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Like individual users, oncology practices differ in their appetites for information technology (IT). Some practices are eager early adopters. Others move slowly, even reluctantly, towards computerization.
Pressures to modernize are building for all oncology practices, though, whether large, small, or moderately sized. These pressures include government mandates that will require electronic medical records (EMRs) for every citizen during this decade. The complexity of care and emphasis on quality measures also encourage the push toward high-tech methods. Likewise, business factors support the movement towards electronic sophistication. These include the need to treat the growing number of cancer patients as efficiently as possible and to have complete records when legal matters arise.
This article provides three case histories, each describing one practice's experience with IT implementation and expansion. The cases describe how these practices handled both human and technical challenges.
“In 1998, this practice took a big leap of faith to implement an oncology-specific EMR. In an era when PCs were just finding acceptance in medical practices, we turned our EMR on all at once,” reports Glenn Balasky. He serves as the executive director for the Mid Ohio Oncology/Hematology, Inc., which includes four office locations and 12 physicians. “Before that time, the only staff people here who touched a computer were front desk staff and the back office billing team,” Balasky says. “Even then they were using old-style video terminals and most staff had never used a mouse. Today, the office has more computers than staff members (since doctors have both desktop PCs and point-of-care wireless tablet PCs).”
Mid Ohio Oncology/Hematology's IT efforts have paid off handsomely. “Our practice has grown and become more productive at the same time,” says Balasky. The group has carefully tracked the value of their IT tools. Their data clearly show that the technology has allowed them to make greater use of staff time and energies to deal with their growing case load and the heightened complexity of care with a slower rate of growth in overhead.
“From a financial standpoint, the practice's charge capture improved by 6% to 8% for medications and visits combined,” says Balasky, “In a paper world, a nurse would pull a medication off the shelf and forget to document that she gave a patient 300 μg of Neupogen [filgrastim; Amgen, Inc., Thousand Oaks, California]. In an electronic world, with the EMR connected to a medication-dispensing machine, a medication cannot be pulled without an electronic order. Also, someone needs to approve the charge for that medication after it is dispensed. You don't lose a charge, because the system requires the nurse to approve the charge or cancel the order—if the patient isn't in that day, for instance,” he explains.
Timothy Moore, MD, notes the medical/legal advantage of having complete documentation of all patient interactions. “I used to have pockets crammed with sticky notes from nurses about patients calling in. I'd try to answer the patients as best I could. The nurses still give me paper messages but not until they have entered each call on a computerized call log,” he explains. “If Joe Smith has mouth sores and I say he needs a certain mouthwash, then she calls in that prescription and enters it in his record.” Everything is there; even if 6 months later a patient maintains that his calls were ignored.
The IT team leaders stressed the practical advantages that the various staff members would gain from the switch to an EMR. With nurses, they emphasized the fact that charts would not get lost anymore—they would always be accessible. Instead of having a single chart per patient available for use by only one person at a time, an EMR would give several users (with administrative or clinical duties) simultaneous access to a chart.
They emphasized the EMR's clinical advantages, too. For instance, a doctor on weekend call would have fast access to a patient's complete chemotherapy record. He or she could then avoid the need to make an educated guess or delay an important care decision.
Before the EMR implementation in 1998, some members of the staff were so technologically inexperienced that they didn't know how to use a mouse. To make the learning process less intimidating, some of those staff members started out by playing PC solitaire. In the end, no one resigned, and everyone adapted.
Moore views EMRs and full IT use as a gateway to tighter clinical trials. “I see the EMR as a way to facilitate accrual to trials and to make sure that the data we obtain is much more useful,” he says. His group had a highly positive experience creating a protocol for a clinical trial through a process that fully involved a drug company representative and the practice's corporate EMR representative. (That representative came from a firm then called OpTx, now owned by Varian Medical Systems, Palo Alto, California; the product is called VARiS MedOncology.)
“Our brains can only handle so many things at once but the computer can catch us and prevent mistakes,” Moore explains. “Say a patient's platelet level is below the required level for a certain chemotherapy course and I try to write a prescription for the chemotherapy order, ignoring the platelet level. The computer won't let me—it assures adherence to the protocol.”
With the movement toward outcome measurement and reporting for medical practices, IT becomes even more valuable. Balasky explains that this can allow us to answer key questions: “Are our treatments extending life or providing the desired therapeutic effect? Are we providing our patients with the best possible outcomes? You would have to send an army of auditors to extract that information from paper charts today, but once we are better able to couple our practice data with data from other practices, this information will start to become incredibly powerful.”
For Wilshire Oncology Medical Group, Inc., the transition toward a high degree of computerization came in two main stages, explains administrator Wendy McNatt. The practice employs nine physicians at six locations in southern California.
“First in 1998, we developed a VPN, a virtual private network. That brought our offices together. At that time, we had five locations, 12 physicians, and 70 employees,” McNatt says. The VPN allowed the doctors to rotate among the locations and see all their own documents (special forms, correspondence, research protocols, etc.). Before the implementation of the VPN, the various locations stored those special items for each doctor, or the doctors carted the items from place to place.
During this first stage, the practice helped staff members overcome any lingering resistance they might have to computerization. “We wanted to understand who would be an early adapter and who would struggle. We ranked everyone here for their technological resourcefulness, on a scale of one to five,” she says. “Things we took for granted, like the instruction to ‘right click,' would leave certain people just looking at us. Instead of waiting for some of the doctors to throw the mouse down the hall, we paired them up with a buddy to assist them.” They also sent physicians and nurses out of the office for training. With the help provided, everyone eventually adjusted to the new technology.
In 2000, when Wilshire's staff had all mastered and enthusiastically embraced the VPN technology, the practice moved into phase two. This stage involved adoption of an EMR. Doctors immediately valued the instant and complete access to information about any patient in the practice that the EMR provided.
The physicians at Wilshire Oncology especially prize the EMR for the improvements it confers in the areas of safety and quality control. “Our physicians get very excited if they see that the national guideline says survival for a certain cancer is 6 years and ours is 7.2. Also, we know exactly what dosages of what medications our patients are on. If there are likely to be any interactions when a prescription is made, we get red flags,” explains McNatt. “Quality is where Medicare and everyone are going now, and we feel we're really a step ahead thanks to having these IT systems in place.”
As the practice at the Rocky Mountain Cancer Centers has steadily grown, so has the group's IT use, explains Jeff Poe, executive director. “We had six physicians in 1992. Now we have 60 physicians and a total of 570 employees working at 18 locations,” he says. “Our IT development has been gradual. We've introduced more technology as we needed it—to communicate, to develop billing, collection, and scheduling interfaces, and to enhance our patient quality initiatives” in addition to fulfilling other tasks. An IT director supervises six employees.
This practice uses e-mail to communicate with patients but only about administrative and billing questions, not medical ones. It is in the process of deploying an electronic health record (EHR) across its 18 locations.
“The staff said ‘over our dead bodies' when we first brought up the EHR, but then they loved it,” recalls Poe. “Before we introduced the EHR, if the triage nurse got 30 phone calls, she'd have to stand up 30 times to retrieve the charts she needed. With the EHR in place, she might stand up once or twice to answer 30 calls. She can do nearly everything from her desk, on the computer. It meant a huge boon in efficiency and quality of care.” His staff also highly values the fact that the EHR lets more than one user have simultaneous access to a patient's record.
Still, EHR adoption wasn't easy for many of the doctors at first. “It was a 180 degree change in the way they thought and worked,” Poe says. “Doctors aren't shy about expressing their frustrations. This is where commitment to the change on an administrator's part really counts, that this is the right approach. The physicians have to be fully engaged, as they can undermine the change [if they're not].”
In early 2005, Rocky Mountain Cancer Centers began using a picture archiving and communications system (PACS) to store all its medical images (positron emission and computed tomography scans, etc.). This aspect of its computerization particularly taxed the data lines the practice was using. With the PACS in place, reports Poe, “we found that our network was really slowed down. We were having failure points during the day.”
They decided to invest in a fiber optic network to link all of their 18 sites. Its “data pipes” have the enormous, potentially expandable capacity that this practice needs. The data loads can be heavy with all the practice management data, e-mail, images, and EHRs involved. Though set up initially to handle 10 MB of data, the network can be readily expanded to handle 25 to 100 MB (through the manipulation of switches and without digging holes in sidewalks or streets or damaging walls).