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Researchers in North Carolina have optimized the EHR to implement EHR templates and EHR triggers to improve the quality of breast cancer care.


Christopher Jason


EHR enhancements, such as EHR templates and EHR triggers, are encouraging tools for promoting an understanding of clinical pathways to improve cancer care in the eastern region of North Carolina, according to a study published in Journal of Clinical Pathways.

The eastern region of North Carolina is a rural region of the state, where individuals are at an increased risk for more health issues, including cancer. According to the study, those individuals have lower survival rates than those who live in urban areas, and breast cancer is no exception.

“Patients with breast cancer residing in ENC [eastern North Carolina] are more likely to have delays in delivery of adjuvant chemotherapy and suffer from higher rates of breast cancer-specific mortality when compared with the rest of the state,” the authors explained. “A regional hospital system that serves this rural constituency is uniquely positioned to address these disparate outcomes.”

Researchers at Brody School of Medicine at East Carolina University wanted to ensure that newly diagnosed ENC patients with breast cancer received timely, evidence-based, and efficient care from their respective health systems by EHR optimization.

The researchers aimed to use the EHR as a tool guiding providers to follow certain clinical pathways.

Researchers integrated evidence-based clinical pathways for breast cancer care into the EHR at Vidant Cancer Care in Greenville, NC. The team also provided a means for rapid analysis of quality metrics.

Researchers collaborated with an EHR Advisory Group at numerous meetings to develop critical pathways. The stakeholders established 75 corresponding elements to individual treatment decisions and these critical pathways were then implemented into the EHR through separate approaches.

“First, standardized VBCC [Virtual Breast Cancer Conference] templates comprised of clinical pathway elements were developed and made live within the EHR,” the writers explained. “These templates were purposefully designed to enable rapid data collection and real-time analysis of variance from minimum quality standards.”

“Each element included in the templates was designed to be analyzable as a discrete variable via use of checkboxes and drop-down menus or as a qualitative variable via use of free-response text boxes,” they continued. “This design allows for rapid extraction of data elements via EHR queries. In addition, specific EHR triggers were developed to encourage compliance with clinical pathways and VBCC recommendations.”

Researchers analyzed 435 new breast cancer cases for two years prior to the implementation to gain a baseline. After three months, researchers will run an EHR query to analyze the results. This three-month re-evaluation will continue routinely at stakeholder meetings.

Early data hasn’t been particularly revealing, but researchers said there is upside to these EHR enhancements.

“Baseline data analysis revealed subpar compliance with multiple elements,” the authors wrote. “Gemba walks demonstrated that the standardized VBCC template is user-friendly. EHR triggers are currently in the beta testing phase. While VBCC participation by physicians at nonflagship hospitals has not been robust, EHR enhancements are a promising tool for promoting adherence to evidence-based clinical pathways, thereby improving the quality of breast cancer care in ENC.”

In particular, researchers said the EHR triggers will be an asset to this study once the triggers depart from beta testing phase.

“We anticipate that our EHR triggers will successfully improve compliance because similar triggers have been demonstrated to be effective mechanisms for identifying deviations from quality standards in cancer care,” the writers explained. “We intentionally limited the number of triggers to two in an effort to prevent “click fatigue,” which is associated with increased patient safety hazards and physician burnout.” 

“Once beta testing is complete and the triggers go live, we will solicit feedback from providers about the perceived benefits of the EHR triggers relative to the additional burden on their workflow.”