Implementing EHRs in Community Oncology Practices

By their very nature, electronic health records (EHRs) facilitate appropriate documentation and make it possible to read and understand submitted records in terms of their appropriate comprehensive nature. Other potential EHR benefits include the ability to enhance communication, measure and improve the quality of care, increase clinical trial participation, mine data, participate in e-prescribing, and improve billing processes.

Improving Communication
To provide quality healthcare, communication is vital. Using an EHR, physicians can more easily communicate regarding current and past medical conditions with other providers in their practice, with referring or co-managing physicians, and with patients themselves. This technology also enhances communication across many providers and service locations-in both the practice and hospital setting.

Improving Quality of Care

Within a practice, physicians may use different treatment strategies or follow different decision-making processes. EHRs can facilitate provision of consistent quality within a practice and help to ensure consistency of therapeutic approaches by different physicians.

EHRs allow practices to produce data-driven reports on patients by diagnosis, stage, and tumor features, with delivered care, outcomes, toxicities, warranted variations, and cost. Putting these data to use, practices can show the value and quality of care delivered while improving efficiencies and safety and facilitating the use of evidence-based guidelines. In fact, EHRs facilitate the delivery of quality care, making it possible to compare an individual patient’s therapy with guidelines established by the practice, or with guidelines established by other entities, such as ASCO, NCCN, payers, or other organizations. EHRs also enhance a practice’s ability to participate in national programs such as:

• ASCO's Quality Oncology Practice Initiative (QOPI).
• Medicare's Physician Quality Reporting Initiative (PQRI).
• Physician- and physician network–driven comprehensive oncology initiatives, including several oncology medical home pilots, US Oncology’s Innovent program, and University of Pittsburgh’s Via program.
• Payer-led quality of care projects.

Improving Research Programs
Oncology-specific EHRs have fields for multimodality care, including surgery and radiation therapy, complete therapy information, and length of course of treatment, which are required for central registry. EHRs make it easier for practices to conduct data projects to understand the nature of the following in their patients:

• Cancer and comorbid diseases.
• Medications.
• General health or performance status.
• Delivered therapies, including multimodality, prevention, recovery, support, and hospice therapies.

These data, in turn, allow the practice to perform an analysis of value, relating quality (delivered care and outcome) to defined delivery costs.

Physicians should consider every patient for possible inclusion in a clinical trial, and EHRs can help physicians review patients for eligibility. The technology can also help practices restrict opening new trials to those types of patients most commonly seen by physicians in that practice.

Improving Billing and Coding
Standardized data elements in an EHR make it easier to document complex clinic work; this documentation in turn supports appropriate high-level billing codes. As payment systems move toward payments for cognitive services, complex care coordination, and oversight and outcomes, the use of an oncology-specific EHR becomes essential. At the same time, the value of EHRs to payers is also becoming clearer. As oncology costs become the number one cost to payers, both payers and providers are recognizing that the ability to analyze and report on the complexity, cost, and outcomes of delivered care will significantly aid physicians and medical groups.

E-Prescribing
Electronic prescribing is gradually being required, and various insurers, including Medicare, have incentive payment programs for e-prescribers. E-prescribing reduces mistakes and facilitates evaluation of the growing list of potential drug interactions. Again, by their very nature, EHRs facilitate e-prescribing.

Challenges Associated with EHRs
At this point, many practices understand the challenges related to EHR implementation. The first challenge is, of course, how to pay for the technology. EHRs entail not only costs for hardware, but also for software and ongoing software needs, hardware and infrastructure maintenance, and training. Staff must be trained and re-trained as systems are updated, and practices will need to hire or contract with an information technology (IT) coordinator and/or IT networking expert. A second challenge is that all members of the practice staff must “buy in” to the need for and benefits of this technology. Moving to an EHR requires time and effort on the part of all staff members. A final challenge is the ongoing commitment required by EHRs. In addition to the initial hardware and software purchases, EHRs require additional programming, maintenance, and development of interfaces.

The Implementation Process
Selecting, purchasing, and implementing an EHR is a complex and time-consuming process, and the practice will need to organize an EHR leadership team that will help each group review all options in the EHR and decide how to standardize each person’s use of the EHR.

Step 1: Product decision
Several competing oncology-specific EHRs are available, as are larger systems that are often hospital-based and that may or may not have oncology modules you can build or buy. When choosing an EHR, keep in mind the importance of being able to generate reports. Another crucial factor in EHR selection is vendor support. We recommend site visits and discussions with EHR-savvy practices before making this crucial decision. For example, ASCO offers a social networking website-Oncology EHR: Quality and Safety-where oncologists can share information about the use of EHRs: http://ehr.ascoexchange.org.

Step 2: Needs assessment
Once an EHR is selected, the next step is to decide how much programming is needed or whether clinical and/or EHR-user networks or other experienced colleagues will let you purchase or copy their programs and methodologies to get you started. If your practice has to program the EHR itself, it can take months to pull staff together to standardize all the chemotherapy regimens with appropriate support regimens and educational input for programming-and all of this must be done before you can implement the EHR in the clinic. You will also need to decide on formats for notes and procedures and therapy administrations, and agree on what data are vital to collect at various types of office visits.

Step 3: Data storage and ownership.
The server on which the data are stored may be hosted by either the vendor or a third-party entity, or it may be located within the practice. Regardless of where the data reside, back-ups are critical. Data ownership is another key consideration. Owning your data is important; however, some EHR vendors reduce the purchase price or maintenance fees in exchange for being able to “sell” your de-identified (HIPAA-compliant) data. Owning your data can be a source of practice revenue if you partner with networks to enhance the details and value of those data. If an EHR vendor owns the server and the de-identified data, it can control when and whether the data are sold. If the practice owns the server and the de-identified data, it can decide when to sell the data-either alone or within a clinical and/or EHR-user network. The ability to report on your care and benchmark with other programs is another key reason to maintain control of your data.

Step 4: Training prior to implementation
Setting aside time for training either off-site or during non-clinical-care time is critical to allow the team to focus on learning the new system.

Going Live
The practice must decide on the most practical method for EHR implementation. Having staff pre-populate demographic information and as much of the previous medical record as possible can be a significant help. This information might include diagnoses, cancer staging and tumor features, previous therapies, medications, allergies, and social, family, and medical history. Practice leaders will need to decide whether to go live with everyone at once or in phases-rolling out EHR use by staffing groups. Multi-site practices need to consider whether to go live across all sites at once, only with certain staff in all clinics, or to roll out implementation site by site. Another important implementation decision is whether to go paperless immediately or continue to use the paper chart for part of the record until more interfaces (with laboratory, pathology, or radiology, for example)can be created or afforded.

Moving from the “story” to mineable data elements
An often unrecognized issue in transitioning to EHRs is the fact that clinicians are trained to capture the patient story (the medical history). In the complex world of cancer care, the key information is not in the story, but in the clickable, mineable data that we need in order to demonstrate the complexity of diagnostic, therapeutic, and care needs for cancer patients. While this transition might be challenging for some clinicians, capturing these data in the EHR allows any provider to review a patient chart and rapidly capture the complete 'story' of that patient, and allows for appropriate care by alternate providers or care team members.

Ongoing needs
After implementation, your EHR vendor should provide ongoing support, upgrades, and training. With EHR adoption, all members of the team will be asked to practice a bit differently. This change can be stressful for the first several months or more, and some practitioners may need additional support. Plan for regularly scheduled supervisory meetings to review the implementation process, address any problems or additional programming needs, and share best practices.

In the end, your practice must understand that electronic health records are here to stay. Initially EHR adoption can be challenging, but ultimately EHRs will help oncology practices improve the quality of their care delivery and their documentation for prompt payment and mandated public reporting. EHR use in oncology practices will allow them to demonstrate the known-but previously hard to prove-value of community, as well as academic, oncology care, thus enhancing professional satisfaction and pride in a demanding career.