Many practicing oncologists likely have a love/hate relationship with their practice's electronic health record system (EHRs). On one hand, EHRs provide important benefits for clinical practice—including the ability to create templated notes which saves clinicians' time related to documentation, remote access of patient records, electronic medication prescriptions, and facilitation of billing. However, current EHR systems are far from perfect. Below, some challenges oncologists face today related to current EHR limitations are described, with a look toward a possible better future as EHR systems continue their development.
Survivorship Care Plans
Initially described by an Institute of Medicine report in 2005, From Cancer Patient to Cancer Survivor, survivorship care plan is a document which the oncologist prepares and gives to the patient and his/her primary care provider at the completion of treatment. The document summarizes the patient's cancer diagnosis, treatments received, and describes a plan for follow-up care. It is recommended by ASCO and now part of the American College of Surgeons Commission on Cancer accreditation standards. Therefore, oncology practices across the country are challenged to each create solutions and workflows to meet this requirement.
ASCO, Journey Forward, and other organizations provide survivorship care plan tools online which oncologists can use. However, EHRs could be utilized to facilitate this process. There are several potential advantages. One, many of the data elements included in a survivorship care plan already exist in the EHR—such as diagnostic information (e.g. stage and type of cancer), treatment information, physician names—so there is certainly the potential for EHRs to help create survivorship care plans more efficiently by auto-populating many of the data elements. A related strength inherent in EHR systems is an ability to template notes; in survivorship care plans, follow-up recommendations can be easily templated, further reducing the time spent by the busy oncologist to create a survivorship care plan document for each treated patient. Another benefit is that once created, the survivorship care plan document automatically exists in the EHR and becomes part of the patient's medical record. EHR systems could also have the ability to track compliance rates with meeting the Commission on Cancer standard.
While the Commission on Cancer requirement is broadly applicable to practicing oncologists across the country, unfortunately, existing EHR systems do not have built-in survivorship care plan tools. Oncologists facing the challenge of meeting the Commission on Cancer requirements can either build templates in the EHR system themselves—or with institutional IT support if available—or continue to create survivorship care plans separately from the EHR using available templates online.
Oncologists want to provide high-quality, evidence-based care—which is also increasingly required by payers. It is challenging for oncologists to keep up with the rapidly evolving clinical trial evidence on treatments for various cancers, as well as clinical practice guidelines from different professional organizations which are updated frequently. EHRs have the capability of helping physicians deliver the best care for their patients by providing decision support.
Based on clinically available information contained in the EHR system—which can include patient age, performance status, cancer type, and stage—guideline-recommended treatment options could be presented in the EHR to help facilitate the oncologist's discussions with patients, and also facilitate ordering of these treatments. These are commonly called “pathways”—and as new research evidence and/or guidelines are published, these pathways would ideally be updated to provide the oncologist with guidance based on the most up-to-date information.
Indeed, there is active work by various companies to integrate clinical pathways with EHR systems, with some commercial products currently available for clinical use by oncologists. These pathways likely apply to most patients seen in the clinic, and their incorporation into EHR systems for decision support at the point of care can help make the oncologist's work more efficient while maintaining (likely improving) quality.
Measuring & Documenting Care Quality
Related to the above is documentation of care concordant with quality measures for practice certification or accreditation. Oncology practices are challenged with needing to demonstrate high quality care meeting or exceeding published benchmarks, which currently consists of a time-consuming process of abstracting medical charts. EHR systems have the potential to make this process much simpler for the practicing oncologist because they contain the relevant data elements (patient and disease characteristics, medical care received) usually required to assess concordance with quality measures.
Recognizing this challenge, ASCO's Quality Oncology Practice Initiative (QOPI) certification program may soon offer an eQOPI option which will allow direct pulling of necessary data from EHRs to assess a practice's provided care with certain quality measures. Continued collaborative work between professional societies and EHR vendors are needed to further perfect this process so that benchmarking the quality of care for each oncologist and practice can occur with minimal burden to the oncologist and in (near) real-time. Ultimately, facilitating a universal participation in quality assessment programs and provision of real-time feedback will be an important continuous learning tool for oncologists and thereby help patients receive the highest quality of care.
Another important challenge is that assessment of “high quality” care should not only involve process measures, but also involve measures of patient outcomes. Examples of process measures, which are commonly used currently, include documentation of specific patient characteristics in the medical record (pathology confirming malignancy, cancer stage, performance status, treatment intent), timely initiation of treatment, and provision of certain appropriate treatments based on disease characteristics (e.g. trastuzumab for HER-2 positive breast cancer). While process measures are an important part of quality assessment, patient outcomes are equally, if not more, important. However, the latter are harder to assess using data elements available in EHR systems. Relevant patient outcomes can include—treatment-related toxicity, quality of life, cancer recurrence, and mortality—but these are often not present in structured data elements in current EHR systems. While quality of life is widely recognized as important for cancer patients and survivors, incorporating assessment of quality of life into routine clinical care using current EHR systems is difficult. Some institutions with strong IT support have built add-on modules to allow assessment of patient quality of life and data display in EHR, but this is not practical universally.
A Challenge for Radiation Oncologists
Radiation oncology has long had only 2-3 EHR systems which are used across the entire specialty. These EHR systems are traditionally associated with the major radiation machine manufacturers, and serve not only as software which organizes patient appointments and medical records, and billing, but also used for prescribing and delivering radiation treatment. With a more recent uptake of EHR systems in hospitals across the U.S., much of it driven by Medicare's meaningful use requirements, hospital-based radiation oncology departments are increasingly facing the challenge of operating with two distinct EHR systems for their daily clinical patient care—the hospital's EHR system and the radiation oncology-specific system. The former cannot be used to prescribe or deliver radiation treatment, while the latter is not built to be a hospital-wide EHR that would be used by all specialties.
Currently, there is no easy solution. For the time being, radiation oncologists facing the situation of operating with and across two different EHR systems are challenged with having to do double-work—entering patient scheduling information and relevant medical records (including consultation notes, labs, pathology, radiology reports) in both systems—in an increasingly busy clinical environment.
The rapid movement toward universal adoption of EHRs in the practice of oncology presents tremendous opportunities, and also the obligation for vendors and professional societies to work closely together to continue to improve the EHR systems for the benefit of patients and clinicians. As cancer care is increasingly multidisciplinary, delivered by teams which consist of surgeons, radiation oncologists and/or medical oncologists, it is of upmost importance that there is multidisciplinary collaboration in working to improve EHR systems as well.
Substantial work is needed to improve the capture of structured data elements in EHR systems—defining a core set of data elements that should be captured, and developing standardized terminologies and ontologies to encode these data elements. Continued improvements in structured data capture in EHRs will facilitate efforts related to automated quality assessment and benchmarking, and better data will also improve the ability of decisional support tools to be maximally helpful. Further, an ideal vision for the future is one where as professional societies create and update guidelines, requirements, and quality measures—they are also incorporated in EHR systems to facilitate implementation. This is technically possible, but requires the will of EHR vendors to work with professional societies with the ultimate goal of benefitting patients.
Another major benefit of this effort is that it may allow the vision of “big data” to become reality—where medical science learns from every patient, not only the 3 percent who participate in clinical trials. An ability to pool anonymized patient data across different EHR systems and across institutions, made possible by all EHR systems having certain standardized data elements, is a powerful vision for the future that can facilitate even faster scientific progress in improving cancer care.
RONALD CHEN, MD, MPH, is an Associate Professor, Department of Radiation Oncology, University of North Carolina at Chapel Hill.