This is the first of a two-part review, concentrating on the ability of oncology electronic health records (EHRs) to enhance patient safety through the chemotherapy ordering and administration process, and on standardization of workflow processes in the practice. In this article, we endeavor to outline broad principles that should be considered when integrating an EHR, and in particular, a chemotherapy ordering module, into practice. We strongly advocate attention to these principles, as any fundamental change in a drug ordering process may compromise safeguards that are present in the practice.
Computerized Order Entry and Workflow PolicyEHRs are being adopted with increasing frequency. They bring efficiencies to practice record keeping and billing. They allow data to be accessed for multiple purposes by different providers and employees of a practice, thereby cutting down on inefficiencies created by relying on one paper record. A true EHR will collect patient data, integrate this information with data from other sources, and guide the provider with clinical decision support in real-time care of a patient. EHRs can also provide data for multiple purposes such as for analysis of practice demographics and reporting on quality measures.EHRs that support oncologists must take into account key areas of practice that differentiate oncology from other specialties. Accurate tumor staging, flow sheets, the need for multidisciplinary workflow documentation, integration of laboratory and imaging reporting, and dealing with chemotherapy ordering and toxicities are some of these unique demands. 1 Particularly demanding is the ordering, documentation, and management of chemotherapy and ancillary medications.Regrettably, medication errors related to chemotherapy from the use of paper-based records and manual systems are not uncommon, and have been the source of some notorious cases of patient harm in recent years. Even when computerized order entry systems are used, errors are still possible because of human error in the process or due to inherent properties of the computerized system. Data collected from three different outpatient infusion centers at the Dana-Farber Cancer Institute in Boston in the year 2000, using a first-generation computerized order entry system, showed a medication error rate of 3% in adult patients (249 errors of 8,008 medication orders reviewed). Of these, more than one third were related to chemotherapy, which constituted 4% of all adult chemotherapy orders written during the interval studied. 2 Of the potential adverse drug events identified, 26% were serious, including such things as missed orders for premedications and overlooked chemotherapy treatment parameters such as a low WBC count.Workflow is the source of much of the risk to patients during a typical visit to the clinic for chemotherapy. In the typical treatment day, the patient proceeds from laboratory to physician visit to the infusion suite for chemotherapy, and each step involves numerous manual processes and hand-offs that are subject...
