We present results of a pilot study of EHR system use and preparedness to demonstrate adoption of MU criteria in radiation oncology. Radiation oncology has a strong emphasis on safety, with ongoing projects initiated by the American Society for Radiation Oncology including Target Safely19
(a comprehensive plan to improve safety) and Integrating the Health Enterprise–Radiation Oncology20
(an initiative to improve equipment and software integration). We found that large academic radiation oncology practices have broad acceptance and staff support for the use of EHR systems to improve quality and safety, and that these practices intended to implement MU-compliant EHR systems within 2 years, if not by the year 1 reporting deadline of October 1, 2011. These findings suggest that large academic radiation oncology practices are poised to be leaders in IT solutions to safety and quality, but further work is needed to study the adoption of these solutions by smaller practices.
We analyzed the adoption of MU of EHR systems within a DOI framework, a widely accepted model to explain the adoption of new technologies in developed countries.21
Applying the DOI model to the adoption of MU criteria, most facilities are currently in the implementation phase of adoption, with a few in the knowledge phase. Most were aware of MU guidelines, and many had plans to complete implementation of MU-compliant systems by the year 1 reporting deadline. No facility had enough experience incorporating the new MU guidelines into clinical practice to reach the confirmation stage. With the high rate of adoption among the surveyed facilities, MU has easily crossed the critical mass threshold among the radiation oncology academic community.
Despite an attempt to include nonacademic facilities, we did not accrue many private practice or small-sized facilities to our study. With a median practice size of six full-time radiation oncologists and daily treatment volume of 70 patients, our results should not be generalized to smaller facilities. Although a reason for the lower rate of responses from smaller facilities cannot be determined, it is possible that the low response rate was due in part to a lack of familiarity with MU criteria among these practices. Future studies will need to assess and address the needs of smaller practices.
Unlike many other medical and surgical specialties, radiation oncology already integrates electronic systems to accomplish such goals as R&V and dose checking in daily treatment delivery. The most popular R&V systems, Mosaiq (Elekta; Stockholm, Sweden) and Aria (Varian; Palo Alto, CA), have been designed to include EHR system capabilities. It is not surprising, therefore, to find high adoption of EHR system use among radiation oncology facilities. In our survey, most respondents (71%) appeared to advocate the effectiveness of EHR systems for quality improvement.
Cost remains a primary concern for radiation oncology facilities. Because commercial EHR systems need to be certified to meet MU requirements,6
most facilities that purchased systems before the past year will need to upgrade. As of June 2011, for the users of Aria and Mosaiq, only the newest versions (Aria Version 10 MR2 and Mosaiq version 2.3) were fully MU compliant. The cost effectiveness of upgrading EHR systems to match MU guidelines has not been well investigated and likely will vary greatly by facility.
Additional ways to improve implementation of MU criteria in radiation oncology include development of specific guidelines adapted to specialty practice. The initial guidelines specify 15 common core objectives (such as computerized physician order entry, medication-medication and medication-allergy interaction checks, e-prescriptions) and an additional menu from which providers need to choose five (such as drug formulary checks, automated patient reminders, ability to generate searchable patient lists). Although pertinent to almost all practices, these criteria were designed to improve meaningful IT use in primary care. Shaping future criteria to match the potential for EHR systems in specialty practices will improve the effectiveness of MU. Multiple other specialities such as ophthalmology, radiology, and otolaryngology have published guidelines to help improve specialty-specific implementation of MU criteria.22–26
Development of guidelines and quality measures that specifically target safety and quality in radiation oncology practices (such as documentation of prior radiation treatment, uniform documentation of quality assurance checks, and ability to share planning and treatment delivery information electronically) would improve outcomes in radiation oncology to a greater extent than the current general objectives. As we found that many facilities do not routinely communicate on IT issues, encouraging greater collaboration between facilities may also increase the ease of MU adoption. MU criteria offer an opportunity to develop guidelines to globally improve safety and quality in radiation oncology practices. More studies are required to define quality in radiation oncology and how EHR systems can potentially improve measures of quality and safety.
Our pilot study of EHR systems in radiation oncology found that most large academic practices had already incorporated EHR systems into practice and planned to meet stage 1 MU requirements. The ability of smaller radiation oncology practices to meet meaningful use criteria remains unclear. Future studies will focus on measures to improve implementation and determine potential unmet needs among smaller practices.