MOUNTAIN VIEW, CaliforniaIMPAC Medical Systems, Inc., an oncology management software company launched 13 years ago in a Silicon Valley garage, now has almost 1,700 clients worldwide, in 52 countries, including many of the leading US cancer centers, as well as specialty treatment centers and private practices.
"We delivered our first system in the first quarter of 1991, about a year after we started the business," David Auerbach said in an interview with ONI. Mr. Auerbach is cofounder and executive vice president of IMPAC, and president of IMPAC’s international operations.
Joseph K. Jachinowski, cofounder, president and chief executive officer (CEO), added, "At that time, an integrated application having practice management, electronic medical records, and imaging features under one umbrella was really a new thought, but to us, it seemed like the logical thing to do."
Today, IMPAC offers a comprehensive information management system that streamlines both clinical and business operations for oncology and related specialties. The IMPAC system provides electronic medical and radiation oncology charting, with integrated image management, practice management, and cancer registry functionality.
Another key aspect of the system that started early in product development at IMPAC was interfacing to outside systems. "Oncology is typically a department or section within a larger health care provider," Mr. Jachinowski said, "so the ability to exchange data with cancer registries, labs, other hospitals, etc, was key to the viability of this system."
Today, IMPAC provides the ability to connect to multiple health care information and imaging systems via the Health Level 7 (HL7) and DICOM standards. HL7 connectivity, for example, allows lab results to be posted directly to the patient’s electronic chart.
"Our focus is oncology," Mr. Jachinowski said, "but we also look at what we call the ‘synergistic adjacencies to oncology,’ specialties that either feed patients into cancer care or provide many services to cancer patients." For example, he said, the company has now started to market systems to urology practices, because of the high number of patients that come from urology into oncology.
James P. Hoey, currently chief operations officer, was the third cofounder of IMPAC. The company is located in Mountain View, California, with a development and support facility in Henderson, Nevada, a sales and support office in Cambridge, Massachusetts, and international offices just outside of London, England.
Electronic Medical Records
The core of the IMPAC management system is the electronic medical record (EMR). IMPAC’s EMR provides all of the information found in a typical paper chart and more. "Whereas a paper chart merely stores information, IMPAC’s EMR is an active clinical tool that assists with diagnosis and staging, provides links to online reference material, and alerts clinicians of findingspatient allergies, contraindications, lab results, etcthat warrant immediate review," Mr. Auerbach said.
The chart is available to authorized users on any PC workstation, whether in the hospital or the physician’s office or home. IMPAC’s image management system, for example, makes oncology-related medical images available for immediate and simultaneous review by multiple clinicians.
IMPAC has added mobility to its EMR by providing the ability to access the EMR securely via a personal digital assistant (PDA) or laptop (via wireless Internet provider or any standard Internet connection) any time, anywhere.
With IMPAC, clinicians can use portable pen-based tablets to review the electronic chart, record data, and process orders at the bedside, Mr. Auerbach said. This portability offers advantages to physicians using PhAST Note, IMPAC’s structured noting system designed to help physicians document patient encounters quickly and efficiently. PhAST Note also reduces the chance of miscoding by suggesting the correct evaluation and management (E&M) code based on the completed documentation.
The IMPAC system includes a library of standard chemotherapy regimens that can be edited to conform to each center’s specific requirements and expanded to include new regimens. Based on the assigned regimen, IMPAC generates a treatment calendar complete with physician visits, chemotherapy orders, required tests, and treatment sessions (see Figure).
Based on the patient’s body surface area or AUC and the dose instructions, IMPAC automatically calculates the medication dose and processes the order. If necessary, of course, clinicians can make adjustments. Pharmacy orders are checked against regimen-specific toxicity limits to ensure that cycle dose amounts are not exceeded.
Advantages for Nurses
In addition to recording the date and time that each drug and dose was delivered, the nurse can fully document co-signatures, blood products, route location, and vascular access device (VAD) details, and also use a drawing tool to illustrate the site of a vesicant administration.
Mr. Auerbach pointed out that physicians and nurses involved in clinical trials can custom design flow sheets and assessment forms to evaluate specific regimens or disease types, or to add specific parameters for pain management or quality of life studies, etc.
"You can set up the charts of patients enrolled in studies to allow inclusion of additional family history, for example, or other data that were not part of the standard chart," he said.
IMPAC integrates core business functions such as scheduling and billing with the EMR. For scheduling, the system has an auto-find feature that locates open timeslots and can provide "wave scheduling" to schedule multiple appointments in virtually any pattern. A conflict checking system prevents conflicts before they happen.
For medical billing, software tracks insurer authorizations and alerts users of pending expirations or when limits are about to be exceeded. It provides a systematic means of capturing billable procedures and supplies. "Electronic charge management reduces the chance of transcription errors, coding inconsistencies, redundant entries, or worst of all, lost charges," Mr. Auerbach said.
Radiation Oncology Charting
The IMPAC system streamlines radiotherapy and intensity modulated radiotherapy (IMRT) processes, from virtual simulation and the generation of complete treatment prescriptions to the automatic set up, verification, and recording of treatments. Treatment plans from any simulation or planning system can be transferred to IMPAC’s EMR via the industry standard DICOM RT format.
The IMPAC system provides a full set of cancer registry tools, providing the ability to collect data to track patients post-treatment, look at outcomes and quality of life, and report to state governments or other central registries. The company maintains its own databasethe National Oncology DataBase (NODB)currently with approximately 2 million cancer cases. According to Mr. Jachinowski, it is "the most comprehensive longitudinal oncology database available for cancer research today."