Creating a process to standardize regimen order sets within an electronic health record.

PURPOSE: US Oncology uses regimen order sets in clinical practice to treat patients. However, the process to assure accuracy and upkeep of these order sets has not been described. The purpose of this project was to evaluate the regimens housed in the electronic health record, iKnowMed, to determine their appropriateness and accuracy. MATERIALS AND METHODS: US Oncology conducted an audit of its standardized regimen library. A utilization review compared chemotherapy regimens in the library and consolidated order sets on the basis of past utilization. Next, internal and external clinical pharmacists were contracted to verify the accuracy, dose, duration, and cycle length of regimens. References cited in the regimen library were evaluated. New or updated references or clinical practice standards were added or modified when necessary. US Oncology corporate pharmacists reviewed the recommendations and discussed findings with an oversight committee. Final proposals were voted on before being incorporated into iKnowMed. An internal database tracking system tool for all reviewed recommendations was created to track and communicate needed changes to the electronic health record. RESULTS: Out of 511 regimen order sets, 51 were recommended for removal or consolidation. Of the remaining 460 regimen order sets, all had some administrative changes. Specifically, 75% had title changes, 14% had cycle-related changes, 31% had reference updates, and 13% had dosing updates. CONCLUSION: Electronic health records systems, such as iKnowMed, can provide standardized order sets for a large oncology network. However, the regimens need to be evaluated routinely using standardized procedures to ensure they are accurate and current.

Benchmarks for value in cancer care: an analysis of a large commercial population.

PURPOSE: Cancer costs are increasing at an unprecedented rate. Key cost drivers include chemotherapy, hospital admissions/emergency room visits, and aggressive end-of-life care. We sought to evaluate these costs in a commercial payer population in collaboration with consultants from Milliman. PATIENTS AND METHODS: We used a retrospective analysis of Medstat 2007 to evaluate chemotherapy costs and use. Included patients had a cancer diagnosis; received chemotherapy during the evaluation period; had at least 1 day of coverage between January 1 and December 31, 2007 (medical and prescription coverage); was younger than age 70, and had active employment or was the spouse of an active employee. Costs are allowed amounts and are trended until 2009. Admission rates and emergency room visits are reported. Hospice use and chemotherapy during the last 14 and 30 days of life were also evaluated. RESULTS: In this commercial population of 14 million patients, 0.68% had claims for a cancer diagnosis; approximately 22% of those received chemotherapy during the study time period. Patients with cancer receiving chemotherapy averaged $111,000 per year in total medical and pharmacy costs. The average hospitalization rate for any reason was 1 admission/yr. Approximately 40% (or 0.4 admits/year) were identified as being chemotherapy related. Of the 3.5% of patients who died in the hospital, 51% received chemotherapy within 30 days of death. CONCLUSION: Understanding the costs of cancer care offers opportunities to formulate a strategic plan to control cancer costs and maintain quality care. Comprehensive cancer solutions to address the full spectrum of care will facilitate improved quality and patient outcomes.

Conservation planning as a transdisciplinary process.

Despite substantial growth in the field of conservation planning, the speed and success with which conservation plans are converted into conservation action remains limited. This gap between science and action extends beyond conservation planning into many other applied sciences and has been linked to complexity of current societal problems, compartmentalization of knowledge and management sectors, and limited collaboration between scientists and decision makers. Transdisciplinary approaches have been proposed as a possible way to address these challenges and to bridge the gap between science and action. These approaches move beyond the bridging of disciplines to an approach in which science becomes a social process resolving problems through the participation and mutual learning of stakeholders. We explored the principles of transdisciplinarity, in light of our experiences as conservation-planning researchers working in South Africa, to better understand what is required to make conservation planning transdisciplinary and therefore more effective. Using the transdisciplinary hierarchy of knowledge (empirical, pragmatic, normative, and purposive), we found that conservation planning has succeeded in integrating many empirical disciplines into the pragmatic stakeholder-engaged process of strategy development and implementation. Nevertheless, challenges remain in engagement of the social sciences and in understanding the social context of implementation. Farther up this knowledge hierarchy, at the normative and purposive levels, we found that a lack of integrated land-use planning and policies (normative) and the dominant effect of national values (purposive) that prioritize growth and development limit the effectiveness and relevance of conservation plans. The transdisciplinary hierarchy of knowledge highlighted that we need to move beyond bridging the empirical and pragmatic disciplines into the complex normative world of laws, policies, and planning and become engaged in the purposive processes of decision making, behavior change, and value transfer. Although there are indications of progress in this direction, working at the normative and purposive levels requires time, leadership, resources, skills that are absent in conservation training and practice, and new forms of recognition in systems of scientific reward and funding.