Over the past several years, we have seen segmentation of EHR product offerings, usually tailored for different clinical settings. In a domain such as Radiology, the specialty requires integration of PACS into the EHR. However, in certain specialties such as oncology, the federal government, professional organizations, and even patient advocacy groups have recommended that the so-called patient-centric EHR requires different functionality than a “one size fits all” EHR. Thus was born CORE, or Clinical Oncology Requirements for the EHR. It was forged from collaboration between the American Society of Clinical Oncology (ASCO) and caBIG (the Cancer Bioinformatics Grid), based at the National Cancer Institute. Several vendors now offer an Oncology EHR.
The rationale is as follows:
- Oncology and cancer care require different clinical workflow than other specialties – especially in regards to the administration of chemotherapy.
- An objective of caBIGis to develop an interoperable framework that connects all of the components of the cancer community — including clinical care, biomedical research, and the regulatory domain. They can provide an interoperable Oncology EHR to meet the needs of the oncologist and, through association, the cancer patients themselves.
On a personal note, when a family member developed breast cancer in 2006, Johns Hopkins Hospital provided her with a password-protected web page that included all of the details of her diagnosis, as well as prognosis of therapeutic outcome based on choice of doing nothing, having a mastectomy, chemotherapy, radiation or a combination of therapies. Thankfully she is in remission. The point is, I can see the relevance of an Oncology EHR to the clinician, but a dedicated web site and/or a Personal Health Record (PHR) would probably be a more digestible solution for the patient.
But wait – it doesn’t stop here. There is now a recommendation from the National Institute of Mental Health that a Psychiatric EHR be developed; emphasizing the inclusion of complex functional brain imaging that goes beyond what is now normally contained in a radiology report or as PACS imagery in an EHR, with a more intensive focus on medication and patient follow-up care and compliance.
In regards to caBIG – although it is a tremendous toolkit and network for bioinformatics, and elements of it are being used for drug discovery in Biotech and Pharmaceutical companies, how much of this work has really filtered down to the hospital oncologist or other specialist for improved clinical practice? I must admit that I have a foot in two domains: bioinformatics and clinical informatics. It has been my observation that biomedical researchers in academic medical or federal research institutions have developed intelligent software applications that can be used to understand complex genomic, proteomic and metabolomic pathways, and associate specific genetic alleles with specific diseases. The National Institutes of Health created the Clinical and Translational Science Awards (CTSA), for funding up to 60 of the nation’s medical schools to perform research and “translate” basic biomedical research to the clinic, the notorious “bench to bedside.”
Maybe we need a translator to translate basic biomedical research discovery, which is evolving at an incredible pace, to the clinician that works in one of the 5,000 U.S. hospitals that are not tightly coupled to an academic medical center?
Is a specialty-specific EHR the correct solution for every practicing clinician? Have we thoroughly investigated the rapidly changing workflow in a variety of clinical practice settings that could benefit from bioinformatics?
And finally, what are we going to provide to the patient? A PHR tethered to a specialty-specific EHR? The ‘Medical Home’ concept being tried in TRICARE in the U.S. military? (see http://www.defense.gov/news/newsarticle.aspx?id=55362)
I don’t know the answers, and I may be naïve about the current state-of-the-art in the EHR world, but I can tell you that a bioinformatics software solution being “thrown over the wall” to the clinic is not going to work. I am not as worried about interoperability issues, although these are considerable, but whether the physician will embrace the vast amount of new biological information coming down the pipeline from a somewhat incomprehensible source.