Information Technology in Radiation Oncology

Electronic Health Records

Electronic health records (EHR), sometimes also referred to as electronic medical records (EMR), are rapidly replacing paper charts in the hospital setting. One of the advantages of EHR is easy availability of healthcare information to all providers, including sharing of health records with patients through web-based secure access. Integrated database analysis allows graphing health trends, reconciling medications, and even flagging of potentially negative pharmacological interactions. In addition, there is increased safety because an EHR can be backed up remotely, which provides redundancy in case of catastrophic loss of the primary record.

However, in addition to being a retainer of information, a paper chart has additional functions which may not be immediately obvious but need to be integrated into the EHR for a successful transition. The following list includes a sample of paper chart functions that need to be transferred to EHR:

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  Information repository: Charts contain information in an organized manner. The EHR must be able to categorize information in a systematic manner such that the care team can easily find and retrieve important information, especially from scanned documents such as pdf files. Search functions should include the ability to search document titles and file contents. The ability to view multiple documents simultaneously is highly desirable.

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  Checklist: The paper chart contains written treatment records, which include checkboxes or signature lines for completed second check, weekly chart check, MD signature, imaging protocol and imaging review, and use of accessories such as bolus. These items provide an easy visual check on performance of quality control processes according to the policies and procedures implemented in the department. Transferring these checks to the EHR system can be challenging, because those paper chart functions were not obvious for the initial software designs in EHR (e.g., missing initials from a physicist indicating the completion of a weekly chart check might not be as obvious in an EHR). Another example is the ordering and recording of the different bolus regimens: bolus qod can be easily verified by the radiation therapist's initials in a paper chart, but equivalent functionality is still missing in most EHR systems. One way to address this is to schedule bolus and no bolus treatments into the treatment calendar of the EHR.

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  Workflow task: A handover of a paper chart from one member of a patient care team to another initiates a workflow task (e.g., a paper chart would move from the dosimetrist to a physicist to indicate plan completion and initiate the second check process). Most EHR systems have several tools to communicate workflow tasks; in addition, tools outside the EHR such as pages, emails, or texts can be used. It is recommended that the department standardize the workflow task method used at each step in the patient treatment workflow to avoid delays in communicating tasks. Task cascading, which automatically notifies the next step in the workflow upon completion of a task, is available in some EHRs.

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  Communication: A paper chart is also used as a tool to communicate essential information among caregivers (e.g., a handwritten note on the treatment record can indicate “please discontinue bolus starting today”). As for workflow tasks, EHR systems may contain multiple possible channels of communication among caregivers. The communication channels among caregivers need to be clearly defined in the paperless policies and procedures to avoid failure of communication resulting in possible negative treatment outcomes. There should be only one location in the EHR for each type of information. Allowing multiple locations will ultimately lead to errors due to missed information.

AAPM TG-262, Electronic Charting of Radiation Therapy Planning and Treatment (in progress), is charged with providing guidance on electronic charting, safe clinical practices for transitioning to electronic charting, implementation in the context of other IT systems (e.g., hospital EHR), and common pitfalls.

Record and Verify System

One particular form of EHR in Radiation Oncology is the record and verify (R&V) system. Originally R&V systems were designed to do just that: record and verify the correct delivery of a treatment. This was especially important and useful in an era when manual actions and entry of data were more common. R&V systems could verify, for example, that the correct monitor unit (MU) were input or that the intended wedge or block was applied during treatment. In some parts of the developing world R&V systems are still not in use.

The role of R&V systems has evolved toward controlling all technical aspects of the delivery system. Some systems now serve as an entire EHR with additional operational functions such as scheduling, communication, and billing. As such, these systems are now often referred to as oncology information systems (OIS) or treatment management systems (TMS), though the term R&V is still in common use.

Integration and Communication Across EHR and R&V Systems

In smaller Radiation Oncology clinics and freestanding centers, the R&V system provides double functionality as the EHR system as well. If the Radiation Oncology department is part of a larger hospital system, the hospital has its own EHR software in place (e.g., EPIC or Cerner). These systems often do not have good functionality for the extended treatment courses and types of records needed in Radiation Oncology. As a result, software tools have been developed using the HL7 standard ( http://www.hl7.org ) to integrate Radiation Oncology R&V systems with hospital EHR, although some of these efforts are still works in progress and many challenges still exist.

The scope of the integration and procedural details should be discussed in detail to outline the information flow clearly and avoid miscommunication. Specific sectors of integration are:

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  Billing: This is typically the most straightforward integration project. Charges are collected within the Radiation Oncology EHR and transferred to the hospital EHR. The main decision required is whether charges get reviewed by a Radiation Oncology billing expert before being released to the hospital EHR. One issue in the United States is that the charges must be billed under the physician who is on site each day, not the attending physician.

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  Scheduling: Scheduling integration is more complex than might be obvious at first sight. For example, in Radiation Oncology it is not uncommon to schedule a patient as a “placeholder” to reserve a requested time on the machine, while the actual treatment start might fluctuate depending on treatment plan completion or timing of chemotherapy. This may not be immediately obvious to schedulers in other departments, who might convey incorrect scheduling information to the patient. Similarly, a patient's appointment may be rescheduled in the hospital EHR, but the change may not be communicated to the Radiation Oncology EHR. Therefore, scheduling integration requires in-depth discussion on to what extent schedules are shared, in which direction scheduling information flows (both ways, one way from EHR to R&V or vice versa, etc.), and who has permission to change Radiation Oncology appointments. In addition, the patient may have multiple appointments in the department on a given day (i.e., nurse visit, treatment, nutrition counseling, etc.), and changing one time will affect the others.

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  Documentation: A patient chart includes various types of documents, such as pathology reports, the history and physical, treatment plan, and special physics consult requests. These documents are not always easily exchanged between systems and can have the potential to clutter a patient's EHR with information which might make it more difficult for care providers outside Radiation Oncology to find relevant information. An integration of document exchange requires answering questions of which types of documents should be shared and when, how accurate document labeling will be accomplished, or, in the case where documents will not be exchanged, which document will be filed in which of the two EHR systems.

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  Imaging: An increasing amount of imaging data is generated in Radiation Oncology for treatment planning, treatment verification, and adaptive planning purposes. Some of the imaging might contain valuable information for outside departments (e.g., an Emergency Room (ER) physician might gain important information from a simulation computed tomography (CT) showing the treatment target if a patient is admitted through the ER during a course of radiation). Other imaging information (e.g., port films or setup images) is not useful to caregivers outside of Radiation Oncology. Therefore, it should be well defined which imaging information is shared across EHR systems. In some countries or states, there might also be legal considerations if images that have not been assessed by a radiologist or are not intended for diagnostic purposes are shared across departments.