EHR should offer information at the point-of-care (and the point of care may move!)

EHR should offer information at the point-of-care (and the point of care may move!)

Douglas W. Blayney, MD, FASCO

Dec 19, 2008

Information at the Point of Care. (I write this while I'm on vacation, four hours from my home and office). My new patient last week was sent by her oncologist in northern Michigan for an opinion regarding his suspicion that she had Hodgkin lymphoma, recurrent within a year after her primary treatment for Stage IIA massive mediastinal disease. She had involvement of the manubrium sternum on the PET/CT scan which she brought with her on a CD-ROM, and I could open it and show it to her and her husband (This is not always easy to accomplish). I was quite suspicious of recurrence, but in concurrance with her referring oncologist, could not rule out a non-Hodgkin lymphoma, or some other malignancy. I arranged for an excisional biopsy from one of our surgeons.

She was also in considerable pain, rating her pain an 8/10, and never being pain free. Though I had to wait for the surgical biopsy, I could at least optimize her pain managment.

When I questioned her and her husband about their regular use of the long acting pain medicine, she gave the common, noncommital answer. I stressed the importance of regular use of long acting narcotic analgesics, and the use of short-acting medications of the same class for breakthrough pain. As we got to discussing things, her husband asked "You don't have any samples of that long acting medicine, do you? It costs us $500 each time we get that perscription filled." I started to explore the intracacies of their perscription drug plan with him.

I went on to write two perscriptions -- one to renew the long acting medication (with its $500 co-insurance), and one for the shorter acting medication (with its $10 copay). I instructed her to use the equivalent dose of the shorter acting preparation four times per day. Only if this was not satisfactory, should she fill and use the more expensive drug.

How much easier it would have been to have her perscription information and formulariy -- allergies, interaction, and co-pays -- available to me as I wrote the perscriptions. Our EMR does not have drug strength availability, otherwise I could have saved a series of telephone calls from her pharmacy and the expense of overnight shipping a hard copy perscription to her pharmacy in northern Michigan to correct a drug strength error I made when writing the original scrip.

I have previously written on my ideal medical record, which produces the right amount of information at the point of care. These features could have saved all of us a lot of time, and saved her and her husband some embarrasement, if I would have had all of the information available as I wrote the perscriptions and had my interactions with her.

.....Later. She had an excisional biopsy, and I found out late last evening that the interpretation was T-cell lymphoma.

I was able to pull up the result from my hotel room, find her telephone number and that of her referring physician on our EMR (usning a VPN and my newly encrypted laptop), and call her with the news and with the plan. I also spoke with her referring physician to coordinate the care. (Her pain was also better controlled.)

Though the news of recurrence was not good, we have a plan to proceed and she didn't have to wait until I returned to the office.

The box score for our EHR is one for two.

Happy New Year.


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Matt Gillman

Jan, 16 2009 5:11 PM

This is a topic that is near and dear. As a lifelong information technology professional, delivering the right information at the right time is the holy grail.

First of all there is an HL-7 draft standard called the infobutton. You can find more information about the infobutton here. “Infobuttons” are context-specific links from one information system (usually a clinical information systems such as an electronic health record) to some other resource that provides information that might be relevant to the initial context. Infobuttons are used to anticipate users’ information needs and provide them with easy ways to obtain answers to resolve those needs. The Infobutton has not really been widely deployed. However, the concept seems to be picking up steam.

My understanding is that two vendors (Epic and Eclipsys) are using infobutton technology in their systems. Several other organizations are starting to repurpose their content for the Infobutton including: LexiComp, Micromedex, Miriam-Webster, National Guidelines Clearinghouse and Elsevier's DrugConsult and FirstConsult.

There is an excellent Powerpoint that was presented at the AMIA 2008 Fall Symposium, in Washington, DC describing many of the details of the Infobutton. The file is big but it can be found here.

So there are two big questions: What will it take to increase infobutton adoption and where will the content come from? Is there a role for ASCO in creating this type of content for the oncology EHR?

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