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The need for ASCO's Clinical Practice Committee (CPC) to focus on Information Technology (IT) as an important issue was re-emphasized for me by recent experience in my own practice. In 1971, my hospital introduced the nation's first computerized medical system for physician ordering and reporting of laboratory, radiology, and nursing data. Over the next 35 years, the system's initial developer was acquired by a series of commercial entities. The most recent acquirer discontinued support of our system in favor of their own newer product. My hospital converted its well-functioning IT product to the new system, and also elected a new and complex pharmacy billing module, all just 2 months ago. It quickly became apparent that the resources allocated for preimplementation physician testing and customization were inadequate, and 1 month later, lead IT and pharmacy staff were no longer with the hospital. There are several lessons to be learned from this situation: (1) the importance, initially, of choosing a vendor that will be able to support the product over the long run; and (2) the evolutionary nature of software development means that adjusting to new product enhancements and upgrades is a fact of life.life.
While one cannot wait for the perfect system, we learned that a phased introduction of modules is highly desirable, especially with early, and possibly incompletely tested versions of new modules. The phase-in can either be by site (e.g., clinical laboratory or radiology department) or by product function (e.g., billing or scheduling), and reduces the risk of a catastrophic, system-wide failure. Our recent experience suggests to us that software developers seem to strive among themselves to offer ever increasingly complex choices, but often fail to provide direction to their customers. Their clients often start out with the conviction that their situation is unique, and choose to not allocate additional financial resources to purchase preconfigured solutions that they fear will not best meet their needs.
Do the current available systems offer enough reliability and features to justify the costs of converting to a paperless electronic environment? Based on my experience with hospital- and office-based systems, the answer depends on the size and complexity of the clinical practice. The average-sized medical oncology practice can expect a high degree of functionality with one of the oncology-specific IT systems now on the market.
For larger practices (specifically, groups with 30 or more oncologists geographically dispersed over multiple office sites and specialty groups, or hospital-based practices), the situation is considerably different. The geographic dispersion and interactions required in these situations call for a complex and robust system. The development of oncology-specific functionality within these systems has lagged considerably. Our subspecialty needs have a small footprint within the health care system. Oncologists should also be aware of the potential to share the IT systems of their independent practice associations. Furthermore, “Stark law” revisions could allow hospitals to offer discounted IT systems to its affiliated medical practices through ambulatory modules, thereby reducing both acquisition and maintenance costs.
The cost of these systems is the main factor slowing their acceptance in clinical practice. While savings can be realized from enhanced operational efficiency, the ongoing cost of system upgrades could mitigate these potential savings. Since we alter the nature of clinical practice, it is difficult to assess whether we are in fact delivering the same care at less cost. Vendors can reduce product cost by offering an application service provider model in which software and data are stored off-site by the vendor, or by selling physician prescribing data to the pharmaceutical and finance industries. Oncologists need to carefully consider their contractual arrangements.
The CPC, the ASCO IT Committee, and the Quality Advisory Group have joined forces to form an Electronic Health Records (EHR) Working Group to study how ASCO can best use its unique position as one of oncology's leading organizations. ASCO's knowledge of the complex changes in chemotherapy administration coding can be used to design software that improves accurate charge capture. Systems can capture quality measures (such as ASCO's Quality Oncology Practice Initiative) and assist in the implementation of ongoing quality improvement initiatives such as a patient treatment summary document now under design by the Quality Advisory Group. As first steps, ASCO will convene a roundtable of stakeholders to evaluate areas of need and host an EHR Vendor Challenge combining didactic lectures with opportunities to directly evaluate current products; the JOP will publish a series of articles related to this rapidly changing field of medicine. Physician involvement in EHR decisions will maximize the benefits realized. As the committee that represents clinical practice, the CPC will stay focused on this issue.