Development of an information technology system to assist oncologists in daily clinical practice

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16028 Background: Daily documentation and maintenance of medical record quality is a crucial issue in oncology. Computerization can offer many advantages, but needs training and motivation of operators and fitting of clinical processes and administrative rules to technological requirements. The electronic medical record (EMR) system, a software application for the entry, retrieval, and display of patients information into a digital database, could quantitatively and qualitatively improve medical recording. Methods: We developed an application system, named G2-clin, including EMR and computerized physician order-entry (CPOE). It was integrated into the hospital information system, for documentation and therapy planning to support physicians in daily clinical practice. G2-clin was developed by internal committee of oncologists, nurses and computer scientists, with an assured information technology during the learning curve and over the years. After training, staff physicians and nurses have routinely used the G2-clin starting on March 2002. Medical records collect all data concerning management of inpatient and outpatient care. Results: To date, 317 chemotherapy protocols are available in the CPOE pick list, including experimental regimens. In 2005, G2-clin registered 1550 new patients, with 7730 chemotherapy courses and was able to provide the following data: drug storage, administration and safety procedures, assessment of adverse events according CTC, specific patient safety policies, monitoring of resources and costs, data analysis for clinical research. Main benefits are improvement of the quality of patient care and safety, practice standardization, decrease in the risk of therapy ordering errors. The main drawbacks are inhibition of patient-physician interaction and visit time extension. Conclusions: According to our pilot experience, G2-clin successfully satisfied requirements of procedures standardization and allowed distribution of accurate data to all operators. Moreover it has been useful in monitoring outcomes of care, effectiveness, efficiency, adherence to clinical practice guidelines, resources and costs. No significant financial relationships to disclose.

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