Implementation of a Computerized System in an Oncology Unit

ABSTRACT

Information management is essential for health professionals in order to maintain a level of productivity for health care services management. This is significant when treating cancer patients. The main target of this study was to employ computers to enhance the daily practice of Oncology Unit (Sotiria Hospital, Athens, Greece). Accordingly, a computerized system was developed consisting of three modules: the EPR, the Image Archive, and the Lab Module. The EPR Module is a database application that stores clinical results, physician orders, and several administrative data. The Image Archive Module is used mainly for the reduction of images volume and the Lab Module stores information about the patient blood samples. These two modules interoperate through EPR Module under strict data security policies. Key physicians, biologists, and secretary personnel are involved in data entry and information management, while the system administrator is responsible for the system functioning. Improved health care, user satisfaction, and cost savings were the most important benefits gained with this system. The need of similar systems in oncology is crucial and could involve additional applications, such as quality of life (QoL) systems.

INTRODUCTION

Health Informatics is one of the fastest growing areas of information and communication technology (ICT) (Eysenbach, 2000). It is a multifaceted field concerned with electronic patient records, image processing, computer aided diagnosis, research support, database archival, and hospital management. Despite the remarkable barriers to adoption there are significant technical, legal, economical, professional, and cultural reasons for the evolution of such systems. In parallel, their use should promote and must certainly not be in conflict with the fundamental principles of medical ethics.

Figure 1. Unit’s computerized system

Unit's computerized system

 

In the clinical work processes, the handling of huge amounts of information is a very important issue. Generally, health care information systems are used to guarantee quality and efficiency ofthe medical practice. The structured analysis and communication of clinical information are necessary in specific areas of health care (Asp & Petersen, 2003). This is extremely important in the case of caring for cancer patients. The cooperative care for cancer patients (declared as “Shared Care”) requires complete, distributed, and summarized clinical records as cancer documentation (Blobel, 2000). Computer-based applications assist crossing specialty boundaries involving members of a multidisciplinary team in an oncology unit (Benghiat, Saunders, & Steele, 1999). Moreover, computer systems support collaboration between patients and health care providers in the area of symptom management (Goldsmith, McDermott & Safran, 2004).

One of the most widely discussed issues among health informatics professionals is the Electronic Patient Record (EPR), also referred to as Electronic Health Record (EHR). EPR is an indicator of the progress in health informatics domain and allows health providers, patients, and payers to interact more efficiently and in life-enhancing ways. It offers new methods of storing, manipulating, and communicating various types of medical information, and is thus characterized as more powerful and flexible compared to paper-based systems. EPR systems are not usually stand-alone, but enhance a variety of add-on components according to the specific requirements of each environment.

In the past, many patient record systems were developed to provide oncology staff with a key infrastructure requirement in information management that is essential to maintain efficient and effective health care (Chamorro, 2000).

In order to embody computers in daily clinical practise and provide qualitative health care to cancer patients, we have developed a computerized system. It consists of three modules: the EPR Module, the Image Archive Module, and the Lab Module. These modules are tightly integrated through the EPR Module that works as the main platform of the system. The system administrator is responsible for the secure system operation and for the users training as well. The system and the users involved are briefly presented in Figure 1.

System Modules EPR Module

The core of this computerized system is the Electronic Patient Record Module (EPR Module). EPR Module is a relational database, which is accessed by the end users through a friendly interface. EPR data include clinical results (laboratory results, clinical outcome) and physician/patient care orders (orders, requisitions, consultations). It also includes administrative data such as admitting diagnosis, patient location, and follow-up appointments. All EPR data are linked to a unique Patient Record Number (PRN). Data are captured at all stages of patient care, from diagnosis to treatment and follow-up. The EPR Module is used further to produce reports, organize data, and provide immediate feedback.

Data are retrieved from the database using various forms. First of all, there is a welcome screen with a few command buttons that allow users to navigate to the other forms. An example is depicted in Figure 2. In this form, the user is able to navigate through a variety of patients’ data (e.g., diagnosis, type of diagnosis) and view the other EPR forms (e.g., “Therapies” form) by clicking on the corresponding button. Additionally, there are search and printing options available.

The Unit secretary is responsible for data entry, under the guidance of the supervising doctor. The data source is the existing paper-based record, which is kept in the Oncology Unit. As shown in Figure 2, the data amount imported in each form is small enough and the included information is well organized. The main idea is that the EPR Module should not be a copy of the paper-based record but a summarized description of patient’s status.

Figure 2. Part of EPR module. User is able to enter various data (personal data, diagnosis, type of diagnosis, symptoms, etc.) through a friendly interface.

Part of EPR module. User is able to enter various data (personal data, diagnosis, type of diagnosis, symptoms, etc.) through a friendly interface.

Image Archive Module

The need that led to the development of the Image Archive Module was the reduction in the volume of images, in order to free space in the Unit’s archive. This module archives two categories of images, the digital and the film-based ones.

The first category consists of digital images (computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET)) that patients deliver to the Unit immediately after their acquisition. Because there is no need for further process, these images are stored in the archive at once. The film-based have to be digitized and then imported in the Archive Module. For this task a film digitizer (Kodak LS40) is used. The images of each patient are stored according to his PRN and can be accessed through the EPR Module.

The software program that controls the digitization process is presented in Figure 3. The user sets the scan parameters (image analysis, image format, etc.), selects the archive file, and scans the films. In case of a problem during the scan process, the system produces an error message and the process is interrupted. A success message is produced only after the successful accomplishment of all the appropriate sequences required of an image digitization process. This program produces images in either DICOM or TIFF format. In our study, DICOM format was used. The DICOM images of each patient are further integrated into the EPR Module.

Lab Module

The Lab Module is a simple relational database that stores information about the patient blood samples that are kept in the laboratory. Additionally, it stores data about the patient chemotherapies (cycle, disease, etc.) that need to be kept along with each blood sample. As in the other two modules, all records are stored according to PRN and can be accessed through EPR. Lab Module is very useful, not only for the biologists, but also for the physicians who are in charge of research projects.

The user is able to perform simple and advanced searches for samples, depending on predefined or chosen criteria. Moreover, various reports are produced according to the given criteria.

Figure 3. Image digitizing. User sets the parameters and then scans the film-based images.

Image digitizing. User sets the parameters and then scans the film-based images.

Users

Key physicians, biologists, and administrative personnel are involved in data entry and data management in all modules.

Specially trained administrative personnel extract data from paper-based records and subsequently insert them into the EPR Module. Data entry is performed on a daily basis; when a patient leaves the Oncology Unit, his personal record (paper and electronic) is updated the same day or the day after. Physicians verify the extracted data and control the whole process for its reliability. Regarding the Image Archive Module, secretaries perform image digitization using the Kodak LS40 film digitizer. They simply pass the films to the digitizer and save the image files in the archive. Finally, biologists are responsible for data entry in the Lab Module.

The system administrator who is a health informatics specialist is responsible for the flawless functioning of the entire system and is also confronted with the training of the staff.

security strategies

Every threat that violates the security of the health care data is carefully controlled using a set of security strategies. The reported strategies could be summarized as follows:

• All modules are password protected.

• There are various levels of authorization corresponding to each kind of user; for example, biologists are not made aware of patient names because all patient data are linked to the PRN.

• The user login and interventions to the system are recorded.

Apart from these strategies, additional actions are taken for other security aspects. The recorded data are backed up at the end of each week and the equipment is locked when it is not in use.

Discussion

In the oncology field, computers may offer great help in data recording and in supporting the clinicians during the therapy process. The collected data are suitable not only for patient care, but also for quality assessment, research, and management. In order to achieve these goals, the best data management should be assured. This need is quite obvious in an Oncology Unit, which is a demanding environment with continuous information overflow and increased pressure for immediate decisions.

Apart from EPR systems, many other computer applications have been developed in the oncology field. A pilot study provided Internet lessons to oncology patients and family members to contribute in a timely fashion to the well being of the patients (Edgar, Greenberg, & Remmer, 2002). Furthermore, various programs attempted either to establish clinical screening programs for the quality of life of cancer patients (Carlson & Bultz, 2003), or to report their psychosocial functioning (Allenby, Matthews, Beresford & McLachlan, 2002).

There are many reasons for using computerized systems in oncology that mainly deal with the quality and efficiency of care. First of all, when using a computer system, voluminous amounts of easily retrievable and analyzed data can be stored. The access to structured and well-organized data offers the health care professionals a better insight into the patient’s condition, which leads to improved treatments. Moreover, the data collected in a computerized system can be easily used for research purposes.

However, the paper-based data management is still a reality in clinical practice. Many hospitals retain paper-based records as the main source of patient data. This is also the case for Sotiria General Hospital, where the Oncology Unit is established. As a result and in order to assure the completeness and accuracy of the EPR Module, many data are entered from these paper-based records.

It is true that the modern radiological equipment yields images in digital form, but the time of film-based radiology has not yet come to an end. Additionally, although the application of PACS (Picture Archiving and Communication Systems) is spreading, it is not always possible to access them. Moreover, image procedures (CT, MRI, PET) do not take place at the same radiologist location for all patients. Usually, each patient carries his images when visiting a hospital, then delivers them to his physician and, finally, the images are stored at the clinic’s archive.

The situation described above causes the enlargement of image volume and leads to storing and accessing problems. Even though the Oncology Unit had a well-organized film-based image archive, we faced these two problems in a very short period of time. Consequently, the Image Archive Module was developed for two purposes: the reduction of images volume and the ease of access to stored images. Because all images are stored in the Image Archive Module, there is no reason to keep them in both formats (digital and film-based). After their storage, the patient receives the original images and keeps them in his personal record. The laboratory is one of the first areas in health care where computers were introduced. Computers support the entire process, from sample collection to final report generation and validation. Apart from this process, oncology laboratories perform additional tasks. The most important task is the storage of patient samples at low temperatures (-80 oC or -20 oC) for future analysis. The numerous samples have to be well-organized in order to avoid changing or losing them. The Lab Module maintains data about the patient blood samples that are stored in the laboratory. The basic advantage of this module is that it offers the possibility for immediate access to specific samples, by using the search facilities of the module. Moreover, the user is able to categorize samples according to patients’ disease or other specific research-targeted criteria.

At this point, it should be mentioned that all users are able to access the modules through the local network. Even though each module serves different purposes, they all work in one. More specifically, through the EPR Module, the user is able to access each patient’s images and blood sample information.

Prior to this system development, most of the hospital employees did not have the opportunity to involve computers in their daily practice. Considering this, we used existing technologies to help staff members and offer them the possibility to work and interact with a system based on the Unit’s specific needs. Naturally, at the beginning several staff members faced difficulties in using the system, because they were not familiar with computers. This problem was resolved after the daily training and the systematic use of the system modules.

Moreover, user satisfaction is an important aspect and is highly correlated to the system layout (Sittig, Kuerman & Fiskio, 1999). The screen design was based on simple and user-friendly methods governed by the principle that users had to type as less as possible. In order to measure user satisfaction, an evaluation method should be followed, such as the distribution of a well-tested questionnaire. Nevertheless, we decided not to perform a thorough analysis of users’ satisfaction, but to briefly evaluate it through the daily practice and the reported problems.

The widespread application of computers increases the accessibility of data, especially when various techniques are applied. Unauthorized use of data is not an illusory danger. Therefore, the access to these data must be regulated. The fact that only authorized users should have access to the data is a logical consequence of the right to privacy. The privacy sensitivity of data is strongly context dependent. Data on various diseases are often considered to be extremely sensitive and oncology data are categorized as such. In our case, data security and patient confidentiality policies were followed to assure the maximum level of system reliability.

In order to reduce the threats concerning data confidentiality, integrity, and availability, some basic methods were used. Regarding confidentiality, all modules are password-protected. The passwords are changed often by the system administrator and are available only to the involved users. Moreover, the equipment (computers, scanner) is under close surveillance and locked when not used, in order to assure physical security. Concerning integrity, data are regularly backed up at the end of the week. Doubtless, database modules enhance various security mechanisms for referential, logical, and entity integrity. For example, each patient receives a unique Patient Record Number (PRN) to avoid duplicate values.

The patients and their families are not actively involved in the system processes, but their role as a data source remains crucial. It is important to note that they are informed that their data are stored in the Unit’s system and that it is possible to request a copy for their own use. The data stored in the system are not used for research purposes or published without the patients’ permission. It is important to note that extremely sensitive patient data (e.g., DNA), are not stored in the Unit’s system in any format. Any sensitive data used for research purposes (research studies, clinical trials) are collected and stored elsewhere as specified per protocol.

Altogether, oncology is often practiced in a quite demanding environment, but not only in the health sector. Doubtless, there are many hospital departments that could benefit from the experience gained using the system described here. For this purpose, the Oncology Unit has already presented its experience to the local staff at Sotiria Hospital and to the public at Med-e-tel Conference (Luxembourg, 5-7 April 2006). The Unit’s future plans include close collaboration with organizations or departments eager to share their vision and exchange information with the Unit.

Regarding images, it is obvious that as cost-effective storage media capacity increases, so will the temptation to store all images digitally. Moreover, the extraction of the appropriate data not only improves health care but also saves time in physicians’ daily practice. As a result, the Oncology Unit invests the saved working hours in other activities without spending extra funds. Apparently, the economic impact of the described computerized approach is very important.

Conclusion

Despite the remarkable barriers to adoption, the use of computers is growing. A variety of health care applications are developed in order to cover the demands of the new era. It is obvious that the Health Informatics field is growing very quickly and some health care areas, such as oncology, may gain important benefits from the implementation of appropriate computerized and digitized systems.

Using the current version of the developed system as an example, we intend to manage patient data in a more beneficial way. Consequently, the collected data could be used in other applications as well. For example, the digitized images could be processed and studied further. Additionally, a quality of life measurement system with immediate feedback of results to clinicians could be developed, as in the Velikova, Brown, Smith, and Selby (2002) study.

Generally, the field of oncology demands new computerized ways of data management. It is clear that computerized systems may open up unexpected paths to new directions in future practice and research.

Next post:

Previous post: