Over the past 20 years, technological advances have transformed the clinical practice of oncology. Significant changes have been made in radiation oncology, novel targeted chemotherapies, and new modalities of diagnostic radiology. In comparison, progress in electronic records has been limited. In 1991, the Institute of Medicine (IOM) encouraged the implementation of computer-based patient records, now commonly referred to as electronic health records (EHRs). Despite the promise of increasing health care quality and decreasing cost, adoption of EHRs has been surprisingly slow. Over the same 20 years, the rising costs of health care, including cancer care, have brought the United States to the crisis point and beyond. The increasing rate of growth of medical care costs, without evidence of a corresponding improvement in health care quality, threatens the system of medical care. Oncology accounts for a sizeable and growing proportion of total health care costs, especially those borne by “entitlement” programs, such as Medicare. The complexity and cost of oncology care require the organizational capacity that a fully functional EHR can offer.
Fully functional EHRs foster the twin goals of increasing quality and decreasing costs in 3 major ways: 1) enabling effective communication, 2) allowing the use of decision support technologies, and, most importantly, 3) generating structured data. First, given the complexity of cancer care throughout the disease process, it is not unusual for a patient to have multiple sites of care (e.g., surgeon and medical oncologist at a tertiary center, radiation oncologist at a location closer to home, physical therapist at a third location, visiting nurse and/or hospice care at the home). Electronic records directly augment the coordination of services between these providers. The ability of individual providers to manage the continuing proliferation of novel chemotherapeutic agents, imaging modalities, molecular diagnostic testing, and the appropriate use of radiation oncology is becoming increasingly difficult. Although decision support algorithms (such as the NCCN Clinical Practice Guidelines in Oncology [NCCN Guidelines]) are available outside of an EHR, an integrated solution will improve the workflow in busy offices. Computerized decision support (CDS), as part of an integrated EHR, will ensure compliance with national guidelines and may even supplant third-party appropriateness review. Finally, the importance of data generation from routine patient interactions cannot be overemphasized. These data allow for the systematic collection of risk-adjusted outcome data to create much-needed comparative effectiveness and utilization review databases.
Practicing oncologists who use EHRs will use them in 1 of 4 ways: 1) as a data repository, 2) as a database that can generate information for clinical and research tasks on demand, 3) as a chemotherapy order entry tool, or 4) as a means of communication with patients via a patient portal. So where are the EHRs in oncology now and why has progress in this arena been so slow? Before discussing the incentives for and barriers against implementation of EHRs, each of these are considered individually.
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