ePrescribing has arrived

We are proud to present our users with our new ePrescribing system!  Partnered with MDToolbox, we were able to do a fast screen integration to easily log our providers and nurse assistants into the ePrescribing  program, and implement a behind-the-scenes SOAP interface to safely retrieve information about sent prescriptions.

Screen integration does not require a full-blown prescription network certification, but does include a basic audit (in this case, by Surescripts).

There are a lot of ePrescribing solutions out there, and a lot are built into larger vendors’ EMR functionality (e.g. Allscripts).  We chose MDToolbox because they support importing of medication list by using RxNorm concept ids, which is the dataset on which we have based our medication list and their cost structure is very flexible.

So far our users have had overwhelmingly positive responses. We are not yet cleared for ePrescribing of controlled substances (EPCS) but that will be implemented in the coming weeks.

 

Looking forward:

We consider Ankhos to be a mature clinical oncology platform and going forward, we are looking at ways to improve profitability, not just productivity.

Our current mission is to develop features in Ankhos to ensure that our medical coders have the information they need to bill properly and with lower risk of claims rejection. This will include implementing reminders for clinicians about what drugs are indicated for which diagnosis codes, and make sure that we have the correct information on file.

Some documentation requirements are as simple as “requires diagnosis code 123”, others are more complex: “Must have a diagnosis of xyz AND must have failed 2 prior treatments”. It is easy for a computer to tell us if a patient has a certain diagnosis on their problem list, it is harder to make more Human decisions like “… have failed x treatments, one of which is Oxaliplatin.”

Questions like “Did the patient’s disease progress on drug ABC or was it discontinued for another reason?” are not reliably answered by a computer. We will have to be very careful about how we implement this interface to not lose all of the physician and nurse productivity gains we have made so far, and at the same time increase our reimbursement rates with well-documented encounters.

The American healthcare payment system is constructed around this delicate balance of taking care of patients and getting paid. As developers we must be diligent about listening to our users and must take great care to not trade too many clicks for cash, lest we succumb to the dark side of the Mega-Click EMR.

An oncology pharmacist’s dream

Recently we have been putting some more polish on some features of Ankhos we have planned for a long time and we have a doozy.

 

Ankhos has been made to live and breathe oncology. For the uninitiated, much of modern cancer treatment involves many planned doses of chemotherapy over regular periods of time.  Doses are assumed to change  at any time given a patient’s response to the medicine. Medication doses may be altered mid-treatment or completely scrapped and a new treatment plan initiated.

 

These rapid and irregular changes in dosing can be problematic for a pharmacist trying to keep the right drugs in stock.  Chemotherapy drugs are very expensive and drugs that are not given are taken as a loss if they expire. For this reason, it is imperative that the pharmacist has an accurate picture of upcoming doses. Bulk pricing may also be available if the pharmacist knows well enough in advance of a big drug need.

 

Because Ankhos’ treatment planning is so comprehensive and agile, we are able to maintain a very accurate picture of what drugs we will need and when. So what is this new ‘doozy’ feature? Let the following screenshot say a few words:

This is a graph of all of the upcoming Oxaliplatin needs for the next two weeks from our test dataset. As you can see, this graph provides a clear picture of when we will need what amount of ‘Oxali’.  In this example, the pharmacist may be able to create two bulk orders, one for early September and one for the end of September, saving lots of money. This chart will also change dynamically, based on any dose reductions or increases, providing a progressively more accurate picture of drug needs in the future.

Future drug planning is not all that we can provide. The date ranges can be changed to include past months to evaluate the general trends of usage of a given drug.

This is the sort of feature that other general practice EMR systems cannot provide. Futher, there is information not shown here for HIPAA reasons. The user can drill-down into these aggregate statistics to see specific treatments per-patient.

The next feature we want to add is to incorporate drug prices and insurance allowables (payment prices from insurance companies) which would turn this into a future estimated profit graph!

We are constantly dealing with government regulations and core features like ePrescribing, but once in a while we are able to create these awesome features that are unique to Ankhos and really wow our users.

 

Ankhos is Paperless; Next step: CCHIT Oncology Certification

I am proud to report that we have reached a major implementation milestone in the development of Ankhos: no new paper is going into any chart! All new patient referral material is being scanned and all incoming documents are reviewed and signed electronically… and our users love it.

 

We have had our nose to the grindstone for 2+ years and it is now time to look up and make sure we are headed in the right direction.

 

In the light of the recent meaningful use audits, I think it was a good decision to finish these core features before attempting meaningful use certification.   The physicians I work with are quickly realizing that it is much easier, desirable and predictable to squeeze money out of increased productivity than to hope that the government hands us a check (and doesn’t take it back).  While we are still headed towards meaningful use, we are going to take a short detour – to CCHIT Ambulatory Oncology Certification. 

 

It’s not that large of a detour either. Because we started with the fundamentals of oncology: regimens, propagating dose changes, a timeline-oriented mentality, and a strong drug administration workflow, we are probably 85-90% towards complete test script coverage.  Having the CCHIT seal of approval for both oncology and meaningful use should help this rocket take off even faster.

 

Are we and EMR vendor? I’m not sure anymore. I’m beginning to think of us as an Oncology Software Vendor.

Guest Post: Joy Hester

Joy Hester, our lead nurse was kind enough to write a guest blog post about her experiences with EMR. She has been with the practice for many years (I won’t say HOW many) and has been invaluable in the development of Ankhos.

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Hello. This is my first attempt at blogging. So I am a little nervous but here I go!

I am a nurse. My knowledge base is in people, not in macros, pigeon holes or textboxes. Over the years I have learned a lot, self taught, what I like to call a “computer geek wanta be.” I know enough to get by. Let’s just say I know just enough to be dangerous.

Having said that, when the very busy Oncology Practice I work for purchased an EMR I was asked to help as a super user and was eager to get involved. Why not? I love this stuff!

I worked on developing the chemo regimens and single agent favorite list of drugs. I also developed documentation tools call Questionnaires for nursing documentation. I thought Questionnaires was an odd name for a documentation tool but, after a while it made sense. The Question was “Why does this have to be so hard?”

I could go on and on about how difficult the EMR was to use but I do not want to relive that. We finally scrapped the drug ordering and administration portion of the software. We now only use the scheduling and note portions of the EMR. We looked at other systems and did not see anything we wanted to pursue.

Then along came Ankhos.

Ankhos is so easy to use. I even have some privileges to add and modify drugs and procedures. These are called Orderables.

In the old system this was the hardest part. We are nurses. We are surrounded by patients who need our attention. We need an easy to use adaptable system where doctors can order and nurses can document treatments accurately.

We now have it.

We are in the enviable position of having an on staff software developer, Nick Orlowski, available to build the software to meet our needs. All we have to do is ask.

Working with Nick, I began to understand that the software should work for me, not me working on the software. I started to ask what Ankhos can do for me. These things are coming and I am excited to see how they develop.

We are accurately documenting on our patients. All the documentation requirements are being met. One of the best parts for the nurses is to be able to pull the treatment to an order sheet when the patient goes to an outside facility for their chemo. Ankhos tracks the location of the patient’s treatment and I am then able to verify the treatment is given after notification from the hospital the treatment is complete.

I review all the previous days encounter forms and having the drugs documented in Ankhos has saved me so much time when there is a question about a charge on a form. All I have to do is pull it up. I would have to physically find the chart to verify the treatment before Ankhos. It is wonderful to have it right there.

We have just begun. I am excited to see what is coming.

 

-Joy

Milestones

Hello, stranger! Been a while!

A few weeks ago I wrote a post about a distinct feature of Ankhos called sandboxing. The feedback from our users has been overwhelmingly positive. Many of our users came from outside clinics or hospitals where drug entry was a daily(or weekly) task and each agent had to be ordered at once.   The ability to easily modify a published regimen (or order labs, blood, etc.) is a boon to provider productivity.

The past few weeks have been very busy.  We have reached some serious milestones in our project:

1. Nurses are completely paperless. All infusion time charting and Nursing notes are done in Ankhos.

2. All labs are available in the EMR, imported directly from the clinic lab machines (as well as a Labcorp interface).

3. All Providers are creating their orders in Ankhos.

a. The new Doc is well-trained as Ankhos has actually helped orient him to the practice’s idiosyncrasies.

4. 10 new Toshiba Sattelite (17″/4 g/300 g) were purchased and placed in exam rooms. I will write another post regarding the decisions and setup of our client hardware.  The biggest draw is the great quality of the wide screen. Ankhos is a web app so we don’t need a lot of processing power.

5. My sister was happily married to her long-time boyfriend in a fabulous wedding in downtown Charlotte.

Hopefully I will get back to blogging our development more in the future as things move more towards maintenance mode (HA!)

The oncologist’s workflow

I’ve been pretty busy lately, but I’d like to share a link I found about the general clinical oncology workflow. Hopefully this may shed some light on why clinical oncology EMR systems are so much different from the EMR systems of other types of practices.

It takes dedication and focus to come up with a competitive product in this market, and just providing ‘templates’ is not enough to increase productivity, safety and ROI.

 

 

Quick edit:

One divergence from the article that Ankhos takes is our lack of automatic drug calculations. There are handy calculators integrated into the system to calculate AUC and BMI, but every dose must be entered by a human in absolute milligrams (or cc, etc.). The computer is not allowed to determine or alter any doses.

Lawsuit mitigation with EMR

We have been using Ankhos in the final stages of beta for a few months now. It is not yet our legal document (we are still charting on paper, as well) but we are very close to ending the beta.  Before we do this, however, I want to make sure our legal ducks are in a row.

One main concern that a healthcare practice faces is impending lawsuits and audits. Electronic systems are  very powerful and very descriptive. There are timestamps and ‘fingerprints’ associated with every action taken in Ankhos. If there was an accusation that someone had not documented an allergy or reaction correctly, or administered the wrong drug, the record of that incident would be easily accessible with an electronic system and the legal accusation would be quickly resolved.

However, electronic systems also present a great opportunity for fraud and tampering. Yes, fingerprints, access controls and timestamps are strewn throughout the system, but the database administrator has final say about everything that is in the database. A diligent fraudster can easily cover up an audit trail that would otherwise prove malpractice.

Because of this possibility, an astute lawyer could raise doubt about the validity of any claims made with reference to the electronic records, and rightly so.  But how do we solve the problem of proving data integrity while at the same time retaining the flexibility of an electronic system?

After some thought and research on best practices, we decided that it was essential to have a third party involved. One whose interests were not co-mingled with those of the practice.  We also wanted to have an irrefutable way to use that third party to validate the state of the database.  We want to be able to say:

“Yes, Mr. Lawyer, this was the exact state of our database (and application code) at this date and time”

Our process is two-fold:

1. During each daily backup, we hash the backup file using the Unix md5 sha512sum hash command [Edit: MD5 is not acceptable and we have changed our process.].  We keep local copies of both the hash and database file. This is a common practice across many download sites. At a later date, the file can be hashed again and compared to the hash on file. If the hash strings match, then the file has not been altered or replaced.

2. The first step is great, but if the database admin has complete control of her data, then she has complete control of the hashes, as well (and any backup trail).

To solve this problem, we email this hash value to a number of public email accounts to which office administrators have access.  The hash value is a short string of ‘random’ characters derived from the database file and cannot be used to reconstruct a backup file (thus, no patient data is transmitted on the unsecure email format). Doing this allows the hash value to have a timestamp assigned by a third, independent and uninterested party.

This way, when a lawyer asks us how we know that database admin we hired didnt cut out any incriminating data, we can point to the timestamp given by the email provider and show that by the power of our email provider and all the SMTP servers involved in this transaction, THIS was the state of our database at this time.

Hopefully this will satisfy auditors and save the clinic time and money trying to prove the state of their documentation.

Screenshot: Advanced regimen sandboxing

**UPDATE  06/05/2012** Contains old screenshots!

 

Ankhos provides lots of flexibility when it comes to creating chemotherapy regimens. Not only is it easy to create a custom regimen, but it’s also easy to modify them on the fly. We do this with a technique we call ‘Sandboxing’.

Whether we’re using a regimen straight from the textbook or creating our own, we have the option to place it in the ‘sandbox’.  Anything can be placed in the sandbox, from entire regimens to x-rays to comp panel orders…. Anything that occurs with some periodicity in conjunction with patient treatment.

Once in the sandbox, these agents and orders can be modified on a  day/cycle basis in order to match the needs of the patient. Clicking on the right and left arrows will increase/decrease the cycle length, and the days of a treatment can either be typed in or inserted on days 1,8,15,… by clicking the weekly checkboxes.

The sandbox outlines a patient’s entire treatment schedule in one fell swoop.  We won’t need to do any physician data entry for weeks… or until a change is needed.

The sandbox pictured above outlines 4 weeks of (made-up) treatment. Once the treatment is in the sandbox, You can cycle these four weeks as many times as you want. Three cycles of CHOP-R? Easy. Weekly CBCs for 6 months? Easy.

The sandbox has received many accolades and nearly every user who has experienced it describes it as ‘very powerful’ or ‘incredibly easy’.

One limitation of the sandbox is that it is not practical to schedule a follow-up  one year from now or mammogram in 6 months, but we solve that problem by ordering the simpler tasks like a normal EMR might… one at a time.

A final note: As far as patient safety is concerned, each treatment must be electronically signed by an MD before it can be administered so any dose reduction that is required does not fall through the cracks.

What’s Next?: No Oncology Trial Patient Left Behind

Now that we’re well on our way to full implementation, we’ve begun to think about the next steps we’re going to take.

Nearly every day I have the opportunity to listen to drug reps pitch their wares to our MDs, PAs and nurses. I have also had a chance to demo a bit of Ankhos to them. Most are completely wowed. They say “None of our other oncology clients has anything close to what you guys are doing. Your software will be a success.”

And then I ask what I ask nearly everyone at the office: “Great! Now what would you like this software to do for YOU?”

The drug reps will take a step back, collect their thoughts and say “We want  to never miss a potential trial patient again.”

So that’s our next goal. We will compile study criteria and patient data and make sure that we have  cancer staging,  treatment plans, diagnoses and everything else we need and constantly monitor our patients for potential trial fits.

I think Ankhos is poised to do this with excellent precision because it is “Regimen Aware”.  It can answer questions like “Is the first time this patient with stage II breast cancer has been on the regimen FLOX with a Creatinine level of x?”

Just like the past few months… I’m very excited and have so much to learn.

Oncology EMR: The human element

I’ve said it before and I’ll say it again. Enthusiastic clients are  a huge part in creating quality software.  I read the Daily WTF often (as most programmers should). This blog reminds me of all the things that can  easily go wrong with a software project if you don’t keep your head on straight and learn to side-step people eager to get in the way. It also makes me constantly appreciate the doctors and nurses with whom I am writing this software. Without their expert and creative input, this project would be a lost cause.

It is this human element; the creativity, expertise and enthusiasm of people that makes Ankhos great.

If you have an EMR vendor who is not excited to work with you, don’t just walk to the nearest exit. Run. If you have an EMR vendor who works very closely and listens to your needs, cherish them and count yourself lucky. If you are looking for an oncology EMR product developed by and for oncologists, stay tuned. Drop us a line, or provide feedback. Ankhos  will deliver.

More screenshots coming soon…