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ORIGINAL ARTICLE - HEALTH SYSTEMS AND QUALITY IMPROVEMENT
Year : 2020  |  Volume : 3  |  Issue : 4  |  Page : 748-754

Implementation of the electronic medical record system in the radiation oncology department of a government health-care facility: A single-center experience


1 Department of Radiation Oncology, Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka, India
2 Department of Radiation Physics, Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka, India

Date of Submission13-Aug-2020
Date of Decision30-Oct-2020
Date of Acceptance04-Dec-2020
Date of Web Publication25-Dec-2020

Correspondence Address:
R A Sunil
Department of Radiation Oncology, Kidwai Memorial Institute of Oncology, Bengaluru - 560 029, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/CRST.CRST_251_20

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  Abstract 


Background: The availability of electronic medical records (EMRs) in the health-care system has greatly helped to improve the quality of care provided to the patients. Installing an EMR system requires consideration of various factors such as the institutional structure, human resources, clinical workflow in the hospital, monetary issues, and coordination between the departments.
Objectives: In this article, we have outlined the steps undertaken to integrate the EMR system into regular clinical practice in the department of radiation oncology.
Materials and Methods: The EMR system was implemented in the department of radiation oncology of the Kidwai Memorial Institute of Oncology, a government health-care facility. The process of integration began in June 2019 and was completed in September 2019. We chose the MOSAIQ EMR software by Elekta systems for our center. The process involved creating a core team, establishing the workflow, customizing the software according to our hospital's clinical practices, installing computers, data storage and backup, entering the old patients' data and reports into the system, and training the staff.
Results: The EMR system was made available for daily clinical practice from September 25, 2019. Since then, we observed a drastic reduction in the waiting time for the patient files to be made available at the outpatient department, as information could be accessed through EMR instantaneously. Furthermore, the patients' clinical data were available without any delay in the treatment planning system rooms, when planning radiation therapy (RT). Finally, in the radiation treatment rooms, EMRs allowed the RT technologists to obtain information regarding the number of fractions planned for a patient without any confusion as opposed to the earlier handwritten RT charts.
Conclusion: The immediate advantage of the EMR system is the instantaneous availability of patient data in the hospital. However, the successful implementation and optimal use of this system require commitment from the health-care staff.

Keywords: Electronic health record, electronic medical record, health information system, radiation therapy, radiation therapy technologist, treatment planning system


How to cite this article:
Sunil R A, Vishwanath L, Naveen T, Pallad S, Mandal SK, Pasha T, Ashalatha, Raj S, Sathyan S, Ganesh K M. Implementation of the electronic medical record system in the radiation oncology department of a government health-care facility: A single-center experience. Cancer Res Stat Treat 2020;3:748-54

How to cite this URL:
Sunil R A, Vishwanath L, Naveen T, Pallad S, Mandal SK, Pasha T, Ashalatha, Raj S, Sathyan S, Ganesh K M. Implementation of the electronic medical record system in the radiation oncology department of a government health-care facility: A single-center experience. Cancer Res Stat Treat [serial online] 2020 [cited 2021 May 18];3:748-54. Available from: https://www.crstonline.com/text.asp?2020/3/4/748/304955






  Introduction Top


The electronic medical record (EMR) system allows the health-care providers to create and store the patients' medical records electronically for use in the hospital which eventually serves as the source of information for creating an electronic health record (EHR).[1] In 2004, the President of the United States of America (USA) set a goal to create an EHR for all the American citizens in 10 years.[2] This paved the way for the rampant implementation of the EMR systems in the hospitals across the USA, followed by other countries. In India, this system is still evolving.

The primary advantage of the EMR system is that it enables a streamlined flow of information using uniform terminologies, which in turn enables better communication between the users of the system. Moreover, it helps improve patient safety through automatic detection of potential drug adverse events and error disclosure and also facilitates better reporting of the events and improved research outcomes.[3] It lowers the costs associated with patient data storage and offers an advantage to organizations over others.[4] The implementation of the EMR system in a health-care setup is however associated with significant factors such as human expertise, the structure of the organization, nature of its workflow, interdepartmental coordination, technical arrangement, and financial assets, all of which impact the wellness of the employees and the quality of care offered to the patients.[5]

There are many commercially available EMR software programs. The five most commonly used ones are Oncology EHR by CureMD; ARIA Oncology Information System by Varian Medical Systems of Palo Alto, California, USA; OncoEMR by The Flatiron Health Oncology; MOSAIQ by Elekta Ltd., Elekta Medical Systems, Stockholm, Sweden, and iKnowMed Generation 2 by McKesson Specialty.[6],[7]

In this article, we share our experience of implementing an EMR system in the department of radiation oncology at a government health-care facility and discuss the advantages and disadvantages of EMR along with the difficulties faced during its implementation.


  Materials and Methods Top


General details

Our radiation therapy (RT) department at the Kidwai Memorial Institute of Oncology, a government cancer care center in Karnataka, India, comprises 23 radiation oncologists, 27 postgraduate students, 12 radiation physicists, 24 radiation technologists, and 7 nurses. Our RT facility also has four linear accelerators; two dedicated RT planning computed tomography (CT) simulators; one mold room, where radiation immobilization devices are prepared; and treatment planning system (TPS) rooms, one each for the doctors and physicists. This new facility provides RT to around 3,500 patients per year. We purchased the MOSAIQ software by Elekta, Stockholm, Sweden, as the radiation machines and the TPS for RT-MONACO were also from Elekta, and hence, it was easy to integrate the software into regular clinical practice.

EMR implementation team

For successful implementation of the EMR, a project core team was created. It comprised a dedicated project leader, application specialist from the EMR software vendor, a physician champion, and a physicist champion. The core team met on a weekly basis to discuss the progress, difficulties faced, and measures to be taken for the completion of the implementation work within 2 months before going live and making the EMR system available for daily clinical work.

Electronic medical record implementation process

The core team laid out simultaneous implementation chores which included workflow establishment, software configuration according to the hospital requirements, facility modification wherever necessary, hardware installation, data backup and storage, entering old reports of the patients into the system as well as the reports that had been generated outside our institute, hands-on training for the staff members, and finally going live.

Workflow establishment and software configuration

When establishing the workflow [Figure 1], we redefined the responsibilities of individual users and created individual login identifications (IDs) with defined user access levels. The EMR software was reconfigured to nearly replicate the existing patient hospital chart [Figure 2]. A separate home workspace and patient chart space were created for different types of users; for example, different templates were created and frozen for the doctors, physicists, and RT technologists (RTTs). The software was reconfigured to make certain entries mandatory, without which the patients' treatment could not be scheduled. Separate tabs were created to review the radiation prescription, the number of fractions received of the total planned, and the total number of days of treatment elapsed for all the users. The diagnosis was entered using the World Health Organization's (WHO's) International Classification of Diseases, 10th revision (ICD-10) codes, and staging was done using the American Joint Committee on Cancer (AJCC) 7th staging criteria. Separate tabs were created to make entries for the weekly reviews of patients receiving RT according to the RT Oncology Group (RTOG) and the Common Terminology Criteria for Adverse Events (CTCAE) 7th edition scoring scale.[8],[9],[10],[11] All the assessments were configured to be entered as a numerical score, so as to make the retrospective analysis easy. Microsoft Word templates such as the RT consent forms, RT planning prescription, and dose constraint forms were created and tagged into the MOSAIQ EMR software. Separate user IDs were created for each user with specific levels of authority assigned according to the nature of their jobs. The rationale behind such restrictions was to prevent other users from accessing those functions of the software that were meant to be used only by the administrative users and to also prevent the possible malingering of the data once entered.
Figure 1: Flowchart depicting the electronic medical record workflow in the radiation therapy department. RO: Radiation oncologist, RP: Radiation physicist, RTT: Radiation therapy technologist, RT: Radiation therapy

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Figure 2: The figure showing the patient file workspace, with photograph, name, UHID number, treating doctor name. It also shows the alerts for any bio-hazard infection along with doctor notes with time and date

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The EMR software was configured in such a way that every time a user entered data into a patient chart, it would tag the username to the entry along with the date and time. Once the data were entered, the deletion of the information was not possible; the data could only be copied and edited without deleting the older entry.

Hardware installation

After redesigning the workflow and reconfiguring the software, we had a fair idea about the functionality of the MOSAIQ EMR system in our existing radiation center. To fully transform into a paperless department, we had to install computers at every location in the hospital where the staff and patients interacted with each other. Printers with scanners had to be installed at all places where there was a need to hand out printed material to the patients. Additional electrical and network wiring was done wherever necessary. Workstations were installed in the examination rooms, mold room, CT simulators, TPS rooms, and the linear accelerator rooms. The exam room workstations were designed to be ergonomically suitable for the users.

Meanwhile, we set up a small testing facility using a computer with trial EMR software, connected to a printer and scanner. In this testing facility, we configured the software according to our hospital's clinical workflow and tested it with respect to multiple simulation scenarios before implementing it in regular clinical practice.

Initially, all the laboratory results and the diagnostic and radiological data were planned to be made available through EMR as soon as we went live. However, this required a software interface between the laboratory and the radiology picture archiving and communication (PACS) system. As this was not possible, we decided to enter these data manually into the EMR system.

Data storage and backup

We had a 100-TB standalone server for data storage, with a backup server. We did not opt for cloud storage of the data as it would have been more expensive and would also require continuous, uninterrupted internet connectivity. Once the allotted storage volume is full, it will be extended by adding a new hard disk.

Integration with the planning system and treatment machines

As EMR was integrated into the TPS, the same UHID number was used in both the places. EMR was also integrated into the linear accelerator treatment sequencers.

Entering old data and outside reports

All the older important doctors' notes, summaries, laboratory reports, radiology reports, and outside reports were reviewed by the doctors. Following this, they were scanned and attached to the particular patient's chart as a portable document format (PDF) file.

Entering the laboratory and radiology reports

As the institute's laboratory and radiology department had different data management systems which could not be integrated into the EMR software, the laboratory and the radiology reports were entered manually into the EMR system, and the same reports were also scanned and attached as PDF files to the particular patient's chart.

Training of the staff members

A representative from the EMR vendor and our core team champions conducted the training sessions for the respective groups. Each staff member underwent 3 days of hands-on training. A summary in the form of a PDF file was distributed to each user regarding the key features of the software and the regular workflow for quick reference, whenever needed.


  Results Top


Going live

After 3 months of repeated testing, we finally went live on September 25, 2019. Since then, all the physicians have been entering all the clinical data in the MOSAIQ EMR system before the patients underwent the RT planning simulation scan. Initially, it took approximately 25 min for the physicians to enter all the data for one patient; however, over a period of 2 months, the time taken reduced to 15 min. In addition, initially, the staff had many questions regarding the workflow, which gradually reduced as the staff members got used to the system. After 4 months, we noticed a drastic reduction in the inquiries about the EMR software configurations that were not related to daily use clinical work and an increase in the curiosity for using the EMR software for supplementary jobs.

Before the availability of EMR, when the patients reported to the outpatient department (OPD) for RT or follow-up, their UHID number was noted, and their file was retrieved from the medical records department, which usually took 20–25 min. After the implementation of EMR, this waiting period has been eliminated and the patients need to wait their turn simply according to the token system.

Before the patient is sent for an RT planning simulation scan, the treating physician enters the RT plan, including the dose, number of fractions, region of the body to be scanned, position (supine/prone, head/foot toward gantry) of the patient during the treatment, etc., into the system. A list of all the immobilization devices that are to be used needs to be made available in the patients' EMRs, which can still be edited during simulation by the RTTs according to the patients' size. As a result, no patient can be taken for a simulation without the knowledge of their treating physician. Before the implementation of EMR, each patient would have to carry the RT chart from the OPD to the CT simulator after their treating physician specified the above-mentioned details in their RT chart. With the implementation of EMR, the patients can directly go for a simulation after RT billing while their treating physician enters the necessary details in the EMR. This not only reduces the need for doctor–patient interaction, which saves time but also decreases the movement of the patients from the OPD to the CT simulator.

Before the implementation of the EMR system, during RT simulation, the immobilization devices to be used for the patients had to be listed manually in the RT chart, making the process time-consuming. However, with the list of immobilization devices available in the institute preloaded to the EMR, the devices can be chosen from a previously entered list; similarly, the technologists on the day of treatment can prepare for the next patient while the previous one is receiving radiation, a process that took 2–3 min before the implementation of the EMR.

During delineation of the target volumes for RT in the TPS, all the clinical details of the patient have to be noted, including the histopathology and radiology reports, to ensure good coverage of the target and elective radiation volumes. This planning process can take a minimum of 1–2 days. However, the physical files cannot be retained in the TPS room for such an extended period of time. Hence, the availability of the patients' clinical details through EMR, allows the doctors to complete their work without waiting for the physical file each time.

After the delineation of the target volumes and organs at risk, the images were pushed for optimization and treatment planning to the radiation physicist. The radiation dose prescription to the targets along with the dose constraints for the organs at risk is done through the EMR only, so that it allows for easy retrieval of the set planning dose parameters and goals achieved in planning RT, for any retrospective analysis.

Once the plan was approved in the Monaco TPS, it was pushed into MOSAIQ, which is an integrated EMR and machines treatment sequencer.

During their review, the patients receiving RT were required to carry the physical chart from the treatment machine room to the OPD, and after the review, they had to return the chart to the treatment machine room. This would cause inconvenience to the patients. With the implementation of EMR, the details of each fraction of radiation were automatically captured in the MOSAIQ EMR. As a result, at any given point of time during the RT, the EMR showed the total number of fractions planned, the number of fractions received, the date of last treatment, and the number of days elapsed since the start of treatment. In addition, it also provided the details of the technologists who treated the patients. This helped in the weekly review of patients receiving RT, without the need for physical charts. This helped to avoid the to-and-fro movement of the patients, which in turn decreased their physical stress and also saved at least 15–20 min of their time.

The assessment of the adverse effects of RT during and after the treatment was performed uniformly using the RTOG and CTCAE 7th edition scoring scales. Before the implementation of EMR, these assessments were performed manually in the patient files without numerical scoring. However, with the availability of EMR, these assessments can be performed according to the site of treatment, for example, the head-and-neck, thorax, abdomen, pelvis, bone and soft tissues, brain, etc. The EMR is configured such that these assessments are displayed in a drop-down list along with a score, and thus, the doctor can make an appropriate choice. Once saved, the scores cannot be edited, but there is no limit on the number of assessments that can be added. As these assessments are based on a numerical scoring system, they can easily be used for any future analysis/research with respect to the disease type, disease site, or technique, thus reducing the time required to search through individual patient records for such details. The EMR software was configured in such a way that moderate or severe adverse effects and laboratory results deviating significantly from the normal range would be color coded to attract the physicians' attention.

As the EMR was integrated with the treatment machines, all the onboard images taken for positional verification of the patients before the initiation of RT and before receiving each fraction were automatically pushed into the EMR, so that these images could be matched and verified for positional errors against the digitally reconstructed radiograph (DRR) images obtained from the RT planning scan through the Monaco TPS [Figure 3]. Before the implementation of EMR, this verification had to be done offline through the treatment machine console. Moreover, this could be done only when the machine was not in use. However, with EMR, this verification can be performed offline in the OPD or in the TPS room, thus saving the enormous amount of time required to check each patient's onboard images on a weekly basis. In addition, it provides information about the trends of the positional variation corrections applied by the RTT before starting the treatment. Apart from this, the physicians can also look for any gross shrinkage in the soft tissue due to weight loss or any other reasons leading to loosening of the thermoplastic cast and take the necessary action immediately. This also helps in better delivery of RT with better conformity and safety and reduces the side effects experienced by the patients.
Figure 3: Picture showing offline review of the onboard cone-beam computed tomography and matching it with the Change to:digitally reconstructed radiographs (DRR) from the simulation scan

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Any instructions to the RTTs regarding the positioning of the patient, calling the doctor for the treatment setup, or the physicist can be specified through EMR by tagging that particular patient so that these specifications automatically reflect in their electronic record at the time of treatment.

As each person has individual login IDs, any entry into the patient chart is accompanied by the date, time, and the name of the person who enters information into the patient's electronic record [Figure 4].
Figure 4: (a) Picture showing the entry of the assessments done along with date and time, the data are depicted in numerical form, with color codes, when cursor kept on the entry, it will show the description. (b) Summary of the diagnosis and notes which includes clinical notes and assessments

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Before EMR was introduced in our department, each doctor was required to maintain a register with a list of patients planned for RT. In addition, the register would contain information about the different steps of the radiation planning process such as simulation, delineation of the target volumes, optimization, along with information about the plans awaiting the doctors' final approval, and the schedule of the patients for radiation treatment. With EMR in place, all of these details are visible to the treating physician along with the total number of patients who are receiving RT, the number of fractions received, and the machine where the patient is being treated. This eliminates the laborious work of maintaining a register.


  Discussion Top


The EMR system has added a new dimension to our clinical practice by allowing the clinical staff to view the history, clinical assessments, and investigational reports of the patient in real time. This has helped to reduce the waiting period of the patients for the retrieval of old files, thereby improving the quality of patient care. Moreover, as EMRs make medical notes more clear and easily available, they help to improve the safety of patient care. In addition, having immediate access to patient information reduces the time taken for RT planning, which in turn helps to start the treatment early. The EMR also accurately identifies all the personnel who enter data into the patients' record along with the exact time of data entry.

As stated by Bain, the implementation of the EMR system helps the clinical staff to review the history and other supporting records during patient care, thereby improving the safety and quality of patient care.[4] Boonstra et al. too, in their systematic review of the implementation of the EMR system, have stated that it helped them provide better care to their patients.[7] They also believe that the EMR system can have a positive effect on the performance of hospitals, but their implementation is a complex undertaking.[7]

A major disadvantage of this system is data and hardware management, as it involves huge costs for the maintenance of computer servers. In addition, the hospitals should have seamless and continuous high-speed internet and intranet services. Finally, for data protection, frequent upgradation of the antivirus software is needed which will impose an additional financial burden. This is in line with the findings of Khatri's study, in which he elaborates on the difficulties faced during the implementation of an EMR system.[12]

As planned initially, the reports of all the investigations performed in our institution were entered manually into the system. After the integration of the EMR with the PACS system of the department of radiology and the laboratory data system, the flow of the reports will happen automatically, thus reducing the work of entering the reports manually.

In the 6 months after the implementation of the EMR system, several functions of the software such as clinical data entry, RT planning process, RT charts, weekly assessments of patients receiving RT, and the daily scheduling of the RT patients in individual linear accelerators have been utilized by our staff. Even retrieval of the data retrospectively could be performed successfully. The members of our department are continuously in touch with the EMR core team to discuss the difficulties faced.


  Conclusion Top


Integrating an EMR system into regular clinical practice is a frightening task. It requires meticulous planning, sturdy physician leadership, and supportive staff. The immediate benefits of the EMR system include the availability of accurate clinical notes, medication lists, easily available patient records, and details related to the documentation of the records. After exploring all the features of the software, we are able to use only a very limited number of functions of our EMR system. As this article describes the process of EMR implementation in a government radiation facility, it may be of help to other institutions that plan on implementing such a system. Regardless of the difficulties we faced during the implementation of the EMR system, we would like to continue the process of paperless patient information documentation and care in our department and try to be eco-friendly.

Acknowledgment

  1. All the radiation oncologists of the department of radiation oncology
  2. All the radiation physicists of the department of radiation physics
  3. All the Radiation Therapy Technologists
  4. The application specialist Mr. Jayesh from Elekta Medical Systems India.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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