Imaging & Informatics Boost Oncology Care

Oncologists have sharpened their abilities to fight cancer in recent decades, relying on physicians from multiple specialties to do so. From the clinical technology perspective, though, some oncologic advances stumbled—owing to fragmented technological game plans.

Clinicians working in the multidisciplinary field of oncology now report momentous gains in quality and efficiency. Immediate access to years of prior patient images, teleconferencing with community oncologists and encyclopedic records of all patient encounters translate to more coordinated and expedited cancer care, which in turn spurs more informed decision-making on tumor boards, in the operating room (OR) and in patient consults.

Oncology has suffered many of the integration and interoperability challenges that have tormented specialties like radiology and pathology.

"All the challenges we normally face to build [and integrate] technology are amplified in an oncologic setting. But by the same token, the benefits can be amplified as well," says Pravene A. Nath, MD, assistant professor of surgery and chief medical information officer (CMIO) for Stanford Hospitals and Clinics, which includes the Stanford Comprehensive Cancer Center in Palo Alto, Calif. The two systems at the heart of oncology's improved decision-making and expedited care are PACS and the EMR.

Images take center stage

"The most significant change in oncology imaging has been PACS. It's impossible to understate the importance of the electronic distribution and viewing of diagnostic images," says Franklin N. Tessler, MD, senior vice chair for operations and vice chair for radiology informatics in the department of radiology at the University of Alabama at Birmingham.

The instant availability of patient images has encouraged nonradiologists to view images and correlate their findings with radiologists' conclusions. "After removing a lesion from a patient with breast cancer, when the lesion is sent to radiology for imaging, we can see the image instantly in the OR, instead of relying exclusively on a phone call from radiology. This is a tremendous advantage," explains Breast Surgeon Frederick M. Dirbas, MD, of Stanford University.

PACS has allowed various members of the care team from medical and radiation oncologists to pathologists and surgeons to synchronously review images across or away from the hospital, and thereby make more informed and coordinated decisions about patient care, says Dirbas.

For patients who receive care away from their home communities, physicians now only need minutes, as opposed to hours or days, to interpret the images prior to patient consults, while electronic archives allow clinicians to review years of patient exams. Previously, clinicians had to retrieve fragments of patients' charts, pages of records and "boats" of films, a time-consuming and commonly incomplete chore, says Tessler, adding, "Having all the information and images in one spot ensures physicians actually look at that information more often."

Tessler offers the example of a lymphoma patient who undergoes a diagnostic CT immediately after PET/CT. With both scans available in minutes, Tessler is able to review the PET/CT while interpreting the diagnostic CT, "which is invaluable." In addition, PACS features like multiplanar reformatting, volumetric analysis and magnification tools have improved diagnostic accuracy, allowing radiologists to highlight key findings for nonradiologists. These advancements go all the way to the OR, Tessler says, with multimodality image fusion used regularly to guide biopsies and other interventional procedures.

EMRs' value

Universal and immediate access to patient images is only part of more informed clinical decision-making. At the University of California (UC) Davis Health System, several years of integration-led informatics has posted every new cancer-related encounter into the network's EMR, which now serves as clinicians' springboard for viewing images from all 18 ophthalmology modalities, dermatology, as well as the hospital's endoscopy PACS and radiology, with pathology nearing the integration finish line.

Although the complexity of radiotherapy treatment planning and the sensitivity of chemotherapy dose orders often lead vendors and providers to separate these programs from EMRs, the informatics team at UC Davis has made treatment regimens and notes available in the EMR, with chemotherapy computerized physician order entry (CPOE) likewise accessed via the EMR.

"Most of our clinicians live in our EMR," says Michael Minear, chief information officer for UC Davis Health System. "All of our encounters across all specialties are based in the EMR. There's no more hunting for data: If the data aren't in the EMR, they don't exist." Image access in the EMR, combined with CD import and advanced image sharing, has helped centers cut down on the need for repeat imaging, Dirbas notes.

Tessler says the availability of information about patient's symptoms, labs and notes from referring physicians in the EMR often leads him to hone in on specific areas of imaging studies. Previously, if accessed, such information would have to be received either via phone or by retrieving a patient's chart. "Now, with medical records at my fingertips, I can often arrive at a diagnosis more rapidly."

Data burdens, data benefits

The technical challenges of integrating clinical IT systems and costs of ballooning PACS archives may seem daunting. "We're creating terabytes a week," Minear points out. He credits a supportive UC Davis administration with funding and making possible EMR- and PACS-based integration. IT staff also play a key role in keeping systems humming and talking to each other.

The results of robust integration and enterprise access to images and data include accelerated and more informed decision-making, which sets the stage for evidence-based, multidisciplinary care.

Virtual Tumor Boards at a Glance

One of the major informatics shifts in multidisciplinary cancer care has been the virtualization of tumor boards. Large academic cancer centers are increasingly leveraging their advanced technological capabilities to provide highly specialized care to patients undergoing treatment at community or rural facilities. Virtual tumor boards connect local clinical teams with specialists at larger cancer centers, creating a lineup of primary care physicians, medical and radiation oncologists, radiologists and pathologists, as well as nurses and physician assistants. These clinicians are linked via teleconference calls, wherein patients' EMRs, images, pathology and other results are displayed by a combination of PACS and EMR interfaces and slide presentations. According to Scott D. Christensen, MD, medical director of the University of California (UC) Davis Cancer Care Network, virtual tumor boards serve two functions: To coordinate care decisions, particularly difficult ones, between specialties; and to provide expert second opinions to patients with limited access to cancer care. At UC Davis, which currently broadcasts tumor boards for five cancer sites to four community partners in Northern California, annual tumor board teleconferences have increased from 20 in 2008 to 97 as of the start of August. A similar initiative at the Michael E. DeBakey VA Medical Center in Houston brings together as many as 60 caregivers, including physicians, physician assistants and nurses from a dozen specialties and subspecialties. "The boards improve the efficiency of referral by avoiding unnecessary referrals and decreasing the number of patient trips and waiting times. Moreover, treating physicians are made aware of treatment options that might not be available at their local facilities or that their local physicians were not familiar with, which is especially helpful for patients in rural areas," says Teresa G. Hayes, MD, chief of the hematology/oncology section at DeBakey VA Medical Center.