How Does IT Affect Quality of Care?

Oncology practices across the country are using computer technology to improve outcomes and quality of care for our patients.

The development of relatively inexpensive computers and the Internet has given us the ability to change more than the way we buy airline tickets, obtain entertainment, and order T-shirts. The adoption of three technologies in particular—electronic medical records (EMRs), telemedicine, and patient-reported symptom monitoring—have had a profound effect on the quality of care provided by oncologists.

EMRs

EMRs are touted as being essential to oncology practices. Practice consultants, healthcare systems, some private payers, and even the federal government are all saying it’s time to move to a computer-based information system. And they’re probably correct. Delivery of cancer care is a complex and potentially high-risk process, and it makes sense to take advantage of the abilities of powerful computers to facilitate oncology practice. Implicit in this technology’s advancement is the potential to improve the quality of care for our patients through increased efficiency and standardization of treatments.

Three years ago, after much research and debate, we decided to purchase an EMR system for our practice in Montana and Wyoming. We became convinced that the potential benefits of a paperless electronic record would outweigh the cost and hassle of implementation. As one partner put it, “we drank the Kool-Aid,” and launched into the brave new world of EMRs.

We wanted our EMR system to facilitate standardization of practices across our four offices. We hoped that the promise of developing a “best practice” for chemotherapy regimens would lead to consistant treatment, more predicatable treatment costs, and ultimately, better outcomes for our patients.

For example, we agreed to standardize common chemotherapy regimens, such as R-CHOP for non-Hodgkin lymphoma. The oncologists agreed to give the same antiemetics, supportive care drugs, and doses of chemotherapy agents based on the best evidence in the literature. Physicians are free to change the regimen if there is a clinical reason for a variation, but the point-and-click nature of ordering a chemotherapy regimen makes it easy to adhere to the guidelines.

Setting up these chemotherapy care plans was a Herculean task. The software came with pre-loaded care plans, but we found it still took many hours of research, multiple meetings among the physicians and nurses, and lots of computer programming time to customize these protocols to fit our practice.

Our practice later joined Cancer Clinics of Excellence (CCE), a group of practices that has agreed to collaborate in order to improve cancer care for our patients. CCE has developed a large set of evidence-based treatment protocols (ETPs) that address best practices for most of the diseases we treat. Our EMR system has the potential to facilitate these ETPs in our care plans, and we are currently working toward that goal.

The EMR has improved code capture and somewhat streamlined our billing process. Because charges for chemotherapy drugs are automatically linked to the system, we have found that we no longer miss billing for our very expensive drugs. Bills are sent to insurance companies faster, and our days of accounts receivable dropped by almost 10 days after we implemented the system.

In these days of shrinking chemotherapy drug margins, it is vital to track utilization of drugs and services. The EMR makes this much easier than our previous system. Some authors have written that this type of information can help in negotiating with payers for better payment rates, and we are partnering with CCE to come up with a way to do just that.

Pharmaceutical companies are very interested in studying utilization data for different disease states, and they contract with companies to abstract that information from practices. Before installing the EMR system, our personnel were required to pull charts, making them unavailable for clinical use, and deliver them to the reviewers who took up a room in our office. Now the abstractors are able to do anonymous chart reviews from a remote location without disrupting our patient care. Needless to say, we are much more willing to participate in these chart reviews, and it has created a source of revenue for our practice.

Our practice has always had a large commitment to clinical research, reasoning that participation in trials ensures that our patients receive state-of-the art treatment and improves overall quality of care. The EMR system facilitates that in several ways:

• Our research assistants are able to screen new patients’ records to see if they may be eligible for one of our trials, even while the patient is being seen by the oncologist.

• The treatment regimens and follow-up visits are pre-loaded into the system, making compliance with the protocol simpler for the physicians.

• With no paper records, everything can be accessed via the Internet (with permission, of course), and site visits by the sponsoring research group can be done remotely. This saves the research group time and money usually spent in travel to our center, and frees up our research personnel to focus on enrolling patients, rather than baby-sitting research monitors.

A huge benefit to our practice has been seen in space utilization. We were aware of the national trend of providing in-office imaging, but our office in Billings did not have the room to house a CT scanner. Now that we have eliminated paper charts and house all of our computer servers in a former broom closet, the old chart room is now home to a CT and a DEXA scanner. This has been a great boon to both patient convenience and our practice’s bottom line.

We would like to report that the installation of our EMR system went smoothly, stayed within our budget, did not cause much disruption of day-to-day activities, and had full acceptance from all employees and physicians—except none of this is true.

The switch to an EMR system involves a massive cultural change in the practice of oncology for everyone involved. The amount of time and the financial commitment required to run a practice is truly daunting. As one of my partners put it, “What’s the difference between implementing an oncology EMR system and having a root canal with no anesthesia? The root canal ends in a few hours.” The good news is that EMR vendors have learned from their (and our) mistakes over the years, and the process is probably less challenging now than it was for us.

Telemedicine

The northern Rockies are known for beautiful scenery and wide-open spaces. But living in this rural paradise poses challenges for delivering cancer care to patients in remote areas. Our practice holds outreach clinics in some of the surrounding communities, but these are usually held only once a month. Cancer patients don’t check the calendar before they get sick.

We’ve been able to take advantage of a program that set up a telemedicine network for smaller hospitals in our region. We are able to see our patients and interact with them on the days we can’t physically be present in the clinic. We can monitor side effects and adjust chemotherapy regimens more efficiently than with our previous system of talking to the treatment nurses.

Satisfaction among our patients and the staff in the outlying areas has improved markedly with the use of telemedicine. Patients appreciate the increased attention, and the nurses like the closer working relationship with the physicians. One patient even told us she feels like she needs to dress up more since she’s going to be on television!

Before telemedicine, we spent hours on the telephone with the treating nurses, going over chemotherapy regimens and discussing patients’ symptoms second-hand. There was no payment for these services, even though they took up a lot of time. With telemedicine, we are able to follow patients better, and we are able to charge for our time spent with the patients.

Patient-reported symptom monitoring

A few years ago, my practice partnered with Supportive Oncology Services (SOS) from Memphis to pilot a new way of tracking patient symptoms during chemotherapy regimens and surveillance after treatment.

SOS developed the PACE System™ (Patient Assessment, Care, and Education) to allow patients to self-report symptoms and to transmit this information to their oncologist. The system takes advantage of tablet computers that are wirelessly connected to a central server, where the data is collected and stored. Symptom information for an individual encounter is printed on a single sheet (the Patient Care Monitor, or PCM), color-coded according to severity, and compared to previous visits. The PCM is then entered into the EMR, documenting a complete review of symptoms.

The system allows us to track our patients’ symptoms better and to use that information to adjust chemotherapy regimens. We are also able to use the data to support a coding level four or five visit, improving reimbursement for office visits.

The future

Advances in technology are changing the way oncologists care for cancer patients every day, and more are on the way. We will be challenged to utilize these developments in ways to improve the physician and patient experience. We also understand that the significant capital outlay required for these advances is limited by the current difficult reimbursement environment facing oncologists, and may hamper our ability to implement these technologies in the future.

Dr. Cobb and Ms. Bealer both practice at Hematology-Oncology Centers of the Northern Rockies, Billings, MT.