SAN BRUNO, Calif--Practice guidelines and outcomes measurement are increasingly viewed as the keys to lowering medical costs while maintaining quality. Once guidelines are devised, the next step is implementation, and this may best be achieved by making guidelines readily accessible via computer programs.
A number of oncology-specific programs are currently in use by various physician groups and managed care companies. Oncology News International interviewed Catherine Harvey, vice president for patient relations at OnCare, a physician practice management company, for a look at how their system, known as OPUS Matrix, works in practice at the 26 sites where it has been installed.
OnCare is currently affiliated with 90 physicians, predominantly medical or radiation oncologists, at sites in 10 states, Ms. Harvey said. OnCare has more than 8,000 patients in its information system to date, adding up to more than 90,000 patient visits.
The chief goal of the Matrix system, she said, is to provide physicians with online decision-making support. To that end, OnCare has developed 36 evidence-based guidelines covering almost all major cancers. In a typical scenario, relevant patient information is entered into the system, including:
- Demographics (name, address, age, height, weight, etc)
- Medical history
- Cancer diagnosis, including stage
- Specific risk factor information for the patients cancer such as smoking habits and family history of the disease, or, for breast cancer, for example, estrogen and progesterone receptor sites.
After these descriptive data are entered, the physician clicks on the appropriate guideline and selects treatment for the patient. The system then looks for drug interactions, potential adverse reactions, and contraindications; determines dosages and schedules; and prints out a flow sheet outlining the patients entire planned treatment course.
"We are linked electronically with First Databank, a company that provides up-to-date pharmaceutical information on line, so we have access not only to data about chemotherapy drugs but all medications that the patient might be taking." This is particularly important, she said, in dealing with cancer patients who may be receiving drugs for other conditions not familiar to oncologists.
"The physician is warned if a prescribed medication might interact adversely with another agent the patient is receiving," she said.
The treatment flow chart is comprehensive, Dr. Harvey explained. For example, if the patient is to receive six cycles of treatment, the flow sheet will project when each treatment is due and warn the office if the physician is going to be on vacation at that time or if a treatment is scheduled for a day when the office will be closed, so that modifications can be made.
The flow sheet also includes information on when laboratory studies are to be done and the actual lab results, with abnormal values highlighted in red.
At the same time that it generates a flow sheet, the system produces physician order sheets, "so that we generate our own legal document out of the system for charting and charging purposes," Dr. Harvey said.
After each treatment, the nurse signs off electronically in the system to acknowledge that the treatment has been completed. This becomes part of the permanent record. A hard copy can be printed for the patients folder.
The system also works to keep the patient up to date by providing a customized calendar, showing when the patient is to come back for treatment, lab studies, etc. In addition, the system can print out patient education material, including drug information sheets on all drugs the patient is receiving.
Central Data Warehouse
Perhaps the most exciting thing about the Matrix system, Dr. Harvey said, is the linkage to a central data warehouse. All information on patient treatment goes to a central computerized repository (located at the companys headquarters in San Bruno, Calif).
"We can tell you about all 8,000 patients treated to date, everything from mortality data to current status. This information can then be stratified and sent back to the medical staff and to the people doing managed care negotiations to determine outcomes and the actual costs of care," Ms. Harvey said.
The system allows detailed outcomes data because of the specific questions it asks about patients every step of the way. For example, when a scheduled chemotherapy dose is reduced or withheld, the system automatically asks two questions: What was the reason, and was the patient hospitalized? "This allows us to paint a picture of specific patient populations," she said, "so we can understand what actually happens in clinical practice."
Another advantage of the central data warehouse is that it provides information on how clinical guidelines are actually being implemented, by individual physicians or physicians in a given area.
"We feel that this aspect of the Matrix system is really beginning to affect quality of care, because physicians are using it to understand their own practice behavior and that of their partners," she said.
The exacting reporting system also allows OnCare physicians to evaluate the cost effectiveness of different regimens by calculating not only drug cost but also the incidence of hospitalization with a particular regimen and other non-drug-related costs.
She noted that managed care companies and other payers "have really warmed up to the system because they have problems getting good outcomes data, and they especially like the idea that we have comparative data across sites, in different parts of the country."
The Matrix system is especially helpful in todays climate, as more payers and managed care plans seek to sign physicians to capitated contracts (or other systems wherein the physician is paid a set fee per member and thus assumes a financial risk if cost of care exceeds fees).
"Physicians are being asked to sign contracts with payers to provide services without a clear understanding of what it costs to take care of patients," Ms. Harvey said, "and with a disease like cancer that requires management over a longer period of time, you really need to understand the whole treatment course to know what it is going to cost."
The central data warehouse allows physicians to understand the resources they are currently using for a given group of patients; they can extrapolate that data to estimate what it would cost to care for any randomly distributed population.
"Being able to show managed care companies actual cost data when evidence-based guidelines are followed provides a basis on which physicians can advocate for reasonable reimbursement for care," she said.
Finally, Ms. Harvey stressed that the companys major goal from the beginning in developing its Matrix information system was to improve care for patients and to ensure that consistent care is delivered across a number of sites.
"Our system houses information that helps physicians and nurses manage patients and understand the clinical and financial impact of their patient-care decisions," she said.