Chemotherapy Management

Jul 22, 2008 at 12:18 PM
I am following with great interest the work on medications and prescribing. I am the Product Manager for a specialist software application in the US specifically for physician order entry and management of chemotherapy. I realise there is a long way to go but am looking to provide input and create a dialogue with other parties that have an interest in this specific area. We are following the developement of these controls closely and are discussing adopting them with some of our planned redesign. Has there been any specific thought given to this area currently?
Coordinator
Jul 25, 2008 at 11:54 AM
Thank you for your interest in MSCUI.  A member of our medications team will reply shortly.
Developer
Aug 4, 2008 at 5:28 PM
It's great to hear that someone working in such a complex and specialist area is taking a keen interest in medications guidance.  Chemotherapy is a bit of a 'holy grail' for medications guidance since it so often embodies all the really challenging scenarios. 

We're keen to hear about your experiences of putting guidance into this context so that it can feed back into guidance where relevant.  We are always collecting materials such as examples of medications prescriptions and administration schedules, scenarios, paper artifacts and so on.  Even when these examples come from beyond the boundaries of our scope, they are always relevant in some way.

As you guessed, there is a long way to go before guidance can step in to the realms of specialist areas such as this and yet we find it immensely valuable to consider chemotherapy scenarios because they allow us to push the boundaries and understand where the weaknesses in guidance might be. 
Sep 4, 2008 at 3:45 PM
Edited Sep 4, 2008 at 3:54 PM
Just getting back from vacation. I understand in the scope of this project that these considerations seems a long way down the line but what I would say to you is that has been precisely the problem I have seen that EMR vendors here in the US have encountered by leaving these considerations too late. Many of the well developed EMR's ( Meditech; Cerner, EPIC, GE) all still fail to deliver on the needs of oncologists. I have been working in this arena for the last 9 years and since I began both Meditech and Cernenr have been trying to delvier oncology modules without success; GE abandoned their efforts realizing the complexity and time invloved and now use our solution integrated with their application; EPIC have a module that continues not to meet the need. What I see in these cases is that sites move to adopt an EMR and quickly the oncologists discover that prescribing in the way they need to is not safely or adequately managed and consequently they all end up going back to paper and having their orders transcribed into the EMR. This is normally when  my company gets involved to provide a solution for the oncologist....

I love the work you present on the medication charts however I would definitely question in its current form what use this would be to an oncologist prescribing chemotherapy. There is nothing in the UI that I see thus far that would facilitate the dose calculations or managing of the remgimen in general that an oncologist would want to see if the electronic health reocrd was going to be his resource. I was an oncology nurse in the UK for many years and our department managed chemotherpay using a supplemental medication sheet which was thought to be safer as it called out chemotherapy specifically and could be managed independently of the main med chart. My thought is that chemotherapy should still be segregated in some way from the main med chart for this reason but also so the treatment protocol could be managed using the health record (by this I mean scheduling treamtnet cycles etc).

I see BMI in the record but nothing on BSA or evidence of ideal body weight or the ability to calculate and adjusted ideal body weight; all values needed by the oncologist to calculate chemotherapy doses (for which there are a nubmer of different forumlae that coudl be used...). The need to calculate doses using per m2; per kg or AUC is a key safety need as is the ability to calculate creatinine clearance.

Anyway the main point I think I am trying to make is to really consider these needs sooner rather than later as otherwise I think you will run into the scenario of the EMR vendors I have seen here and realise you have a big hole that it will be very difficult to fill...
Sep 4, 2008 at 6:24 PM
Food for thought:

To illustrate some of my points, take the following example in the context of the UI for prescribing you are showing right now:

I am an oncologist who has just seen a new referral of a post surgery colon cancer patient who will need adjuvant chemotherapy. They will receive standard adjuvant therpay of the 'FOLFOX' protocol which will ge given every 14 day for a total of 12 cycles. (this regimen is very common indeed). To prescribe this treatment for one cycle the prescriber needs to order the following

Ondansetron 8mg/dose PO X1 Day 1 and Day 2            - example anti emetic given with the protocol
Dexamethasone 20mg/dose PO X1 Day 1 and Day 2    - as above

Oxaliplatin 85mg/m2 using real body weight IV X1 Day 1 ; given over 2 hours minutes in 5% dextrose 500ml
Folinic acid 200mg/m2 using real body weight IV X1 Day 1 and Day 2; Given concurrently with oxalipatin in 250ml 5% detrose
Fluoururacil 400mg/m2 using real body weight IV X1 Day 1 and Day 2 IV push
Fluoruracil 2400mg/m2 using real body weight as a  Continuous infusion Day 1 given over 46 hours


  • This needs to be managed as a 'drug set' or complete protocol and shoudl not require the user to enter each drug manually
  • The EHR should calculate the patient's BSA and provide alerts for abnormal BSA's to guide the prescriber
  • Doses of all drugs should be calculated by the EHR and dose limits checked; alerts provided
  • The prescriptions shoudl include all required infusion information and instructions
  • The prescritpion should calculate calender dates for administration based on the chosen start date for the protocol\
  • The oncologist shoudl be able to manage the care pathway/treatment plan for the regimen
Developer
Sep 5, 2008 at 11:21 AM

That's a mighty chunk of food for thought that will take some time to digest. I sincerely hope there is scope for it to go further than that and we can use your input as part of an exercise that allows us to look at what happens when guidance is scaled up to include a specialist area such as this.  In the ideal world we would have the ongoing support of an oncology clinician and software vendor in order to produce work of a high enough standard for guidance.

Guidance for prescribing is a rapidly evolving area and is currently being informed by emerging standards for prescribing in the UK.  Again, for the moment, this falls short of standards for oncology for all the reasons you are only too well aware of.  For example, although we are well aware of the practice of prescribing 'drug sets' and following protocols, we haven't focused our research in this area. Having said that, you are right, now is the time to effect a change.

 

As you say, a special view is almost certainly needed for chemotherapy.  Nonetheless, if the needs of cancer care have implications for generic guidance, that's something we should look at now.  With a little help from you, we could work your examples above into notional views that are guidance-compliant.  The exercise would help us to understand what's missing and what would need to change for these views to work for an oncology clinician.  That, in turn, might have implications for existing and emerging guidance.

Many thanks for the information above and especially for the colon cancer patient scenario.  We will use it to supplement our existing requirements and scenarios.

Sep 5, 2008 at 4:18 PM
Sarah, I am very keen to help, just let me know.