Development and Experience With an EMR-Based Radiation Oncology Toxicity Recording Instrument (ROTOX): Benchmarking and Quality Improvement

Abstract

To report physician experience with a radiation oncology toxicity recording instrument (ROTOX) in a hospital EMR; to audit clinic action in relation to high grade toxicity documented by ROTOX; to determine institutional benchmarks for toxicity from pelvic and head/neck radiation. The on-treatment visit (OTV) for Radiation Oncology is essential in patient management. Radiation toxicities recorded during the OTV may be inconsistent due to lack of treatment site-specific templates. A CTCAE (version4.0)-based ROTOX was embedded in the EMR used by our medical center. Flowsheet functionality was combined with synopsis reporting to show sequential data in graphical form. A site-specific checklist was created with a hard stop requiring physicians to complete ROTOX at each OTV, permitting access to patient clinical data and allowing efficient review of toxicities. Reports were generated to analyze toxicity by physician and disease site for the 6 months since implementation of the program. Physician acceptance of the new process was assessed by electronic survey, and nursing and physician actions taken in response to high grade (≥3 CTCAE) toxicities were audited. For 6 months since implementation in April 2013, 4443 OTV’s were recorded with toxicity grading for 698 individual patients, of which 400 were for breast or pelvis radiation treatment courses. 107 episodes of high grade toxicity were identified over this period, with toxicity specific intervention documented in 95%. A random sample of OTV notes prior to the implementation of ROTOX was reviewed and assigned a numerical score based on completeness and comprehensiveness of toxicity grading; this baseline average score improved from 41% to 99% when re-sampled after implementation of ROTOX. 47% of physicians responded to the electronic survey. 60% reported benefits from cumulative and synopsis toxicity views for patient care, but were neutral about ease of navigating ROTOX. None reported difficulty or burden with the instrument. A subset of cervix and head neck cancer chemoradiation patients underwent focused review over a 6 month period to establish clinic benchmarks for toxicity. Results were as follows (grades 2 and 3 toxicity shown in percentages in parenthesis): Cervix - anemia (28%, 2.5%), diarrhea (10%, 0%), dysuria (5%, 0%); head neck - dry mouth (17%, 7%) and mucositis (21%, 3%). EMR based ROTOX enables consistent recording of treatment toxicity with physician acceptance, and allows clinical response to be tracked. In a uniform sample of patients, population benchmarks can be developed and toxicity tracked. In the 2 sites analyzed, high grade acute toxicity was low for our patients. Prospective tracking and correlation of high grade acute and chronic toxicity with patient, physician and treatment characteristics will be possible with this instrument.