John Cox invited me to his Texas Oncology Practice at the Methodist Charlton Cancer Center in Dallas, to talk about multidisciplinary breast cancer clinics. After lunch, which was attended by most of the practice’s oncologists, John showed me his iKnowmed EHR. The iKnowmed product has changed since we first used it in October, 2000 at Wilshire Oncology, integrating with our inventory managment system (here) though the user interface, the chemotherapy regimen layout, and the visit documentation features look very similar. iKnowmed is an oncology-specific EMR, and includes physician chemotherapy order entry (CPOE) as well as a documentation feature. It is currently "stand alone," and doesn't integrate with more general EHR or hospital-based EHRs.
The Methodist US Oncology practice went live with iKnowmed in 2008, and they have “retrofit” their exam rooms for the computer terminals, with the computer display and keyboard retrofitted onto the existing desk and stool.
Documentation of a visit can occur using two methods:
- Free text dictation or hand typing with a “copy and paste” word processor feature, or
- Structured text with check-box and copy the previous note to the current text.
Free text dictation is much more like the traditional physician work flow, where the doc or physician extender dictates into a telephone or other device, the note is transcribed by a transcriptionist, and entered into the record for editing. The note can be edited using a rudimentary text-editor, including a Windows clipboard-based "copy and paste" function. Though this leads to a much more readable note, it is more labor intensive. Of more importance, however, is the difficulty extracting data from this free-text dictation. For instance, if staging information or diagnosis date is dictated, there is no good way to retrieve this data for reporting – compiling staging information or extracting other diagnostic data, etc – or for automated coding for calculation of level of service and billing.
The structured text method does allow for easier data extraction and ease of entering formulaic data – a normal chest exam can be entered with one mouse-click, for instance. Additionally, the “copy to current” feature – e.g. copying the physical finding from the last recording to the current recording is also one or two mouse clicks – can facilitate quick entry of data. The price of using this technology is often a note that is more awkward to read and to interpret.
In terms of workflow, John told me that he usually prints out his most recent progress note and the medication list to take with him into the patient's room. In the room, he uses the swivel-mount screen to review lab studies and radiology reports with the patient, and enters the follow-up instructions (return appointments with lab studies etc) while interacting with the patient in the exam room.
The infusion nurses like the documentation features available to them. Their documentation is mostly menu-driven (i.e. drop-down boxes). They can document standard infusion notes very quickly (e.g. iv site, timing, reactions) using the drop down menus.
Because iKnowmed does not integrate with the system used by John's hospital, he and his colleagues have developed a work-around to keep track of inpatient chemotherapy. iKnowmed can be accessed from the inpatient computer terminals, and chemotherapy delivered as an inpatient can be recorded into the office EMR, so it is visible and trackable for all to see. This is a useful safety feature -- the ability of the outpatient EMR to track chemotherapy dosing wherever it's given. Furthermore, access to the outpatient record allows "cut-and-paste" of medical history details into the inpatient narrative record. Not ideal of course, but a real step-up compared with the paper world.
The Methodist practice participates in the “Pathways” project, as will as the CMS Physician Payment Reporting Inititiave (PQRI). John demonstrated the diagnosis-specific therapy choices, which were Pathways-compliant, which appear when a chemotherapy regimen is being chosen. First on the list is a clinical trial, and then followed by the practice-approved regimens for the patient’s disease and line of therapy. In order to prescribe a non-pathway regimen, a reason for the exception needs to be entered in free text; the reasons are reviewed centrally as well as by the other group members. John’s Methodist practice is exploring insurance contracting which ties reimbursement incentives to the pathway compliance levels. The US Oncology network has published interesting data on their pathway compliance, pathway adherence and its influence on survival (no influence), and its potential for cost-saving.
For a patient for whom a PQRI measure is appropriate (e.g. an early stage , hormone receptor positive breast cancer patient, for whom adjuvant endocrine therapy is appropriate within one year of diagnosis) there is a small reminder box which appears during the interval when PQRI compliance is assessed (e.g. during that year after diagnosis). It’s clear that the EHR makes keeping track of PQRI compliance much easier.
So, in summary, the iKnowmed product has evolved in the last ten years, and is used in most of the workflow of this outpatient medical oncology practice. I didn't have an opportunity to question the radiation oncologists in the facility on their experience, either using the EHR in their own care of patients, or in reviewing the care provided by their medical oncology colleagues. The potential for documentation as either fre-text dictation or "click to current" with typed annotations probably increased the EHR acceptance, but at the tradeoff of making data extraction and quality measurements more difficult.