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Implementing EHRs in Community Oncology PracticesDocument Transcript
by Cary A. Presant, MD, FACP;
Linda Bosserman, MD, FACP;
Wendy McNatt; and Brandon Emilio
The use of electronic health records (EHRs),
also known as electronic medical records (EMRs), ted records in terms of their appropriate comprehensive
is an important component of healthcare reform. In nature.
fact, adoption and use of EHRs is not merely a goal Other potential EHR benefits include the ability to
of healthcare reform; it is an already funded part of enhance communication, to measure and improve the qual-
ity of care, to increase clinical trial participation, to mine
healthcare reform. Now more than ever, community data, to participate in e-prescribing, and to improve billing
oncology practices need information on how to processes.
implement EHRs successfully. As early adopters of
EHRs in the practice setting, our hope is that other Improving Communication
To provide quality healthcare, communication is vital.
oncology practices will benefit from some of the
Using an EHR, physicians can more easily communicate
strategies used and the lessons learned by the Wilshire current and past medical conditions with other providers
Oncology Medical Group. in their practice, with referring or co-managing physicians,
and with patients themselves. This technology enhances
communication across many providers and service loca-
tions—both in the practice and hospital setting. EHRs pro-
vide comprehensive patient records so that physicians have
at their fingertips past treatments, pathology, and all other
rior to federal mandates, oncology practices invested aspects of a patient’s history that might not otherwise be
in EHRs for two main reasons: immediately remembered or so easily accessed in a paper-
1. To document medical history, findings, and care based record.
2. To provide sufficient documentation for appropriate
and adequate payment for services that are medically Improving Quality of Care
necessary for the patient and have been provided by the Within a practice, physicians may use different treatment
practice. strategies or follow different decision-making processes.
EHRs can facilitate provision of consistent quality within
By their very nature, EHRs facilitate appropriate documen- a practice and help to ensure consistency of therapeutic
tation, and make it possible to read and understand submit- approaches by different physicians.
30 Oncology Issues July/August 2009
■ ASCO’s Quality Oncology Practice Initiative (QOPI)
■ Medicare’s Physician Quality Reporting Initiative
■ The Cancer Centers of Excellence program, the nation’s
only practice-owned and physician-driven network of
■ Payer-led quality of care projects.
Improving Research Programs
Oncology-specific EHRs have fields for the multimodal-
ity care, including surgery and radiation therapy, complete
therapy information, and length of course of treatment,
required for central registry. EHRs make it easier for prac-
tices to conduct data projects to understand the nature of
■ General health or performance status
■ Delivered therapies including multimodality therapies,
as well as prevention, recovery, and support therapies.
These data, in turn, allow the practice to perform an
analysis of value: the quality (delivered care and outcome)
against defined delivery costs.
Physicians should consider every patient for possible
inclusion in a clinical trial, and EHRs can help physicians
review patients for eligibility. The technology can also
help practices restrict opening new trials to those types of
patients most commonly seen by physicians in that practice.
Improving Billing and Coding
Above left, Linda Bosserman, MD, FACP, (left) and Standardized data elements in an EHR make it easier to
Traci Young, MSN, RN, ONP document complex clinic work, which in turn supports
PhotograPhs courtesy of the Wilshire oncology Medical grouP
Top, Dr. Presant (far right) and Dr. Gargi (second appropriate high-level billing codes. Many physicians are
from right) with two of Wilshire Oncology Medical so worried about chart audits that they have traditionally
Group’s nurse practitioners. undercoded their work. As payment systems move toward
Above, nursing and administrative staff at Wilshire payments for cognitive services, complex care coordina-
Oncology Medical Group. tion, and oversight and outcomes, the use of an oncology-
specific EHR becomes essential. At the same time, the value
EHRs allow practices to produce data-driven reports of EHRs to payers is becoming clearer, as well. As oncol-
on patients by diagnosis, stage, and tumor features with ogy costs become the number one and number two cost to
delivered care, outcomes, toxicities, warranted variations, payers, both payers and providers are recognizing that the
and cost. Putting these data to use, practices can show the ability to analyze and report on the complexity, cost, and
value and quality of care delivered, while improving effi- outcomes of delivered care will distinguish those physicians
ciencies and safety and facilitating use of evidence-based or medical groups providing high quality and value to con-
guidelines. In fact, EHRs facilitate the delivery of quality sumers and payers, compared to those physicians who need
care, making it possible to compare an individual patient’s improvements.
therapy with guidelines established by the practice, or with
guidelines established by other entities, such as ASCO, E-prescribing
NCCN, payers, or other organizations. Electronic prescribing is gradually being required and vari-
EHRs also enhance a practice’s ability to participate in ous insurers, including Medicare, have incentive payment
national programs such as: programs for e-prescribers. E-prescribing reduces mistakes
Oncology Issues July/August 2009 31
McKesson’s ASP-type EHR,
EHR Options Altos, has all the programmable entry
options of Varian’s ARIA. Because
To date, several different types Altos is an ASP model, the system
of EHRs have been useful in the does not require as much IT support
medical oncology setting. onsite for servers and back-ups.
Of the oncology-specific Other EHR systems can be
EHRs on the market, two— customized for medical oncology
ARIA® (Varian) and MOSAIQ® practice use; but—compared to
(IMPAC)—are owned by radiation oncology-specific systems that are
and facilitates evaluation of the grow- therapy equipment makers. Both updated for the growing number of
ing list of potential drug interactions. have oncology modules that are oncology diagnoses, AJCC staging,
Again, by their very nature, EHRs highly detailed and integrated with and tumor features which correlate
facilitate e-prescribing. their associated radiation therapy with therapies and outcomes—
EHR. Both require servers for data, keeping a non-oncology-specific
Challenges Associated with although practices interested in system up to date will require far
EHRs these EHRs could network to share more IT support. Several hospital
At this point, many practices under- servers, programming, and systems, which do not have as many
stand the challenges related to EHR IT support. of the oncology capabilities as the
implementation. Another oncology-specific EHR, Varian or IMPAC systems, could
The first challenge is, of course, the IKnowMed system used by US interface with an HL7 compliant
how to pay for the technology. EHRs Oncology, is programmed centrally system in a practice. (HL7 is
entail not only costs for hardware, and standardized across all user the national standard for digital
but also for software and ongoing practices. communication.)
software needs, hardware and infra-
structure maintenance, and training.
Staff must be trained and re-trained
as systems are updated. Managers, nurses, assistants, and The Implementation Process
physicians must all be trained and receive timely updates. Selecting, purchasing, and implementing an EHR is a
Practices will need to hire or contract with an informa- complex and time-consuming process, involving decision-
tion technology (IT) coordinator and/or IT networking making, needs assessment, contract negotiations, and staff
expert. To prepare adequately for the upfront and ongoing training. The practice will need to organize an EHR leader-
costs, all of these factors must be considered when budget- ship team. This team can be composed of champions from
ing for an EHR. each area of the practice (e.g., physicians, mid-level provid-
A second challenge is buy in. All members of the ers, medical assistants, oncology nurses, and managers) to
practice staff have to “buy in” to the need for and ben- implement the system practice wide. Or, these leaders can
efits of this technology. Moving to an EHR requires time work with individual groups within the practice on their
and effort on the part of all staff members—the time specific needs (e.g., templates or chemotherapy orders).
needed to introduce the new system, enter old and new The leadership team will help each group review all
data into the system, and record each interaction is con- available options in the EHR and decide how to standard-
siderable. Staff must be willing to spend the extra time ize each person’s use of the EHR. The team and the prac-
to make this technology improvement in the practice. tice staff need to understand the interaction of the different
Practices should assess staff compliance with EHR usage components within the EHR. Remember, the final deci-
and develop practice-wide methodologies for data entry. sions and plans must be discussed with all practice staff,
To enjoy continued improvements in use and adoption of physicians, and EHR users.
best practices, the results of these reports should be fed
back to staff on a regular basis. All staff must understand Step 1: Product decision. Several competing oncology-
that the EHR is for: specific EHRs are available today, as well as larger sys-
■ Documentation of care tems, which are often hospital-based and that may or may
■ Prompts to ensure adherence to clinical guidelines at the not have oncology modules you can build or buy. When
time of decision making choosing an EHR, keep in mind the importance of being
■ Collection of data to understand which patients with able to generate reports from the system. Another crucial
which diseases get which therapies with which outcomes factor in EHR selection is vendor support. In fact, support
and toxicities at what cost. services are an important negotiation point in any EHR
purchase. (For more, see “The Art of IT Contract Negotia-
A final challenge is the ongoing commitment required by tions,” Oncology Issues July/August 2008, available online
EHRs. In addition to the initial hardware and software at www.accc-cancer.org.)
purchases, EHRs require additional programming, main- Non-EHR users may find it difficult to fully evaluate
tenance, and development of interfaces (e.g., interfaces for EHR needs and the impact of implementing and using an
laboratory, radiology, hospital, and e-prescribing). Some- EHR in an oncology setting. To help in this process, we
one—an IT or other staff member—must adequately super- recommend site visits, discussions with EHR-savvy prac-
vise and update the EHR on a regular basis. tices, and reviews by the growing number of practices expe-
32 Oncology Issues July/August 2009
rienced in EHR use. For example, help with data back-up and performance issues.
ASCO offers a social networking Finally, the practice must realistically assess
website—Oncology EHR: Quality how the project will be financed and budgeted.
and Safety—where oncologists can Remember to factor training time into your bud-
connect and share information about the use of EHRs in get. Finally, the EHR and all supporting hardware must be
oncology practices. This tool is available online at: http:// delivered and installed.
Step 4: Training prior to implementation. Physicians and
Step 2: Needs assessment. Once an EHR is selected, the staff will need to become familiar with the system before
next step is to decide how much programming is needed or busy providers are ready to use the EHR while caring for
whether clinical and/or EHR-user networks or other expe- patients. Setting aside time for training either off-site or
rienced colleagues will let you purchase or copy their pro- during non-clinical-care time is critical to allow the team to
grams and methodologies to get you jump started. If your focus on learning the new system and the interactions and
practice has to program the EHR itself, it can take months use rules for the major tasks for which they are responsible.
to pull staff together to standardize all the chemotherapy The more comfortable and competent staff is with EHR use
regimens with appropriate support regimens and educa- before your “go live” date, the better your implementation
tional input for programming. And all of this work must will go. You will need to plan for additional training as the
be done before you can implement the EHR in the clinic. practice staff becomes more familiar with the system and is
You will also need to decide on formats for notes and proce- ready to learn the more sophisticated features of the EHR.
dures and therapy administrations. On the plus side, taking A helpful strategy is to create priority lists for these more
time to standardize these materials at the outset will make complex features, updating the lists as the team becomes
later data pulls much easier to accomplish. (This work is not more fluent in EHR use.
something most practices realize at the start as they have You will also need to have a training program for new
not previously had significant data on care delivery.) employees. Practice “super users” may be able to meet
The practice must decide what data are vital to collect at ongoing training needs if their schedules allow for time
various types of visits, e.g., new visits; decision-making or away from clinic work.
therapy ordering visits; follow-up visits, etc.
Step 3: Negotiation and IT support. Practices must now The practice must decide on the most practical method for
identify a vendor and enter into negotiations. The question EHR implementation. Having staff pre-populate demo-
of where the data are stored is paramount. The server may graphic information and as much of the previous medical
either be hosted by the vendor or a third-party entity or it record as possible can be a significant help. This informa-
may be located within the practice. Regardless of where the tion might include:
data reside, back-ups are crucial to ensure that no data are ■ Diagnoses
lost in the event of a hard drive malfunction. ■ Cancer staging and tumor features
Data ownership is another key consideration. Own- ■ Previous therapies
ing your data is important; however, some EHR vendors ■ Medications
reduce the purchase price or maintenance fees in exchange ■ Allergies
for being able to “sell” your de-identified (HIPAA com- ■ Social, family, and medical history.
pliant) data. Owning your data can be a source of prac-
tice revenue if you partner with networks to enhance the Practice leaders will need to decide whether to go live with
details and value of that data. If an EHR vendor owns the everyone at once or in phases—rolling out EHR use by
server and the de-identified data, it can control when and staffing groups, e.g., front office staff. For example, imple-
whether the data are sold. If the practice owns the server mentation could start with the administration and schedul-
and the de-identified data, it can decide when to sell the ing staff, then phase in chemotherapy ordering, and next
data—either alone or within a clinical and/or EHR-user add medical assistants entering vital signs and medications.
network. The ability to report on your care and bench- Finally, add in clinicians with notes and orders.
mark with other programs is another key reason to main- Multi-site practices need to consider whether to go live
tain control of your data. across all sites at once, only with certain staff in all clinics,
As mentioned previously, your practice will need to or to roll out implementation site by site. Going live one site
hire or contract with an IT expert to handle networking at a time allows the support team several weeks to ensure
and ongoing IT software and hardware needs, as well to that a site is up and running with any issues identified and
Oncology Issues July/August 2009 33
EHR use in oncology practices
will allow transparent and
accountable reporting on
resolved before adding other clinic ongoing upgrade development strategies, many vendors
sites. Regardless of the initial approach, experienced users offer some type of user group, Internet blog, or chat room
know that post-implementation, the EHR will need ongo- option to share best practices and information. In the end,
ing updates and modifications. So having a practice-wide most EHR users come to realize that sharing of develop-
system in place to keep all users up to date is important. ment needs, creation of best practices, and ongoing pro-
Another important implementation decision is whether gramming needs can be best accomplished by networking
to go paperless immediately, or continue to use the paper with similarly committed users.
chart for part of the record until more interfaces (with lab- With EHR adoption, all members of the team will be
oratory, pathology, or radiology, for example) can be cre- asked to practice a bit differently. This change can be stress-
ated or afforded. Some practices opt to scan all documents; ful for the first several months or more, and some practitio-
others find it more cost effective to keep a paper record but ners may need additional support or “work arounds.” Plan
have the essential EHR data for analysis until more funds or for regularly scheduled supervisory and group-wide meet-
interfaces are available. ings by specialty to:
■ Review the implementation process
Moving from the “Story” to Mineable Data ■ Address any problems or additional programming needs
Elements ■ Share best practices.
An often unrecognized issue in transitioning to EHRs is
the fact that clinicians are trained to capture the patient With the practice’s data goals in mind, keep a flexible
story (the medical history). In the complex world of cancer approach.
care, the key information is not in the story, but in the click- To maintain efficiencies, identify creative solutions for
able, mineable data that we need (and have not previously older physicians or those who are not using the EHR ‘real
had access to) to demonstrate the complexity of diagnostic, time.’ For example, develop paper templates (that mirror
therapeutic, and care needs for cancer patients. For exam- EHR templates) that a physician or busy mid-level pro-
ple, descriptions of individual characteristics of patient vider can quickly check off by cancer type. Then, medical
tumors are very helpful in making treatment decisions, assistants or other practice staff can enter these data after
but to “mine” this information, data elements must include hours or after clinic. This process allows the practice to run
defined stage, specific features such as HER2 status, organs smoothly while the necessary data is collected in the most
involved, comorbidities (coded, not just mentioned), diag- efficient way for the team. Younger doctors and staff are
nosed symptoms, and performance status. more familiar with computers and EHRs, so over time this
With the transition to EHRs, some clinicians may find challenge may be less of an issue. Still, to operate efficiently,
the move from “storytelling” to capturing key data ele- all practices will need to keep a close eye on the amount
ments a challenge. However, capturing these data in the of time highly compensated staff spend documenting elec-
EHR allows any provider to review a patient chart and tronically and ensure that documenting via the EHR is as
rapidly capture the complete ‘story’ of that patient, and it fast and efficient as alternate strategies.
allows for analysis of appropriate care as well as continu- In the end, your practice must understand that elec-
ity of high-quality care by alternate providers or care team tronic health records are here to stay. Initially EHR
members. Many doctors will want to continue dictating adoption can be challenging and disruptive, but ulti-
notes as they have been trained to do. As your cancer pro- mately EHRs will help oncology practices improve the
gram’s EHR implementation matures, you may find your quality of their care delivery and their documentation for
goals moving from dictation to the development of meth- prompt payment and mandated public reporting. EHR
odologies and programming to capture standardized key use in oncology practices will allow transparent and
data elements via clicks—for example, drop-down boxes of accountable reporting on delivered care and demonstrate
data elements that clinicians simply select by a keyboard or the known—but previously hard to prove—value of com-
mouse “click.” By collecting these mineable data elements, munity, as well as academic oncology care, thus enhanc-
clinicians will be able to better report the complexity of the ing professional satisfaction and pride in a demanding
delivered care and decision-making—to other providers, career.
payers, and patients.
Cary A. Presant, MD, FACP, is staff oncologist; Linda
Ongoing Needs Bosserman, MD, FACP, is president; Wendy McNatt is
EHR implementation is just the beginning of your jour- practice administrator; and Brandon Emilio is IT techni-
ney. Your EHR vendor should provide ongoing support, cian with the Wilshire Oncology Medical Group in
upgrades, and training. Because user input is important for La Verne, Calif.
34 Oncology Issues July/August 2009