In May 2008 the Kansas City VAMC in Missouri, the Chemotherapy Quality Improvement Team (CQIT) was formed to evaluate and improve the chemotherapy delivery process in response to a significant medication error. At the first meeting, the team quickly determined that the chemotherapy ordering process should be improved. Up until that point, chemotherapy was ordered on handwritten, self-duplicating forms. The finished order forms were often difficult to read. Further, the forms were not consistent with American Society of Health-System Pharmacists (ASHP) Guidelines for Preventing Medication Errors with Antineoplastic Agents. 1 A solution using existing technology was needed and obtaining third-party software was not an option at the time.
Chemotherapy Ordering Options
The VA Computerized Patient Record System (CPRS)
electronic health record system could not support the
complexity of chemotherapy orders without some adjustments.
One consideration was to build “order sets,”
to allow sequential ordering. With this approach, once
an order set was engaged, all the chosen medication orders
would automatically fire in sequence.
Order Sets
The order set method of standardization in chemotherapy ordering would channel all chemotherapy orders to the pharmacy through the computerized physician order entry (CPOE). However, a major drawback to building this type of order set was its lack of flexibility. A veteran’s care plan rarely adheres to the “standard” and modifications are the norm. The ASHP recommendations regarding chemotherapy order contents could not be honored.
The final product presented to the pharmacy as a clump of orders with no sequencing, no explanation of deviations from standards, base doses, or name of the desired regimen. With this approach, no diagnosis or stage of cancer was offered to allow a pharmacist to check for the appropriateness of the regimen. Also, a complete treatment summary was not communicated, so details, including base doses and calculated parameters, such as body surface area (BSA), were not available for order checks. Probably the biggest drawback was the intense amount of support a program like that required. Order sets are difficult to write and maintain in this age of drug shortages and in the evershifting terrain of medical oncology practice.
Progress Notes
Another alternative identified was to work within the CPRS-based electronic progress note functionality. This option offered a number of positive features. First, the finished product appeared in a visually appealing sequential document. An option existed for the provider to detail calculated parameters and to discuss variances from standard. Course number and order sequence could be communicated to the nursing staff. Best of all, using a 2-template strategy, a simple system was developed that allowed much of the order to be prewritten. Order entry required minimal physician time while producing a high-quality chemotherapy order that was consistent with the ASHP recommendations for safe chemotherapy ordering (Figures 1 and 2; to download a sample of the template and treatment note, visit (http://www.fedprac.com/AVAHO).
Once the Kansas City VAMC decided chemotherapy ordering should be implemented through the electronic progress note functionality, Information Resources Management (IRM) staff and the oncology pharmacist worked together to develop a templated process that would make the most sense and require the least work for all parties. Strong consideration was given to the amount of labor needed to support the process, because that had been observed as a stumbling block in other sites’ attempts to develop similar processes.
Chemotherapy Ordering Process
When the provider engages the dedicated progress note, the more complex of the 2 templates engages. The template automatically pulls in identifiers and allergies, height, weight, creatinine, and age data and offers links to 2 dose calculators. It also prompts providers for information that is required for all orders, such as diagnosis, stage, protocol title, treatment date, inpatient or outpatient, BSA calculation, BSA qualifier (total, ideal, or adjusted body weight, capped doses, etc). Providers must indicate whether the patient is also to receive radiation, and there is an option to provide retreatment parameters for multiday orders. Once this dialogue is completed, the information provided populates into the note.
After the first template is completed and has populated into the note, the provider moves to the “shared templates” in CPRS and selects a treatment-specific template. Currently, > 150 treatment templates are in use at the facility for routine medical oncology practice. A parallel process also exists that has been modified for investigational protocols. Once a treatment template is selected, the provider populates the required fields with doses and completes the progress note. The 2 templates flow together to create 1 seamless treatment note. Providers can deviate from the template standard