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Implementing EHRs in Community Oncology Practices






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Implementing EHRs in Community Oncology Practices Document Transcript

  • 1. Implementing EHRs in Community Oncology Practices 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, P 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
  • 2. ■ ASCO’s Quality Oncology Practice Initiative (QOPI) ■ Medicare’s Physician Quality Reporting Initiative (PQRI) ■ The Cancer Centers of Excellence program, the nation’s only practice-owned and physician-driven network of community oncologists ■ 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 patients’: ■ Diseases ■ Medications ■ 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
  • 3. 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
  • 4. 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. ehr.ascoexchange.org. PhotograPh/BigstockPhoto 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. Going Live 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
  • 5. EHR use in oncology practices will allow transparent and accountable reporting on delivered care… 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 PhotograPh/BigstockPhoto 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