It’s rare to find a group of physicians, administrators and the government in agreement. However, in the case of electronic health records and oncology practices, all players seem to be on the same page. Now is the time for oncology practices to adopt an EMR, opines Robert S. Miller, MD, medical oncologist and physician advisor for medical informatics at Sidney Kimmel Comprehensive Cancer Center at The Johns Hopkins Hospital in Baltimore. Teresa McKay, CEO of West Michigan Cancer Center in Kalamazoo, Mich., ups the ante. “We are long past the time for dialogue about EMRs; it’s time for action. If practices don’t embrace the EMR quickly, they will be left woefully behind and will be acquired by other practices or have to seek refuge in hospitals.”

Current market penetration is low, but interest is high, largely due to Health Information Technology for Economic and Clinical Health (HITECH) Act incentives that offer EMR users up to $44,000 in carrots to demonstrate meaningful use. While money talks and has certainly spurred interest in adoption, there are other compelling reasons for oncology practices to consider investing in EMR technology. For starters, an EMR improves patient care in an entire host of ways, increasing access to information, improving safety and more. Plus, even in the pre-HITECH era, a well-deployed system delivered ROI by slashing labor and supplies budgets.

Despite documented benefits among early adopters, implementation can be tricky. Experienced users also agree on another issue—no oncology EMR is perfect. As oncology practices set their sights on EMR nirvana, Health Imaging & IT provides a guide to help users optimize the gains.

The rationale

West Michigan Cancer Center has documented hard ROI from its EMR deployment; the 12-physician practice calculated more than $300,000 in cost savings during each of the first two years of deployment and nearly $600,000 in savings annually in the third, fourth and fifth years. “We didn’t anticipate significant financial gains with the project,” confesses McKay. Instead, the practice used patient care as the justification for early adoption of an EMR in 2004. “We felt very strongly that if we did not deploy an EMR we could not continue to provide high-quality patient care. Efficiency and ROI happened as by-products after the fact.”

The paper chart business impacted service to both referring physicians and patients. If a referring physician requested an update in the pre-EMR days, one of the practice’s eight medical records staff had to physically locate the chart and send it via dumbwaiter before anyone could respond to the physician. Today, all data including images can be accessed in exam rooms. “Our doctors look brilliant,” claims McKay.

A Field Guide to EMR Acronyms

CCHIT: Certification Commission for Health Information Technology (CCHIT), a non-profit organization dedicated to accelerating the adoption of robust, interoperable health information technology. The organization expanded its EHR certification program into oncology last spring and appointed a volunteer work group to develop criteria for EHRs in oncology this summer. CCHIT was named an authorized testing and certification body with the Office of the National Coordinator (ONC, see below) at the end of August. EHR & EMR: Although the acronyms are used interchangeably, an electronic medical record refers to the electronic record of health-related information on an individual that is created, gathered, managed, and consulted by licensed clinicians and staff from a single organization who are involved in the individual’s health and care, according to the now-disbanded National Alliance for Health Information Technology (NAHIT). NAHIT defines an electronic health record as the aggregate electronic record of health-related information on an individual that is created and gathered cumulatively across more than one healthcare organization and is managed and consulted by licensed clinicians and staff involved in the individual’s health and care. Interoperability is the cornerstone of an EHR. ONC: The Office of the National Coordinator for Health Information Technology (ONC) is the principal federal entity charged with coordination of nationwide efforts to implement and use advanced health information technology and the electronic exchange of health information. ONC establishes standards and certification criteria for EHR certification while the Centers for Medicare and Medicaid Services (CMS) handles meaningful use requirements.

Similarly, paperless medicine is standard at Memorial Sloan-Kettering Cancer Center in New York City. “Everyone in the facility has access to the electronic chart. It’s much safer for patients because we can look up allergies, chemotherapy medicines and support medications,” explains Nancy Sklarin, MD, director of clinical operations at Evelyn H. Lauder Breast Center and institutional director of chemotherapy practice. Safety and efficiency are optimized as the practice doesn’t lose or duplicate orders.

Miller sits squarely in the patient care camp. “The EHR gives oncologists the opportunity to do a better job and provide higher quality cancer care. Oncology is one of the most data-intensive specialties. We have a workflow that is particularly dependent on data including imaging, pathology and laboratory data, and to have data in an electronic format that are searchable and can be manipulated is beneficial.”    

Economic gains are real and quantifiable. Paper charts cost West Michigan Cancer Center $25,000 annually. Plus, charts were duplicated multiple times for each clinic, increasing staffing costs. Transcription costs added to the bill. Other fiscal factors also enter into the ROI equation. “From the charge capture perspective, the EHR helps a practice avoid missing charges,” says Miller. And patients at West Michigan Cancer Center don’t proceed to chemotherapy without clearing financial counseling. It’s a more streamlined and direct process with an EMR, and it helps the practice ensure reimbursement.

The process

The combination of clear data and federal carrots has led to an uptick an interest, but facilities and practices need to consider their goals. If the sole objective is meeting meaningful use and earning incentives, the practice can easily locate checklist documents to determine which products accomplish the criteria. However, the EMR offers the opportunity to re-invent practice workflow. As new sites race to deploy and gain HITECH incentives, they need to reflect on internal needs in addition to federal funds.

Sklarin of Memorial Sloan-Kettering worked with the center’s EHR team to set specifications for chemo ordering. Flexibility and customization were key considerations, but a smaller practice with fewer internal resources may want the system to set ordering specifications to avoid overwhelming the implementation team. “Implementation has to be planned and managed very carefully,” cautions Sklarin.  

Practices should look at their own workflows and determine if workflows need to be adjusted in the deployment, recommends Miller. For example, are data entered as free text or in a codified format? If the practice uses dictation, data won’t be searchable. Such considerations may come into play in the next two years as stage two of meaningful use may incorporate reporting to quality registries, which would require searchable data.

“Determine which workflows will work in an electronic environment and which will need to change,” recommends Miller. It’s important not to memorialize inefficiency by duplicating less than efficient workflows, he says.

McKay spearheaded the deployment process by convening a multi-disciplinary implementation team that met weekly to determine goals and assignments. The practice also removed its nursing manager from clinical duties so she could focus on the deployment. The transition started with simple processes. Demographic data entry—height, weight and medications—was first on the list, followed by scheduling, infusion nurses and medical transcription. Every stakeholder was asked to provide input about workflow needs.

The other key player is a physician champion. Radiation oncologists, suggests McKay, tend to be more open to EMR use as they interact with technology more regularly than medical oncologists. West Michigan Cancer Center carefully selected its pilot medical oncologist to ensure early success and paired the nurse manager turned clinical information specialist with him until he felt entirely comfortable with the system. After the second physician user, a computer literate clinician, was trained, natural competitiveness took over and physician users climbed on board. Ultimately, the practice finished full deployment three months ahead of its 12-month schedule.

Vendor training is another essential. “As a rule of thumb, just double what the vendor tells you and negotiate it upfront,” advises Miller.

Users and usability

An EMR implementation is a bit of a balancing act. “No EMR is going to meet 100 percent of the practice’s needs,” admits McKay. On the flip side, the No. 1 complaint about electronic records is usability. The best time for buyers to establish optimum usability is during the decision-making process. That means involving end users—nurses, pharmacists, physicians, IT, administration and support—in the process; the system must be appropriately configured for all of them, says Sklarin. In addition, new sites should complete scenario-based testing prior to rollout to make sure the system works as intended.

Miller recommends sites ask potential vendors about formal and informal usability testing in addition to taking EHR software for a pre-purchase test ride to get a sense for vendors’ commitment to usability.
 

Great performance

Compelling data from early adopters and the passage of HITECH remove barriers to EMR adoption. In addition to qualifying a practice for federal incentives, a well-implemented EMR or EHR improves patient care, enhances the bottom line and provides an opportunity to reinvent workflow. The key is designing the project for practice-wide, long-term success, which means involving stakeholders to establish processes that reflect meaningful use and specific practice needs. On the external side, stay on top of the federal requirements, attend to the payor landscape as a few insurers are beginning to offer adoption incentives and work with the vendor to ensure that the system meets current and future practice needs.

The Insider’s Guide to Optimal Treatment Planning System Deployment

State of the art treatment planning technology helps improve target coverage and boost efficiency. Source Philips Healthcare Moffitt Cancer Center in Tampa, Fla., is a National Cancer Institute Comprehensive Cancer Center with a strong radiation oncology program committed to efficient and effective state-of-the-art treatment. Approximately 50 to 60 percent of its cases are treated with IMRT, and an increasing portion of those represent volumetric-modulated arc therapy (VMAT) plans.  Last year, Moffitt Cancer Center deployed a new radiation therapy treatment planning system. The practice’s planning and implementation processes provide a sound model for improving workflow, integrating IT and bettering patient care. “We put together a very detailed RFP listing more than 100 characteristics that we sought in a treatment planning system,” recalls Craig W. Stevens, MD, PhD, chair of radiation oncology at Moffitt. Key factors included the ability to handle VMAT-based treatment planning, very rapid dose calculation algorithms and highly accurate dose planning algorithms. Stevens convened a multi-disciplinary planning team with IT playing a prominent role. “We knew we needed to integrate into the hospital architecture,” explains Stevens. IT assisted with the configuration of the solution and helped with memory, connectivity and firewall questions and challenges. In addition, IT staff recommended an enterprise solution with a central server, a model that boosts workflow by allowing physicians and dosimetrists to access plans from anywhere. The new treatment planning system delivers improved turn-around time; however, Stevens says that turn-around speed is not the primary advantage. Faster treatment planning means more iterations, which provides dosimetrists with a higher degree of meticulousness. They can better optimize treatment delivery, says Stevens, and the center has been able to treat patients to high dose with the potential for cure who otherwise would have had palliative treatment. In addition to further fine-tuning planning, the new system delivers economic benefits. “We’re handling about 20 percent more patients than before with the same number of dosimetrists,” reports Stevens. And because the center opted for an enterprise system, the larger caseload does not require additional workstations, representing a cost-savings. Another financial advantage of the new enterprise system is the ease of expansion to satellite centers. The center has already expanded the system to its existing satellite and anticipates reduced upfront costs as it opens new satellites, says Stevens. Finally, dosimetrists can work offsite or from home, boosting flexibility and efficiency. Stevens credits the optimal deployment to a carefully planned rollout. The center did not want to disrupt its entire department and 10 dosimetrists with training, so it staggered two-week training sessions for its staff, slowing down treatment planning for each group as it went through training. “This approach let us develop our own expertise internally,” explains Stevens.  Looking back, looking ahead During the planning process, Stevens recommends that facilities determine their needs before talking to vendors and then ask each for specifics about how its system can help the center meet its needs. “We also asked for a few capabilities that we knew no one could provide, so we could see what each company had in the development pipeline,” says Stevens. It is important to think ahead as treatment planning continues to evolve. “In the future, treatment planning is going to become a more dynamic process with adaptive plans changing based on treatment response and changes in normal tissue,” predicts Stevens. This necessitates a robust system with rapid dose calculation algorithms and hefty automated contouring capacity. Finally, as sites aim to optimize efficiency, connectivity between treatment planning systems and record and verify systems will become more important. In the next  10 years, the ability to complete dose calculations and rapid re-planning will likely reside within the record and verify system because of the increasing use of cone-beam CT in treatment planning, says Stevens.