Cancer Treatment Centers of America (CTCA) serves patients in five hospitals, each providing both inpatient and outpatient services, around the country. Timothy Birdsall, ND, Chief Medical Information Officer there, says he thinks of an electronic health record system as “a big fancy typewriter and filing cabinet” or a vehicle for improving patient care and making clinicians' work easier. In an interview, he discussed CTCA's use of clinical decision support functions embedded into the EHR system.
What is clinical decision support?
“Clinical decision support boils down to using technology to prompt clinicians around specific things that, according to best practices, they should do or should not do. Most of what is being used today is knowledge-based clinical decision support. A classic example would be drug interactions: If a patient is on Drug A, I should not give Drug B because those two drugs interact. Those things fall in the category of the “don't do this” group of clinical decision support.
“There is also a proactive ‘do this’ set of things. For example, if a patient presents with chest pain, giving aspirin within 30 minutes of hitting the door is a best practice—and clinical decision support can also prompt people to do that.
“CTCA hospitals, and practically all hospitals, have for decades had paper-based resources, such as practice guidelines, that approximate clinical decision support. But those are difficult to use because it requires somebody remembering to do those things in a certain situation; the EHR automates it.”
How does Cancer Treatment Centers of America use clinical decision support?
“We initially focused primarily on order sets, and four years later, we have more than 1,000 order sets active in the system. We made a decision early on that all of our chemotherapy regimens would be built as order sets and that the order sets would be the basis by which chemotherapy would be ordered. I think that's fairly unique in the oncology world.
“You can have an order set that has a lot of options in it. You can have certain things pre-checked with specific doses and routes of administration and infusion rates already pre-built. The system can pre-select either the most commonly used ones or the ones that are recommended based on guidelines or best-practice information. That makes it easy for physicians to do the right thing, but the system allows them to modify a regimen as needed for an individual patient situation.”
What is included in a chemotherapy order set?
“The typical chemotherapy order set for us would obviously include the specific drugs, the specific doses of those and the sequence in which they're going to be given. It involves the route of administration, infusion time, how frequently it is going to be repeated and the other medications that are given along with the chemotherapy, such as antiemetic medications or medications to prevent allergic reactions or for growth factor support.
“It also includes things like an order so that our patient educator knows to educate the patient about their chemotherapy drugs and the infusion processes. It would include a trigger to make sure that the patient has formally consented to the chemotherapy.
“It even includes miscellaneous nursing functions for patients with a central line or a port—those devices may need to be flushed with saline periodically, so those orders are also placed in the chemotherapy order set. We have nurse care managers who are responsible for calling to check on patients at the point in time when we would expect their blood counts to hit a nadir. That is all scheduled as part of the chemotherapy order set.”
Does CTCA monitor whether physicians are complying with order sets or how they modify them?
“We do have the ability to track the changes made. Frankly, it has been challenging for us to analyze that in the way we would like. Many of those chemotherapy order sets are so complex that there may be a lot of variation—changes in dosage, changes in infusion time and those kinds of things—that may occur over time. Those changes are not really non-compliance with the order set as much as they are simply medical management, but differentiating between those two has been a challenge for us. So we are actually in the process of redesigning many of those order sets to get to a better sense of that.
“We do have the ability to determine very easily whether the order sets are being utilized. The percentage of chemotherapy being ordered outside of an order set is very low, primarily because we have made it so much easier to use the order sets than to place all the individual orders one at a time.”
How do the order sets influence physicians' decisions?
“The order sets themselves don't have an appreciable impact on treatment decision-making. Once the oncologist has decided what is going to be used, then he or she places the order.
“In other areas, however, order sets have significantly improved prescribing practices. For example, we have a venous thromboembolism (VTE) prophylaxis order set that is part of every admission order set.
“When a patient gets admitted, there is a screening questionnaire that assigns risk based on a variety of criteria. If a patient reaches a certain level, the physician is triggered to initiate some prophylactic therapy of some form. The physician can choose not to do those things, but has to document the reason. We saw a very dramatic increase in the number of patients who had VTE prophylaxis appropriately ordered for them because literally you cannot admit a patient without ordering the appropriate things or documenting why they are not appropriate.”
What other clinical decision support functions do you use?
“We do have all kinds of clinical decision support [CDS] other than just order sets. Our EHR loves to use medical logic modules (MLMs), which are small programs written that are triggered by an event. Say, if a patient has this diagnosis or this combination of diagnoses and I order something that is contraindicated, the system alerts that I either need to do something else or that there may be a problem.”
You used the term “knowledge-based clinical decision support” to describe warnings, alerts, order sets. Is there a “non-knowledge-based” category of CDS?
“Non-knowledge-based CDS applies to situations where the EHR can help assess risk. For example, if it determines that a patient has a combination of three things—let's say hypothetically that a patient has been hospitalized more than five days, has oral intake of food that has been meeting less than 50 percent of the caloric requirement, and has a systolic blood pressure of 100 or less—my EHR system tells me that that patient is at risk for hospital readmission shortly after discharge.
“That information tells me that I should be much more proactive as I am preparing that patient for discharge, making sure that the patient has the support in place to stay out of the hospital. We are still in the very early stages of this. Now that we have four years' worth of data in our system, we are to be able to start extracting pieces of information to ask, ‘What are the unique things about our patient population that we can learn, and therefore, improve their experience by tailoring what we do to improve their outcomes?’ I'm very excited about that.”
Part 1 of a Series
This is the start of a series about how information technology is changing the practice of oncology.
PODCAST: Chemotherapy Order Sets—Lessons Learned
Creating chemotherapy order sets is not easy. Listen on the iPad edition of this article to hear what Timothy Birdsall says are the lessons learned in developing Cancer Treatment Centers of America's more than 300 chemotherapy order sets.
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