EHR Integration: The Next Necessary Step for Optimized Cancer Care

Today, guideline-concordant biomarker testing is standard of care for cancer programs and practices seeking to offer patients the latest and greatest in comprehensive, advanced cancer care. However, the implementation of biomarker testing has introduced a score of formidable challenges and complex processes for cancer programs and practices nationwide, particularly for those with limited staffing, funding, infrastructure, clinical and leadership support, and technical expertise to support this process.

The use of electronic health record (EHR) systems in the clinical workflow is improving efficiency and streamlining processes. Yet, as cancer programs and practices ramp up clinical and technological infrastructure, there is a need for greater EHR integration—in the form of add-on modules, integration with reference labs, customizations, and other workarounds—to overcome the numerous hurdles and better serve patients with cancer.

Ensuring a seamless flow of information across the continuum of care is not only critical to improving clinical decision-making, consistency of therapeutic approaches, and health outcomes, but also has the potential to reduce growing burdens and stressors experienced by the oncology workforce. A recent survey by the American Society of Clinical Oncology (ASCO), designed to evaluate oncology workforce career intentions, indicated that the “Use of the electronic health record” was 1 of the top 2 work stressors for oncologists in active practice – and the number 1 ranked stressor indicated for those working at a non-academic institution or practice.

To help address these challenges, the Association of Community Cancer Centers (ACCC), with its project partner LUNGevity and with support from AstraZeneca and Genentech, launched an educational initiative, EHR Integrations: Effective Practices to Facilitate Timely and Comprehensive Biomarker Testing.  As part of this initiative, at ACCC’s 40^th Annual National Oncology Conference in Austin, Texas, an exclusive EHR Working Summit was held on October 4, 2023, to understand the barriers to integration and explore effective practices/workaround solutions for streamlined biomarker test ordering and results management—the next necessary step for optimized cancer care.

EHR Working Summit

Bringing together leaders and stakeholders from oncology, industry, and multidisciplinary cancer care teams nationwide, the Summit provided a much-needed forum for discussion and action planning on current barriers and effective solutions for EHR integration – in particular the creation of interfaces between the EHR system and reference labs performing biomarker testing.

As attendees arrived, they were invited to share where their organization was with respect to EHR integrations by placing a sticker on a door entry chart.

Within minutes of the opening roundtable discussion question (“What single barrier, if removed, would most enable effective use of EHR for comprehensive biomarker testing?”), it became clear that the five-hour summit would be a springboard for a multitude of ideas and actionable solutions.

Participant responses spanned the need for interoperability, automation in ordering, insurance authorization support, quicker turnaround times for ordering and results, and most importantly, the need for 1 platform and 1 name for all things biomarker.

As Christopher McNair, PhD, associate director for Data Science at Sidney Kimmel Cancer Center at the Thomas Jefferson University Health System summarized, “Providers and care teams are looking for standardization in biomarker testing while balancing the growing testing landscape—who to test, when to test, what to order—rather than a ‘wild west’ of testing.”

Wild West of Testing

In many ways, the Summit revealed what most cancer programs and centers already know to be true. Without clearly defined protocols or standards, anything and everything goes. To illustrate the inefficiencies around biomarker testing, ACCC presented a landscape analysis on the current state of health technology performance and interoperability, which identified key issues, such as:

• Lack of access to computerized order entry in EHR systems for biomarker testing
• Lack of clarity and ability to track multiple types of tests (eg, somatic vs germline; tissue vs blood; predictive vs prognostic)
• Inefficiencies in communication between departments
• Logistical challenges related to entry and retrieval of results within EHR systems

Through a series of case study presentations, breakout groups, and action-planning activities, participants gauged their organization’s current state of EHR integration, explored barriers and discussed pain points, and brainstormed on actionable steps and solutions programs could take to move the needle forward on integration.

Many participants stressed the need for precision medicine “champions” or advocates within hospitals and cancer programs. “Multidisciplinary decision-making is necessary—make a precision medicine committee with representation from all disciplines. Bring together champions and align [this] with other institutional priorities,” said, Jennifer Johnson, MD, PhD, FACP, associate professor in the Departments of Medical Oncology and Otolaryngology and co-director of the Precision Medicine Initiative at Sidney Kimmel Cancer Center at the Thomas Jefferson University Health System.

Building on Dr. Johnson’s thoughts, Crystal Enstad, MBA, BSN, RN, OCN, oncology nurse manager at Sanford USD Medical Center Sanford Cancer Center emphasized the need for a “roadmap from healthcare systems that have implemented, streamlined, and are now leveraging their EHR systems for others who are just beginning the process.”

Industry also had much to add.  James Chen, MD, senior vice president of Medical Informatics at Tempus discussed the need for interoperability. “We don’t have the same way of communicating across all labs and EHRs at either the clinical or genomic level, we don’t always use the same language. We need interoperability — full stop.”

John Mueller, director of Commercial Programs at Foundation Medicine emphasized the importance of clinicians and care teams making the case for EHR integration. “You need to have the courage to speak up, be your own advocate, go to the folks within your hospitals and be loud to the people who can change things.”

Signs of Progress

Those that have been successful at making inroads with EHR integration had plenty of advice to share.  Karen Huelsman, MS, LGC, precision oncology lead and genetic counselor at TriHealth Cancer and Blood Institute, presented a case study that outlined their integration process. Huelsman noted that “strategically aligning their genomics module implementation with their first EHR integration worked very well.” Customizations and enhancements began immediately after their “go live” date and included tools like a genomics order filter, which enables teams to pull up genomic orders in EPIC rather than relying only on the media tab to view scanned PDFs, as well as the use of smart phrases rather than copy and pasting or manually typing. “I work at the intersection of germline and somatic,” she said “As a genetic counselor, I used to review every test report looking for cases that needed germline follow up. Having this integration and with filters and reporting is a huge time-saver.”

Wendi Waugh, RT (R) (T), CMD, CTR, administrative director of Cancer Services and Community Health and Wellness at Southern Ohio Medical Center (SOMC) also presented a case study on their experience with biomarker testing processes and integration, which features a series of well-orchestrated steps for the entire biomarker testing process as well as a dedicated navigator to support testing. But rapid advancements in biomarkers have not come without its challenges. “There have been huge changes in biomarkers in such a small period of time, but this has created one of the biggest challenges…if we could not squish it all together, and slow it down, but why would we slow it down when we were making so much progress with patients and evolving oncology…it [biomarker testing] is now a standard of care, yet the incorporation of testing lags behind in both clinical and the payer environments, in addition to the administrative burden,” said Waugh.  Aggregating information has also been 1 of the most challenging aspects at SOMC, as their current process is manual and data quality management is still a work in progress.

Sandra Kurtin, PhD, ANP-C, AOCN, assistant professor of clinical medicine and adjunct clinical assistant professor of nursing at the University of Arizona Cancer Care Center, presented the Summit’s third case study and agreed that it can be difficult to keep up with the evolving science and technology. However, after her cancer center was required to undergo 2 rounds of integration (an EHR integration with EPIC followed by another EHR integration with Cerner when infrastructure changed), she has become a pro. “I like to think I’m bilingual—I speak IT [information technology] and I speak clinical—and I believe that EHR integrations should be collaborative. We need to make IT processes reasonable for clinicians.”

Looking Forward

The EHR Working Summit is only the start of this important work. Easing EHR integration implementation across cancer program and practice settings—beginning with many basic shared issues around operationalization— can help, as well as addressing clearly identified gaps in current resources.

The EHR integration landscape is complex. However, ACCC and its partners are committed to providing the education, tools, and resources necessary to promote innovation and a clear path to optimized biomarker testing. As a result, ACCC and its partners aim to release an EHR Integration Roadmap along with a comprehensive resource library in early 2024, with plans to develop other resources to help guide cancer programs and practices on solutions and effective practices for facilitating timely and comprehensive biomarker testing.

To find more tools and resources related to EHR Integration, visit the EHR Integration webpage.

ACCC’s EHR Integration: Effective Practices to Facilitate Timely and Comprehensive Biomarker Testing education program is made possible with support by AstraZeneca and Genentech.