let Georgia Cancer Specialists create its own oncology module, Feinberg says, but disagreed with the direction that the group chose. So the group went its own way, constructing an EMR on the NextGen platform, and the vendor built its own version.

Georgia Cancer Specialists now sells its EMR to other NextGen oncology users, and it also offers its chemotherapy order sets for free at www.chemorders.com. The group’s initial effort to use NextGen failed, Feinberg says, because it took the physicians too long to document what they were doing. He responded by building new templates and pick lists that captured all the required information quickly. He also programmed the EMR to allow “charting by exception.” With that feature, doctors didn’t have to keep noting, for example, that certain patients were missing breasts because they’d had mastectomies.

After this second iteration, Feinberg says, documentation went much faster. “When doctors were going to order a CT, they could finish that order in under five seconds, and it would identify the body part, with or without contrast, and where it was going to be done, and what was the time frame and the reason for the test.”

Feinberg feels strongly that EMRs are essential to reduce unexplainable variations in care. “The one thing we’ve got to do is improve the quality of care we provide. And the best way to do that is by using the validated protocols that have been published.”

Like Jordan’s group, Georgia Cancer Specialists has decided to mandate the use of chemotherapy regimens based on the best available evidence. When a physician feels she has to deviate from those protocols because of comorbidities or other patient conditions, she must justify her reasoning in writing.

Today at Georgia Cancer Specialists, Feinberg says, “we see an 85 percent compliance with the protocol as written. By doing that, we significantly decrease variance. Less variance means fewer errors, which decreases patient risk and physician liability. It translates into a better quality of care, no matter how you measure it.”

But despite the proselytizing of EMR champions like Feinberg, most oncology practices have yet to be automated. Says Brent Clough, CEO of IntrinsiQ, maker of IntelliDose, “Pen and paper is our biggest competitor.”

Ken Terry is a freelance journalist with years of experience in healthcare technology coverage. He can be reached via editor@physicianspractice.com.

This article originally appeared in the September 2008 issue of Your Best Practice.