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Integrating electronic health records into the oncology office, while taking into consideration the principles of electronic health record usage, is a great way to improve the chemotherapy ordering and administration process.
This is the second of a two-part review, concentrating on the ability of oncology electronic health records (EHRs) to enhance patient safety through the chemotherapy ordering and administration process and the standardization of workflow processes in the practice. In part one we outlined broad principles that should be considered when integrating an EHR, and in particular, a chemotherapy ordering module, into practice.1 We strongly advocate attention to the principles listed in the sidebar, as any fundamental change in a drug ordering process may compromise safeguards that are present in the practice. In this article we endeavor to highlight concrete operational issues that are informed by the use of these principles.
Two key concepts raised in part one need to be re-emphasized. The first concept introduced in part one is the importance of workflow. A practice must recognize that chemotherapy ordering safety with EHRs can be impacted not only by the EHR product (the software) but to an even greater extent by the workflow in the clinic.3 When an existing clinic workflow does not work well with the EHR to be implemented, both should be carefully evaluated. It should not be assumed that the existing workflow is ideal, and changes should be considered that improve safety, efficiency, and compatibility with the EHR.
The second concept is that in order to institute these principles, the practice must have a formal governance structure in place to address the many decisions demanded by the system and the changes in workflow. In large institutions, existing committees such as a pharmacy and therapeutics committee may take on this responsibility. Smaller practices will need to create this process. The committee can be small but should be multidisciplinary, including oncologists, nurses, nurse practitioners, pharmacists, and administrators who are completely engaged in the process. The committee serves to standardize regimens for antineoplastic agents including ancillary medications and to ensure that all orders are supported by credible literature. In addition, the committee analyzes errors and near misses that occur in the practice to alter systems or work flow to reduce the likelihood of subsequent errors. We cannot overemphasize the need to optimize clinic workflow and implement a formal system of accountability before the implementation of an EHR.
Standardization of regimens provides predictability for the entire patient and staff experience in the chemotherapy suite. It supports accuracy, reduces errors, and enhances workflow by decreasing ambiguity. Standardization has been shown to improve safety in the airline industry as well as in medical specialties such as anesthesia.4 The following practical considerations are best practices that should be considered when creating standard chemotherapy order sets:
EHR systems bring incredible tools to the clinic, but adopting such systems requires attention to the way the providers interact with it. EHRs must be integrated into an interdisciplinary process of ordering, preparing, and administering chemotherapy. As such, the system facilitates the principle of shared responsibility (where ordering clinicians, infusion room nurses, and pharmacists share the responsibility that orders are correct), redundancy (where the system decreases the likelihood that errors will reach the patient), and minimization of ambiguity (where the system helps ensure that orders reflect the intention of the ordering provider).
When decisions are made concerning the integration of the EHR into the clinic, safety concerns take precedence over convenience. In this process, workflow is always taken into consideration. The governance committee and the personnel of the clinic must develop and adhere to rules of workflow. Of note is that all workflow rules exist with or without the presence of the EHR; however, the EHR can force these rules to be hard wired into the clinic. Examples of best practice workflow rules and the intersection with the EHR are as follows:
EHRs have the ability to automate many routine processes in clinics. Compared with a paper chart, they allow the categorization of clinical information into formats that permit easier access to multiple users simultaneously. EHRs hold the promise of enhancing our ability to deliver safe and quality oncology care. However, as with any technology, integration into the clinic must be accompanied by a careful assessment of workflow and with great forethought. EHRs are not an out-of-the-box solution that will solve all problems within a clinic. EHR integration into an oncology clinic is a disruptive process. If practices adopt the principles and workflow considerations outlined in these two articles, we believe that a safer environment for our patients will result. These principles and workflow rules may vary with certain systems or in individual practices, but as a whole they form a solid framework for the creation and implementation of computerized systems for chemotherapy ordering, preparation, and administration and the workflow that surrounds these activities.
Commercial vendors who market computerized chemotherapy order entry systems should take these principles into account in the creation and modification of their systems. Institutions and practices should use these principles as criteria for evaluating systems they are considering for purchase.
Accuracy: Orders should reflect the intent of the ordering clinician and the independent understanding, confirmation and approval of the nurse and pharmacist.
Standardization: All aspects of the ordering process should be standardized.
Automation: Whenever possible, calculations should be performed automatically by the computer system to reduce clinician workload and avoid errors.2
Decision Support: The system should contain embedded tools that allow for computerized clinical decision support, including dose ranges, maximum dose thresholds that cannot be exceeded, dose reductions, drug interactions, and allergy alerts.
Flexibility: The system should be able to be modified as current treatments change and new treatments are developed.
Workflow Integration: The system should be designed to be an integrated element of the interdisciplinary process of ordering, preparing and administering chemotherapy.
Safety Over Convenience: When decisions are made concerning the design and functionality of the system, safety concerns should always take precedence over convenience.
Efficiency, Reliability, and Usability: Orders should be able to be entered and communicated to pharmacy and support staff in the same or less time than if done on paper.
ASCO is committed to providing oncologists with tools to enhance the safety of patients and assist the oncologist in providing quality cancer care. EHRs have the promise of transforming our practice. ASCO offers an extensive review of the steps and pitfalls of choosing and implementing an EHR in a recently published field guide. The Oncology Electronic Health Record Field Guide: Selecting and Implementing an EHR is available through ASCO (www.asco.org/ehrfieldguide).
ASCO members will also find additional resources, including links to online virtual meeting presentations from the ASCO EHR Symposium in September 2007 and to selected articles published in Journal of Oncology Practice (www.asco.org/ehr).
All authors are members of the Electronic Health Records Workgroup of ASCO.