Addressing Challenges in EHR Integration

The United States health care system has been staring down a health care workforce shortage prior to and since the COVID-19 pandemic. Contributing factors include changes in the incidence of disease, population demographics, insurance status, and retirement rates. In fact, more than 1 in 5 oncologists are aged 64 and above, as future workforce projections show a bleak picture, where demand outpaces supply driven by an aging population.

A nationwide survey of 1,000 oncology care providers found 58% reported burnout related to daily tasks and required documentation (including electronic health records [EHR] and prior authorizations). Another survey revealed that burnout caused 28% of providers to quit a job in health care and 48% acknowledged concerns with the health care system’s ability to retain and hire staff in the absence of automation. Additionally, barriers exist in cancer biomarker testing workflows, complex ordering processes, timely results reporting, and data-sharing. These challenges are often compounded in lower-resourced community cancer programs and practices, where funding for new technology, integration tools, and training for staff is limited.

To tackle these issues, The Association of Cancer Care Centers (ACCC) in collaboration with its project partner LUNGevity, and with support from AstraZeneca and Genentech—implemented an education program called, EHR Integration: Effective Practices to Facilitate Timely and Comprehensive Biomarker Testing. As a result of a multistakeholder working summit, ACCC produced a roadmap and resource library to help guide cancer programs and practices as they explore EHR integrations/work-around solutions to optimize biomarker testing and reporting.

As the concluding blog post of a 3-part series within this initiative, ACCCBuzz engaged in a discussion Josiah Allen, PharmD, a clinical pharmacogenomic pharmacist and Jake Barnes, an IS application manager, both from St. Elizabeth Healthcare in Kentucky, focused on the obstacles encountered in integrating a biomarker testing add-on module in their EHR.

ACCCBuzz: What led you to become an advocate/champion for EHR integration? 

Barnes: It has been a largely manual process to get information back into the EHR, especially when we're talking about logging discrete, variant information related to the genotypes and phenotypes. It is an inefficient process and prone to error. That was a big part of how I got involved, I decided we could support the rest of the organization with a solution.

Dr. Allen: There are 3 driving factors for EHR integration. First, everything that Jake said, it’s a lot of manual work that we can streamline. The more we can leverage automatic systems to do that work versus having humans do it, which is more time consuming and error prone, the better. Increasing efficiencies and giving more time to practice at the top of what we are supposed to be doing which is providing patient care. Second, the breadth of this information. We chose to use standardization of a 27 gene panel for all our patients. So, for example, whether you're getting the test for psychiatry or oncology, you get the same panel of genes. We know that psychiatry patients or oncology patients can have heart disease, cancer, mental health conditions, and many other things going on that can give us information. And so, we want to make sure that the testing is as impactful as possible across the entire health of the patient and not just siloing ourselves within one particular disease state.

The challenge that comes with that is, if you have an oncologist who's ordered this testing, and there's something that's relevant for the cardiology team, how does the cardiology team get informed that there's an actionable result? Unless there's a system in place to surface that information at the right time, in the right place, to the right person? Using the EHR to do that is absolutely critical. The third thing is FDA regulation. There has been a lot of change in the regulatory environment for laboratory developed tests as well as clinical decision support tools in the past, I'd say 6 to 12 months. And the FDA who has historically had a hands-off approach to this area is starting to say no, we need to regulate this area a lot more. That puts our third-party vendors in this sort of gray area where we do not know if they will be around 6 months from now. That is another reason to bring this stuff in-house and manage internally, to have more control over our own destiny, if you will.

ACCCBuzz: Can you recommend some initial steps that can be taken when cancer programs and practices are beginning to think about EHR integration?

Dr. Allen: I think one of the things we did correctly was getting people involved early in the process. We engaged the IS [information systems] team the year before we expected implementation. It is a real benefit to start those conversations and build fluency early on. Genomics is a completely different language for most people, so there is a lot of background work needed to build a shared vocabulary.

Also, establishing support early on. We were fortunate to have executive team members who were passionate about this and wanted to make it a distinctive part of our program. We also were grateful to have clinical champions, several of our oncologists, who really bought into the vision early and said, this is the best thing that we can do for patient care.

Barnes: I would add, evaluate multiple ways of doing things. This means examining what it would look like if we enhanced this work, worked with third party vendors, etc. It is going to be a different fit for every organization.

ACCCBuzz: What are common pitfalls or missteps other programs and practices can look out for?

Dr. Allen: After several years using third-party tools, we decided to bring a lot of this stuff internally. I think third-party vendors can offer a lot. Obviously, they come with caveats, everything does. The challenges with third-party vendors are around the degree to which they can integrate with your system. We found it to be a shallow implementation. If you really want to do a deep integration, they just can't do that. The EHRs themselves are designed to limit the degree to which these third-party vendors can integrate with your system. While it worked for us for several years and it was a great way for us to get our feet wet, we built up our in-house logistics and expertise.

Barnes: It is definitely a resource intensive lift. I currently have 2 analysts working on the outpatient decision support pieces, and I want to say we're probably somewhere between 250 and 300 hours just for that. That does not include the time for the internal lab integration, or the genomic indicator build and some other dependent factors. So, it really is a pretty heavy lift. That is, in the beginning, once we got into maintenance mode (after “go live”), it will be much less obviously.

ACCCBuzz: Why is standardization in biomarker testing a necessary next step? 

Dr. Allen: We routinely discuss standardization of data. We have historical data that uses certain nomenclature, in many cases, there's 4 or 5 different ways to call the same variant, or similar variants. When you have multiple ways of talking about the same thing, it really requires you to build your informatics to support standardization. 

Also, as we move toward more interconnected health systems, it allows different health systems to share records. Genomic testing is often a one-time test that should be able to travel with the patient throughout their life, in every single health system that they visit. So, if you don't have standardization, that data can travel across the river and not be able to fire any of other health system’s clinical decision support tools.

ACCCBuzz: What tools or resources can optimize the EHR integration process to help more programs and practices who are just getting started or are stuck in the process?

Dr. Allen: The EHR provides some foundational content within their genetics module, which is helpful. But it's also written by people who don't want to put their foot down on anything in particular. What I mean is since they are not clinicians, the EHR does not want to be too prescriptive, this makes their content less actionable than before. So that makes it really challenging then to accept the content, because we want to be as prescriptive as possible, within the realm of what's clinically appropriate for our clinicians, because at the end of the day, they just want to know the answer. That is, they want to know what they should do if presented with information. And so, trying to be as prescriptive as possible is key. I think this is an area where clinicians need to lead the pack and say, no, this is what we need to say.

There are published guidelines that are helpful. But even those require interpretation and implementation. I think a better approach is to crowdsource content, sharing information across a community of institutions to create a menu of sorts where people can choose from what works for their institution specifically.

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.