The Long Road-and the High Road-to Successful Implementation of OncoEMR

Mark Rubin, MD

Lucio Gordan, MD

Tim Boozan, RN

Today at Florida Cancer Specialists, the largest private oncology practice in the state of Florida, a fully integrated, highly efficient, oncology-specific electronic medical record (EMR) forms the backbone of the practice. This valued outcome, however, comes as the result of a long process-years of hard work by many people in our organization. As we move toward marking a decade of the utilization of Altos OncoEMR, we would like to reflect on the experience and, if possible, lend some insight to others regarding the choice, integration, and optimal utilization of OncoEMR, and of an EMR system in general.

One of us (Dr. Mark Rubin) was the first adopter of OncoEMR within our organization. Working closely with our EMR partner, Altos Solutions, we helped develop the product, installed our internal infrastructure, and prepared and trained our physicians and staff as we moved towards practice integration. Another of us (Dr. Lucio Gordan) was the lead physician at one of the large practices we integrated into Florida Cancer Specialists as part of our expansion initiative. Thus, while two of us are practicing hematology-oncology physicians with experience in health electronic record systems and/or medical software development, we bring two completely different perspectives to our current roles as physician-managers of the technology and data platforms for Florida Cancer Specialists.

Tim Boozan has provided instrumental assistance over the years. Building on all our experiences, we have put together a short guide to “best practices” in the selection, implementation, and utilization of an oncology EMR.

Select an Oncology-Specific EMR

Maybe the most important decision that our practice made was the selection of an EMR that was oncology-specific. OncoEMR was not developed as an EMR that was adapted to oncology; it is an EMR that was developed to serve oncologists and oncology patients, with the flexibility to be used in a practice of any size. OncoEMR was designed to mimic how an oncologist thinks and treats a patient; as a tool, it reflects and incorporates the complexity and intricacies of our specialty. The decision to use OncoEMR helped shape our practice, positioned us to grow, and allowed us to change along with our specialty. Learning to use and take full advantage of the features of the product that are unique to oncology has been a key factor in maximizing the benefits of OncoEMR (Table).

Select a Committed EMR Partner

Table: Best Practices for Use of Altos OncoEMR

OncoEMR has a wealth of helpful features. In order for your practice to reap the greatest possible benefit from the product, it is important to be sure you are utilizing these features to the fullest. Key among these are the following:

• Regimen/Protocol Building: OncoEMR has the ability to build complete and total protocols that include managed care, regimens, labs, diagnostic testing, office visits, and more, with each element automatically scheduled as required. Make sure that all aspects of your practice’s protocols have been incorporated into the new system, rather than continuing to handle one or another of these as you did previously.
• E-Prescribe: This feature gives you the ability to order your patient’s prescription directly in OncoEMR and send it to the patient’s preferred pharmacy. Make sure that all pharmacies used by the patients in your practice have been linked to the system so that you can get the greatest efficiency from this feature.
• Document Management: Document volume is enormous in most practices. OncoEMR provides many options that can help a practice manage documents, and we found that it really increased our overall efficiency to take advantage of these, even though it can be tempting to stick with systems already in place. For example, we already had a fax-via-email program we used, but we found that the ability to fax directly from the EMR and to import documents via fax servers reduced the need for scanning and thus saved a significant amount of time.
• In-Box: The in-box design of OncoEMR can also help a practice’s physicians manage their documents more efficiently. The in-box is divided into sections, including messages (eg, information sent by other staff members to their physician colleagues alerting them to important data about a specific patient), laboratory results (divided by acuity), radiology reports, outpatient and hospital billing to be entered and signed off on, and documents to be signed (dictations, outside records, pathology results), as well as other miscellaneous documents scanned into patient charts. The in-box is the most important component of OncoEMR outside the treatment plan. It is important that all documents flow through the in-box so the physician knows in real time what is happening in his practice. To allow physicians to filter through all this material and focus on what is most important, we use a combination of proper categorization and smart alerts. For example, while all warfarin management notes flow through the in-box, the ones the physician should be concerned about- ie, abnormal values, as well as an inappropriately long time to retesting-are flagged and reported separately.
• Alerts: OncoEMR has the ability to allow practices to build alert screens that remind, warn, and instruct physicians and other clinicians regarding best practices in patient treatment. These alerts can help tremendously to improve patient care; however, careful thought must go into setting up the alerts, and time must be budgeted for this task. What worked for us was to set up small teams, one for each tumor type.
• Reports: OncoEMR has a wide variety of reports that can potentially enhance physicians’ ability to manage their practice. If the data is in the EMR, there is the ability to report on it. However, the sheer number of possible reports that can be generated can be overwhelming. We found it important to decide on the 10 or so reports we felt would be the most helpful-and then to work with the physicians in the practice to make sure these were regularly used.
• Physician Portal: The ability to share a patient’s critical treatment information with physician referral partners or with those physicians who are assisting with the treatment of a patient can be an invaluable tool. Currently, there are limitations in the ability of OncoEMR to automatically exchange information with another electronic health record system. However, interfaces can be built between OncoEMR and many laboratories, radiology centers, and pathology companies. Also, information within OncoEMR can be exported as an image (fax transmission or PDF) to outside systems.
• “See Your Chart”: Although it is not directly part of the EMR, “See Your Chart” is a useful tool that can enhance the patient experience and help improve physician-patient communication. While we definitely recommend using “See Your Chart,” we think it is important to explain to patients upfront, in order to avoid confusion, that no test results that are abnormal or that require follow-up or discussion will be visible to them in “See Your Chart” until their physician has had a chance to discuss these results with them.
• Start at “Find Patient,” Then Go to “Tx Plan”: A practical tip for quickly getting localized in OncoEMR is to first go to “Find Patient” and enter the patient’s name. Once in the patient’s records, the second step is to go to “Tx Plan.” This screen allows you to navigate through the most important ordering systems: flowsheet (medications, chemotherapy regimens), laboratory, radiology, and multiple orders, among other features.
• “Summary”: The “Summary” button is a useful and important function that brings up concise critical information about a specific patient, including demographics, diagnosis, allergies, medication list, treatment summary, and access to the e-prescribing portal, among other things.

If the choice of an EMR is the most important decision, the choice of the EMR vendor partner that supports the product is directly related to that decision. As all of us have learned over the past 10 years, in oncology, the only certainty is that change is just around the corner. We have found Altos Solutions to be committed to continually adapting OncoEMR to the changes occurring in oncology. This helps us to meet the demands of the continually evolving oncology practice environment, thereby maintaining-and even enhancing-our ability to provide our patients with the best care possible. For example, Physician Quality Reporting System (PQRS) implementation was integrated into the EMR in a way that enabled us to improve compliance by requiring each physician to complete PQRS inquiries at the time a patient was seen.

Select a Physician Leader and Super Users

The purchase of an EMR is one of the most important investments that any practice makes. It should be treated that way. Thus, it is essential to commit the human as well as financial resources required to work with your vendor partner to fully understand the product and optimize its use in your practice. Make sure you have a physician and a non-physician staff member (known as “super users”) who fully understand the program and its features, so that you can maximize its intelligence, efficiencies, and oncology-specific features. And assuming you have selected a vendor partner who is committed to continually improving the product and changing with the environment, it is important that the physician leader and non-physician super user commit to keeping up to date with those changes that will improve your practice and your treatment of patients. Remember, your EMR is no longer the wave of the future; it is the mandate of the present.

Commitment to the EMR and its Utilization

Another key recommendation that is important if you are to get optimal value from your EMR is that your practice must have a total and complete commitment to its use. When merging with other practices, we typically find that these practices want to stage the move to an EMR or only utilize parts of the program. It is imperative that all physicians and employees use the program to maximize its positive impact on the practice and its patients. The sum of its parts is far greater than the individual components. As stated previously, if you are investing in this program, you should maximize its utilization. If necessary, the transition to OncoEMR can be done in stages so as not to overwhelm physicians initially; however, the nature and order of the stages is important. Using the EMR to execute chemotherapy order efficiently and safely should be accomplished early on. Other components, such as OncoNotes, can be activated later.

Converting to OncoEMR From Another EMR

When implementing a conversion from a pre-existing EMR to OncoEMR, it is important to make sure that information technology staff from both companies build bridges that will make possible accurate and seamless transposition of as much information as possible from “point A to point B.” Doing this will save a significant amount of time, as it will obviate the need (or at least much of the need) for manual data entry by the providers.

The Myth of Cost Savings

In the many conversations we have had with other practices and internally with Altos Solutions, we have discussed the cost savings associated with the utilization of OncoEMR. The conclusion we have come to is that a practice cannot just plug in the EMR and expect instant efficiencies. The savings are related to the EMR’s many features, but these must be maximized in order for there to be a significant impact on your practice flow-and your bottom line.

Summary

We believe that no matter where a practice currently is in the EMR process-vetting products or companies to determine what will best meet its needs, implementing the new product just selected, or trying to take maximum advantage of the product already in use-we hope these suggestions, based on our experience, will contribute to your anticipated success. It is not uncommon for practices to become overwhelmed in the choice, implementation, and utilization of their EMR. What distinguishes those practices that are successful in their use of the EMR is their commitment to the product and their recognition that it is the central element in the treatment of their patients. Consistently exploring better ways to use OncoEMR, staying educated about the changes that occur, and taking full advantage of its best features will keep it simple and actionable for your practice.

Financial Disclosure:Dr. Rubin has options at Altos. Dr. Gordan and Mr. Boozan have no significant financial interest in or other relationship with the manufacturer of any product or provider of any service mentioned in this article.

Acknowledgements:The authors would like to express their deepest gratitude to the Florida Cancer Specialists Integrated Clinical Services Team, Executive Board, and Senior Management Team, and to Altos Customer Service for their unwavering support.