In the era of pay-for-performance in cancer care, the electronic medical record (EMR) is a "must-have" for maximizing practice efficiency.
LOS ANGELESIn the era of pay-for-performance in cancer care, the electronic medical record (EMR) is a "must-have" for maximizing practice efficiency. Without EMR, "we will not be able to collect the depth and detail of material that we need to argue for better reimbursement," community oncologist Linda D. Bosserman, MD, said at the "Advances in Oncology" symposium. Dr. Bosserman is president of Wilshire Oncology Medical Group, Inc., La Verne, California, and chief quality officer for CCE [Cancer Centers of Excellence] Partners, a not-for-profit company owned by oncology group practices committed to EMRs and to delivering quality oncology care using evidence-based protocols.
Dr. Bosserman emphasized that detailed data collection for quality assessment and monitoring is necessary to comply with the quality measures developed by Medicare, ASCO, and NCCN to ensure documentation of evidence-based treatment and follow-up, supportive and palliative care, and risk assessment and prevention. Dr. Bosserman, who uses EMR extensively in her practice, reviewed practice areas where EMR systems can simplify the data collection recommended by ASCO, NCCN, and Medicare. She noted that the demand for increasingly detailed data may require expanding the capabilities of current EMR systems.
Data on Disease Stage
An ASCO talk reported that 30% of Medicare patients did not have a staging notation on the patient's chart, she pointed out. ASCO recommends that oncologists measure the percentage of patients who have a stage and a TNM diagnosis noted on their charts.
The advantage of using an EMR system for data capturing, she said, is that "every patient has a diagnosis or numerous diagnoses of cancers, and the TNM goes with it automatically, as well as the cancer features." Another major ASCO quality guideline is to report pathology results on the patient's chart, which is a clickable item in the EMR used in Dr. Bosserman's practice.
Both Medicare and ASCO ask oncology practices to provide the percentage of chemotherapy plans documented, as well as doses and time intervals following initiation of treatment. ASCO also asks for documentation on number of chemotherapy cycles given. "When you have an electronic record, and you order, for example, dose-dense AC-T, you've ordered a specific dosing regimen and cycle number, so you will be 100% compliant with those ASCO QOPI (quality oncology practice initiative) and Medicare quality measures," she commented.
Signed informed consent to receive chemotherapy is another important ASCO measure, and becomes critical as increasing numbers of patients are treated with oral chemotherapy such as capecitabine (Xeloda), she said. In her practice, patients are informed by doctors, then have a detailed follow-up with oncology nurses for education about their treatment. The nurse provides a written treatment calendar, individual drug information sheets with review of common and uncommon toxicities, and follow-up information, after which patients sign a paper informed consent form and the nurse documents this in the EMR.
"We've developed an entire electronic chemo teaching form for the nurses, where they can rapidly check off the standardized teaching points and informed consent process as a document in the patient's record," she said.
A Medicare PQRI (Physician Quality Reporting Initiative) measure on medication [see also page 50] asks for the percentage of patients, within 60 days of hospitalization or admission to an extended care or rehabilitation facility, who have a reconciliation of the discharge medications with the current medicine list. "It's a very common oncology parameter, and I think it's going to be an important one," she commented.
Specific Cancer Types
Each type of cancer has specific data collection requirements. For breast cancer patients, for example, ASCO asks about the percentage of patients for whom combination chemotherapy was recommended within 4 months of diagnosis for patients who are younger than age 70, AJCC stage I to III, and ER/PR negative. The EMR, Dr. Bosserman pointed out, is a one-stop repository enabling practitioners to access or provide all of this information.
An exception with the EMR system she currently uses is that it does not fully allow oncologists to systematically record or calculate why a patient did not receive the planned therapy. "We don't have a place to record that we recommended a treatment, the patient accepted it, modified it, or declined it. So, again, it makes us think about how we're going to add that data piece," she said.
Practitioners also need to track the percentage of breast cancer patients with documented HER2 status by IHC or FISH, and the percentage of HER2-positive women who received a recommendation for, and actual treatment with, trastuzumab (Herceptin). Another important measure is to be sure that no HER2-negative patients received Herceptin.
ASCO also asks what percentage of ER/PR-positive patients received recommendations for, and actual treatment with, tamoxifen or aromatase inhibitors. Medicare wants to know what percentage of patients who had breast-conserving surgery received radiation therapy. Thus, many standard patient management protocols "will now be associated with a measurable, trackable, number," she said.
Regarding colorectal cancer, Dr. Bosserman noted that about 30% of Medicare patients are not getting adjuvant chemotherapy for node-positive colon cancer, underscoring the importance of being able to track this information. "We have EMRs in our practice going back 4 or 5 years, and we were able to track 15 patients in one specific health plan that had 70,000 members," she said. "All but 2 patients who had stage III colon cancer received adjuvant therapy; one was 92 years old and one was 91; both had a documented discussion in the chart, and both patients said 'No.' So, I was able to complete that circle in the practice report, but again, how we get that data into our electronic system remains a challenge."
For lymphoma patients, she noted, there are no current Medicare measures, but ASCO QOPI measures ask about the percentage of lymphoma patients who get CHOP or R-CHOP with standard white cell growth factors. They also ask for the percentage of CD20-positive patients who received rituximab (Rituxan) and, conversely, the percentage who received rituximab but did not have CD20 status documented, which, Dr. Bosserman said, "is not acceptable."
Pain, Follow-up Care
The ASCO measures ask oncologists to document what percentage of patients had pain evaluated in the first visit and to show that the narcotic pain medication provided had been assessed for efficacy in that individual. In Dr. Bosserman's practice, electronic tablet intake provides every patient with a complete pain review system that can track four visits deep.
Follow-up care must also be well documented, with ASCO recommending that patients get copies of their treatment summary. "MOASC [the Medical Oncology Association of Southern California] is looking actively at this," Dr. Bosserman said. Eventually, she said, "patients are going to have access to their records and emergency information, whether it's in electronic form, on a zip drive, or a Google website, and so it is important to think about how you're going to provide that information to the patient."
Hospice care, while not a current Medicare measure, is of major importance in oncology, she said. ASCO recommends documentation of the percentage of patients enrolled in hospice or referred to palliative care specialists before death. A Medicare measure that will become effective in July 2007 asks what percentage of patients have an advanced care directive or a designated decision-maker identified in the patient record.
'Where the Money Is'
"Data collection is where the money is," Dr. Bosserman concluded. "Health plans spend huge amounts of dollars buying data that is months or years old and not connected to key information to assess appropriateness."
She stressed that "doctors have the comprehensive information in their practices that is important for themselves as well as health plans, patients, and Wall Street for assessing quality. We need to look at optimizing these scrubbed data sources financially to support the cost of implementing, documenting, and reporting the details of high-quality care."