Data collection has to be improved in order for physicians to be able to convince payers to support certain types of costly therapy, a panel of physicians agreed during a wide-ranging OncLive Peer Exchange conducted at the 2015 ASCO Annual Meeting.

Payment issues, electronic health reporting, how to attract younger physicians to oncology, and the growing role of women physicians in this traditionally male-dominated profession were discussed in the Chicago forum.

Below is an edited and condensed version of the discussion, which was moderated by Andrew L. Pecora, MD, editor-in-chief of 

and chief innovations officer at John Theurer Cancer Center in Hackensack, NJ. Participants included Michael Kolodziej, MD, national medical director of Oncology Solutions, Aetna; and Jeffery C. Ward, MD, of Puget Sound Cancer Centers, Edmonds, Washington.

A range of oncology practice management issues were discussed in an OncLive Peer Exchange meeting held at the 2015 ASCO Annual Meeting in Chicago. Participating were Jeffrey C. Ward, MD; Andrew L. Pecora, MD; and Michael Kolodzeij, MD.

Suppose in the advanced stages of treatment you get a positive signal that says an mTOR inhibitor might work with a patient. Of course, it’s not FDA-approved, and the payer won’t pay for it, and the patient can’t afford to pay for it. What do you do?

: I think the big challenge for payers is trying to sort out what’s legitimate and what’s not. The question is, how do we get payers to say “Yes”? If we could develop a methodology by which we actually collected information about these one-offs, we would not only improve care for all patients with cancer, but we would make the no-yes dichotomy a heck of a lot easier for payers.

: I think that you explain that this is a very rare case, and you’ve done this test and it demonstrates that it may work. And insurers say, “Yes, we will pay for it as long as that data gets into a registry—that we learn from it.” You know that 97 percent of the care that we give, we learn nothing as far as outcomes.

How do you view the rapid movement toward personalized medicine— the use of genomic testing, and the new and expensive medications such as checkpoint inhibitors?

: Now, we’re restricting care really to patients who have either a high risk of systemic disease or have systemic disease, and they are clearly the single most expensive group of patients. The general thinking is that we would like to make sure that the right patient gets the right treatment at the right time. What I think is not necessarily a path forward is unbridled enthusiasm and, “If it works in this, it must work in that.” I’ve heard it more than once: “I’m an oncologic chef.” Those days are over. You had better be a good oncologic short-order cook, because we depend on you to make that hamburger right. But an oncologic chef where you decide you’re going to try a little bit of ingredient A and ingredient B is probably an unsustainable approach going forward.

: I think disparities are predominantly created by access. The barriers to access can include socioeconomic barriers, and language barriers when we’re talking about immigrant populations, and then cultural issues. There are some issues with trust with the medical establishment. I think if you remove those barriers and patients have access, you’re going to see most of those disparities go away.

How should we think about and address the comorbidities and behaviors that lead to cancer?

 This probably is the primary intent of the quality metrics which have been widely criticized—for example, Administration for Community Living (ACL) program in Medicare. The idea that we can improve population health with the ACL&mdash;making sure that people get their mammograms, have colonoscopy, have their A1Cs checked, don’t use cigarettes, and monitor their weight&mdash;is population health management. This is not really an oncologist issue. This is an issue for primary care.

How do we encourage more young physicians to enter the oncology field?

: Well in our payment reform session here at ASCO, one of the commentors was a young oncologist, and he stood up and said that people are not going into oncology because of the uncertainty and the reimbursement system, and in their perception, oncology is a place where doctors struggle to be happy.

I think that the way to change that is to deal with a payment reform piece— deal with that in a big way. Once you get it out of the way, then oncology is going to be a glamor profession.

: I’m not sure I’d call it a glamor profession, but make it a really fulfilling career decision, and make sure that it involves team-based care. I’m a big fan of the Medical Home Model, and one of the core principles of the Medical Home Model is team-based care. And I aspired to that when I was in practice, but there was no scaffolding upon which to execute that. Team-based care diffuses some of the responsibility but also enriches the career paths of all those people who are part of the team, and I think that’s really key.

There’s a rising population of women who are now practicing oncology. How is this significant and relevant for the field?

: If you look at new medical school classes, many of them are more than 50 percent female, and I think that that enriches and brings a reality to what we do and is changing some of the paternalism of how we practice in a very positive way. It does create some struggles. I think that’s evident not just in medicine but across the United States where we’ve changed from a culture where you have a single breadwinner to 2 breadwinners. What does that do to your family life and to relationships?

Let’s talk about traditional models of care and payment, fee-forservice, chemotherapy “buy and bill,” and your thoughts about new models.

The system is problematic insofar as it creates the impression of conflicted interest. But because of this perception of perverse incentive, there has been a continued erosion of the way chemotherapy gets reimbursed. The buy-and-bill model, which has funded the infrastructure to allow community practices to perform, I think, is in jeopardy.

How do we move from being paid for services to being paid for a product?

 You have to somehow indirectly reward the physician for, if you will, good behavior. I think it gets to be really complicated.

 I have real problems with bundles. I think that you have to be very careful about how they’re constructed and what you’re doing. I think that bundles will prove to be, if we do them wrong, a way that will further consolidation and further the [mergers] into institutions, whether that’s good or bad. AP: I think we all agree that the site of service does impact cost, and that the best place for a cancer patient to get their care is in the community setting, in a private office, in most cases. How do we preserve that model?

 I think the truth is that a lot of community oncology practices have focused a lot of their business efforts, operational efforts, on the efficient administration of chemotherapy. That’s what they do, and they do it well. What I’m proposing is that we rethink and potentially retool to deliver the optimal patient care experience.

Whoever, whatever the nurse is who’s doing the calls—you know what’s going to happen, right? Whoever the Incident 2 physician is that day, you know what’s going to happen. So all I’m saying is, we need to get practices comfortable with the idea of examining processes of care. And I’m not sure that’s going to cost a ton of money, but it does require a lot of effort on retooling.

How are health exchanges and the new private plans impacting oncology practices?

I think we have to understand that these initiatives are not healthcare reform, they are insurance reform, and much of what’s happening is that there are patients who now have access to the system who didn’t have very good access before. Many of them are still underinsured.

They had a choice when they decided to develop what was an acceptable insurance plan: they could make it cheap or they could make it good, and they made it cheap.

How much time are oncologists spending on documentation?

 In our practice we have used two different electronic records in an effort to try and improve documentation and to make sure we’re doing all the right things and increase efficiency. The first one was with US Oncology. It was a medical record that was designed, really, thinking of the physician’s workflow. It did not improve our efficiency but neither did it make our efficiency a whole lot worse. And it served a purpose in that it was searchable if the doctor chose to use it the right way. And I think it improved the care that we gave in many circumstances, if for no other reason than that you could now read what the doctor had decided he wanted to do.

Then we moved to the current system that our hospital uses, and my documentation time increased by about 2 hours every night for the first 6 months. I see probably 2 or 3 fewer patients every day than I saw before, and I spend at least an hour to 2 hours longer documenting what I did.

Are electronic health records contributing to efficiency or are they an impediment to efficiency?

I think there’s huge variability in the way physicians use EHRs, and it’s driven largely by the fact that they are clunky, they require extra work to use right, and so people find workarounds. In our EHR there is a place to do staging. You have to go to that, you have to work through the staging, you have to check boxes. So what do half the doctors do? They dictate the stage in their note and it never goes in the box and it’s not retrievable. So I don’t think that EHRs are doing, in that sense, what they necessarily were promised to do, and it’s because the entry of information is so difficult.

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Data collection has to be improved in order for physicians to be able to convince payers to support certain types of costly therapy, a panel of physicians.

Lack of Drug Information Makes it Hard to Get Payer Approvals

Many healthcare reforms are dramatically changing the payment landscape for oncologists, policy expert Debra Patt, MD, said in an address at the 14th Annual International Congress on the Future of Breast Cancer, held in July at Huntington Beach, California.

Patt, a medical oncologist with Texas Oncology and a researcher in Healthcare Informatics for McKesson Specialty Health and The US Oncology Network, discussed the implications of reforms on payment structures and gave advice on which programs and developments to watch carefully.

Her talk covered the Delivery System Reform Incentive Payment (DSRIP), the Affordable Care Act, the Medicare Access and CHIP Reauthorization Act (MACRA), Right to Try laws, the “Cadillac” tax, the 21st Century Cures Act, and similar programs.

Oncologists can expect governmental policies on payment to remain in flux for years, she said, as the aging baby boomer population combined with a shift toward chronic care treatment will contribute to an anticipated doubling of the cancer care population in 20 years. “The cost of cancer care is going to be much more important, and the policies that we use at the state and federal level will try to influence how we try to control costs and still provide care for our population,” she said.

The Affordable Care Act was designed to increase insurance coverage, and prior to its advent there were about 46 million uninsured adults and children in the United States, but owing to out-of-pocket costs, coverage remains very expensive for this cohort, Patt said. The rise of expensive oral oncolytics has made it more challenging for patients to pay for their prescription drugs, though the closing of the Medicare coverage gap—the “doughnut hole”&mdash;is expected to increase access to care for individuals with Medicare Part D prescription coverage, Patt said.

The Cadillac Tax Will Cause a Reduction in High-end Plans

In addition, oncologists need to be aware of what the so-called Cadillac tax on high-end insurance coverage will do, Patt said. “The natural consequence of this 40% excise tax is many employers will eliminate their high cost plans and have lower cost plans,” she said. She noted that many unionized workers enjoy coverage from these high-end plans and will be affected, too. The tax goes into effect in 2018.

Medicaid expansion has extended care to many oncology patients, but the poorest states with the largest populations of uninsured have held back on participating, Patt said. “If Texas were to expand Medicaid, think of what the natural consequence would be if the federal government stopped paying for so much of it,” she said. “Either education costs would be decreased or the budget would have to be decreased or tax would have to increase.”

At the time of this writing, 31 states had adopted Medicaid expansion, allowing people under age 65 at 133% or lower of the federal poverty threshold to receive coverage. States that have not adopted include Patt’s home state of Texas, Maine, Georgia, Louisiana, Florida, and Mississippi. “It’s a huge burden to the Southern states,” she said, noting that Texas has a population of 27 million and about 14 percent of the uninsured in the US.

The failure of poor states to implement Medicaid expansion under ACA accounts for what Patt called a disappointing dent in the uninsured population in the US. In 2008 it dipped as low as 14.4% of the population, then gradually climbed to 18% by late 2013, aided by recessionary forces. It now stands at 11.4%, lower than in 2008, but not as much as was anticipated, considering the downward boost the rate should have gotten from ACA, Patt said.

“I saw 4 patients without insurance with local advanced or metastatic breast cancer in the last 2 weeks in Austin. It’s such a challenge. It’s really such a hardship,” Patt said.

DYSRIP programs under the Section 1115 Waiver extend care to uninsured populations, but their mechanisms are “elusive,” and it’s essential for physicians to understand these better, Patt said. “I think our patients will be better served if we can be effective advocates to help them get what they need.” DYSRIP funds took her by surprise when she suddenly saw more patient navigators in her local hospital, wondered why, and then found out they were paid for with DYSRIP money.

Smaller Players Will Lose Negotiating Strength

Smaller players in the oncology sphere will have more difficulty negotiating for favorable prices, as the ACA has also spurred a consolidation push among payers, affording them tremendous leverage, Patt noted. UnitedHealthcare now measures about $125 billion in annual revenue; Anthem has about $70 billion, but has just announced a merger with Cigna, which would create a $105 billion colossus. “If they have to alleviate high cost plans and administer low cost plans and seek to control costs, that will give them market power for negotiation,” Patt said. Hospital systems are doing the same thing, she noted. Hospital mergers have soared since 2010, and amounted to roughly100 in 2014. In the five years before 2010, the yearly average was 60 or below. “The natural consequence of all of those mergers and acquisitions is that if you are a smaller shop, it’s harder than ever to have bargaining power,” Patt said. “Your contracts are likely to be lower and it’s hard to maintain financial health.”

Rather than predicting a trend of rising healthcare costs from these consolidations, Patt said a vicious cycle was more realistic: “Once government subsidizes health insurance, consumers become less sensitive to healthcare costs. Hospitals expand to reflect the increase in demand; the government spends more than it expected, cuts payments to providers; hospitals merge to reduce fixed costs and gain market power; private insurers increase their premiums; health insurance becomes less affordable to consumers; and back up again.”

Alternative payment models in healthcare—value as opposed to volume&mdash;are getting a bigger boost from MACRA than ACA, she said. Figuring out how to manage under the Oncology Care Model and other incentives is going to be a bigger challenge for smaller practices, she said. A heavy concentration of poorly reimbursed treatments will be tough to ride out for the “2 doc practice,” she said. “You have to be a bigger group so you’re able to average everything out. I think that would be a major stress on smaller practices.”

She mentioned the proposed 21st Century Cures Act, which was passed by the House in July and is designed to broaden drug access; a New England Journal of Medicine article described the legislation as potentially weakening standards for drug approval.1 Patt said biosimilars, despite very active lobbying to control the introduction of these products, are not liable to be held back. “For example, in Texas, physicians have to be notified within 5 days, but it’s not like (drug distributors) need to ask permission; so, I think we’ll be seeing a lot more of biosimilars.”

Patt also predicted that oral drug parity laws—laws that equalize terms for payment for oral drugs as well as infused&mdash;will likely increase patient access. Conversely, Right to Try laws have been passed in many states, but, even so, the money has to be available to pay for the drug. “What we have in many states now is that a doctor in combination with their patient can elect to treat them with a drug that they think is in their best interest if there is some clinical trial evidence that it would be helpful. But the insurer is not obligated to pay for it, and the pharma company in many states does not have to provide it, but the doctor will not be held liable for administering it to the patient if there is some data, and they do believe that it’s in their best interest,” Patt said, concluding, “I don’t know how impactful that will be.”

Another thing adding to the competitive difficulties faced by oncology practices is the encroachment of drugstores in the oncology space. “At Walgreens in Arizona now, you can get your labs done,” Patt said. “Some CVS stores are infusing specialty pharmaceuticals in their offices.”

“There’s a lot of state variance in scope of practice about how much individuals can do; how much autonomy advanced practice providers can have has a lot of state variation. It’s just interesting that that happens at a time when we’re going to be asked to do so much,” she said.

Asked if she thinks physician-owned practices will survive, Patt responded that the coming years will be an extreme challenge. Larger practices will be better prepared with information technology support, and understanding of the costs of care, and the ability to grow and meet needs. “But small practices, I think, are at great risk.”

Avorn J, Kesselheim A. The 21st Century Cures Act—will it take us back in time? 

Many healthcare reforms are dramatically changing the payment landscape for oncologists.

Shifting Reform Landscape Is Perilous for Small Practices

The erroneous autocorrect, the restrictive dropdown menu, the deadly software glitch: anecdotal evidence of computer foul-ups abounds in the literature on electronic health records (EHRs) and medical malpractice awards.

It may be too early to say whether EHRs have increased or decreased liability for physicians as a whole, mostly because settlements lag so many years behind treatment, but some say the technology generally reduces total medical errors (though not as much as predicted) and has no effect on insurance rates.

At the level of the individual practice, however, EHRs can increase malpractice liability—if those practices fail to recognize the major risks associated with the technology and adopt policies that minimize those risks, experts interviewed for this article said.

The fundamental transparency of EHRs makes it harder to camouflage actual mistakes, they said. It also makes it harder to camouflage sloppy work habits or even to justify good work habits that can be made to look sloppy in court. Defending malpractice lawsuits, therefore, requires not only a commitment to good care but a commitment to the unimpeachable documentation of good care.

“EHR vendors initially promised better notes with less work, but the truth has largely been the opposite. A typical physician probably needs to spend an extra working hour every day to produce records with far more extraneous information but far less core content,” said James J. Stark, MD, founder of Stark Oncology Consulting, in Suffolk, Virginia.

“It is an added hour of the most tedious possible work. It generally produces no benefits to patient care, and it generates zero extra reimbursement, so there is a tremendous temptation to cut corners with copy-and-paste and other shortcuts. Physicians who want to avoid malpractice verdicts must resist that temptation. They must accept each day’s wasted hour as a cost of doing business. Those who don’t can rest assured that lawyers will eventually tear their records apart, creating the appearance of malpractice even in the absence of actual malpractice.”

While the logic of that advice is clear, doctors, nurses, and administrators, at some point, may become so overwhelmed with professional or personal obligations that they do begin to cut corners.

Practices, therefore, must create specific policies concerning the record-keeping obligations and implement safeguards that prevent workers from shirking those obligations, experts said. Good software can certainly help. It can, for example, send out alerts when users fail to do the bare minimum, but it still takes humans to distinguish good records from the shoddy notes that can endanger a practice.

Audits Help With Troubleshooting and Training

The Oncology Institute of Hope & Innovation, an independent practice with a dozen offices in and around Los Angeles, conducts regular audits of patient records. Audits are time consuming, but they go faster with EHRs than with paper records that are stored off-site, and they minimize the risk of problems related to either lawsuits or billing.

“It’s rare to find a problem, but the auditing process is still valuable for a number of reasons,” said Matthew Stevens, the Oncology Institute’s General Counsel and Compliance Officer. “It allows us to evaluate how well we’re training people to use the software and to make improvements. It also allows us to find problems before they come up in lawsuits or billing disputes and, quite often, to correct them. Finally, it gives everyone a strong incentive to be diligent about keeping the sort of good records that impress auditors.”

Early EHR advocates predicted that system users would require much less oversight by administrators and one another. They said smart software would automatically force users to keep good records (or automatically warn administrators in the event of failure), and thus reduce malpractice awards by making poor record keeping nearly impossible.

Early EHR advocates said that software would eliminate a wide range of errors that were possible with paper records, but many of their predictions have yet to come true. EHR usage is generally associated with fewer medical errors, but many mistakes that programmers promised to make “impossible” still happen.

“EHRs have truly eliminated a few simple errors, like those arising from illegible handwriting, but once you get past that, they’ve created trade-offs for practices to consider. If you set a system up to warn you of every possible error, you’ll waste countless hours on erroneous warnings and learn to ignore the warnings. If you set the system up with virtually no warnings, you risk mistakes you could have avoided,” said Sandeep S. Mangalmurti, MD, JD, the lead author of a much-cited article that warned readers of the 

 back in 2010 that EHRs might end up increasing medical malpractice suits.

“The clinical decision support is even more problematic. ‘Teaching’ systems enough about balancing standards of care against individual patient needs has proven exponentially harder than many people anticipated. Such features probably have some value when they prompt users to consider something they’d forgotten, but we’re far from the point that healthcare providers should lean heavily on the decision algorithms. We’re not even at the point that EHRs can reliably spot when you mistakenly chose ‘twice daily’ rather than the neighboring ‘daily’ on a drop down menu.”

Another problem with the dreaded drop-down menu and other EHR features designed to prevent doctors from doing the “wrong” thing arises when physicians try to override them. Some systems make it very hard to order anything unusual, even something as small as a low dose of medication for a patient with renal or hepatic failure. Practices need to have tools that allow such decisions and convey them clearly through the system so caregivers don’t mistakenly revert to defaults.

It is also highly recommended that systems have policies on documenting the reason for overriding recommendations. Each time a doctor deviates from EHR guidelines designed to reflect standards of care, the system’s implicit disagreement with the decision could be used as evidence in a malpractice suit. In other words, a system acquired to reduce medical errors and defend against lawsuits could become an effective witness for the plaintiff. The only way to minimize potential damage from such evidence is to document a full understanding of the system’s reasoning and produce a full explanation for the disagreement—and to do it in real time. A note typed before something goes wrong necessarily demonstrates that a doctor at least made an informed decision. A note typed afterward does not.

Indeed, according to Mangalmurti and others, time plays a greater role in guarding against EHR-related lawsuits than many physicians realize. The detail that such systems provide when users undertake any action can be extraordinarily revealing. They can, of course, show whether a physician truly did read a vital part of the record, check test results, or read an X-ray before deciding on a course of treatment. They can also reveal just how long a doctor spent studying the record and reading the X-ray before making the decision, a feature that leaves doctors open to second guessing.

Practices that wish to minimize the risk of liability related to timing need policies that demand not only that users read records fully and document their own actions thoroughly, but also that they do so within timeframes that courts typically deem reasonable. They also need training that conveys to all users just how much detail EHRs can provide about timing and how bad it looks when they do or say anything that EHR data or metadata can disprove, even if it’s just misremembering how long they spent looking at something.

article warned of these risks, even though it appeared at a time when less than 10% of the nation’s medical practices used anything beyond the most basic EHR systems. It anticipated an even greater risk, however, in periods of transition, when practices are just adopting new systems. Many service providers have since passed through that initial transition, but the dangers remain for the many practices that still use paper records and the many others that will switch to a new EHR.

The Unfamiliar Is a Breeding Ground for Error

“The move from familiar to new systems increases error rates in basically every human endeavor. Unfortunately, case law to date provides basically no recognition of this fact,” Mangalmurti said. “As a result, practices must plan for transitions incredibly carefully. They need systems to ensure that results and orders don’t fall through the cracks, and they absolutely must provide effective training to everyone. System users should be fully comfortable with their new tools before they ever use them with actual patients.”

Research to date on EHR-related liability provides little systematic information about how system records are being used in lawsuits, but the literature indicates that good policy and training has protected healthcare providers against liability related to e-mail and other electronic communication. When medical offices first started to go digital, many predicted that e-mail would lead to a variety of problems that ranged from insecure communications that violated the federal Health Insurance Portability and Accountability Act to questionable diagnoses based on written complaints rather than physical examination. Medical publications echoed with warnings. Practices responded with policies and training.

That said, new communications technologies bring new dangers, and the danger that has begun to worry some attorneys who defend malpractice suits concerns record-sharing among various medical offices. Many independent practices rarely share full patient records, for the simple reason that their software tends to be incompatible, but regulations designed to encourage interoperability may soon make it easy for practices to forward entire records.

Such capacity could provide physicians with more information about their patients, information that could improve the quality of care, but it could also create monumental new obligations.

“The record for a patient with a number of conditions could easily run to hundreds or even thousands of pages. It is clearly unreasonable to expect providers to read that much material on each patient that they see throughout the day. Therefore, providers will need to develop a consistent practice with respect to how they use and maintain both the information and the physical records,” said Bobbie Sprader, JD, a partner at the Ohio-based law firm of Bricker & Eckler who specializes in defending medical negligence suits.

“When it comes to charting in the electronic medical record, I think we are a long way from having identified a best practice. For now, I would advise providers to protect themselves by taking advantage of the ability to enter free text whenever they can. A full 25 pages that do nothing but record drop box selections do not explain the thinking behind a decision as well as a single precisely worded sentence. Ultimately, 1 goal of a medical record is to communicate and the best way for caregivers to communicate quality care through the medical record is to record their findings and thoughts as clearly and effectively as possible,” Sprader said.

It may be too early to say whether EHRs have increased or decreased liability for physicians as a whole, but some say the technology generally reduces total medical errors and has no effect on insurance rates.

Electronic Health Records Can Increase Malpractice Liability

Next-generation sequencing—the rapid analysis of genetic biomarkers that may be triggers for cancer&mdash;is an advance in medicine that has many physicians and researchers excited, but substantial concern remains about the usefulness of the data generated.

A big question mark hovers over the clinical utility of the information that comes back from the testing laboratory, and there is also concern about physicians’ ability to interpret these reports accurately and act appropriately when treating their patients.

Lack of clinical evidence, lack of standards in reporting, lack of physician education, the danger of acting on genetic variants of unknown significance, industry hype, and the variety of the tests on the market were all cited as hurdles by oncologists and others interviewed by 

“There are many concerns, and also great excitement,” says Richard L. Schilsky, MD, chief medical officer of ASCO. “NGS can reveal the entire portrait of a tumor, and in doing so identify treatment options that might not have been immediately obvious from other forms of testing.”

With little standardization and huge volumes of data, the reports that come back from labs are confusing for doctors to understand, Schilsky said. It’s unclear how reliable the information is, and because tumor characteristics can vary inside the same patient, a single biopsy sent to a lab for NGS testing may not yield a true picture of a patient’s disease, he says.

Nevertheless, the US genomics testing market was estimated at $5.9 billion in 2011 by research firm Booz Allen Hamilton, with nearly 2900 different tests available in that year.1 A subsequent study released in June by Grand View Research predicted growth would continue and that the US genomics testing market would measure $27.87 billion by 2022.2

With this scale of growth and marketing in mind, the FDA has been working to develop a set of standards and processes to ensure that the tests are reliable. The agency is also working also to develop clinical databases that will help physicians to make better decisions about what to do based on the information they get from these tests, says Elizabeth Mansfield, PhD, director of personalized medicine for the FDA.

“There are a lot of ways to make errors in sequencing, and our concept is to develop a set of process and material standards that will, we hope, allow us to essentially be confident that a lab that develops a test will do it in a manner that generates a test that is accurate and reliable,” Mansfield told 

She says the FDA aims to publish a report on these activities by the end of the year.

In a public forum held early this year by the FDA to discuss the issues involved in this process, David Litwack of the FDA’s Office of In Vitro Diagnostics and Radiological Health talked about the importance of producing tests that measure what they purport to measure and do it accurately; and further, of the need to ensure that what manufacturers and labs say about their tests is true.3 “We recognize that NGS is incredibly important.…We want to allow it to continue while we still perform our mission of protecting patients, making sure that it is used in a safe and effective way.”

The standards the FDA is developing will help to inform manufacturers and laboratories that the tests they are offering work right and are accurate and reliable, Mansfield says. “We’re not necessarily attempting to standardize the results,” she says.

Mansfield says doctors are very much in the catch-up mode as they try to understand how to use these tests and what to make of the information they produce, adding that “We’re trying to address the interpretation part through the clinical validity database building side of our project that will provide clinical evidence for given variants.”

From that point on, doctors will be on their own, she says. “We can’t tell doctors what to order. That’s their practice of medicine. We hope that people over time will catch up to the technology and understand what they should order.”

What doctors know already is that NGS tests offer far more information than is useful, says Schilsky. “Roughly 40% of the time, NGS tests reveal an abnormality that’s defined as being actionable. That’s a definition in the eye of the beholder—something that the doctor might be able to act on. Only in half of those cases can the doctor get access to therapy that is thought to be beneficial, and in less than half of those cases is there evidence that the patient actually benefits from the treatment, so we’re still at a point where NGS testing is more of a promissory note than it is a highly accurate predictive test,” he says.

“What’s fueling the hope is the remarkable, periodic responder—the patient who has a dramatic improvement after receiving some therapy predicted by the test that wouldn’t have been considered&mdash;but those cases are quite rare.”

Each NGS laboratory appears to have its own language for reporting results, and doctors often have to rely on the quality of the interpretation and recommendations that come back from the laboratory. The degree of clinical evidence that backs up the findings is also important, because it is a measure of how reliable the recommendations are. But there is huge variation.

“It’s a very confusing time right now, largely because of lack of standards and because of lack of transparent information—in terms of how the variants that are detected are associated with different clinical outcomes and different therapies,” says Schilsky.

Two oncologists who role-played point-counterpoint on the subject at the Miami Breast Cancer Conference this year spoke to 

 about the positions they took in the debate and why.

One of those physicians, Pat Whitworth, MD, director of the Nashville Breast Center in Tennessee, says that despite the concerns that many have expressed, germline NGS testing remains extremely valuable and useful, and Whitworth says that there is a need for doctors to learn what they need to know about this technology quickly, especially if they intend to continue practicing in the oncology field for the next 5 to 10 years or longer.

“Originally it was BRCA1 and BRCA2, and now we have a good bit longer list of genes that are more or less penetrant as risk-modifiers for breast cancer. Now we have panel testing, and what I was advocating in that debate and what I am advocating in real life is, if the woman has a family history that suggests she may have a Mendelian pattern, a genetic pattern of cancer in her family, then that family needs to be evaluated.”

Whitworth is a co-founder of Targeted Medical Education, a company that seeks to promote access to and knowledge of advanced medicine among physicians. He expresses confidence in the quality of the genetic tests that are available. He says that for the veteran companies in this space to have survived, their technology has to be reasonably sophisticated and practical. “I have not really run into companies that had a presence over a year or two that were in this space that were doing bad work.”

Physicians are so busy with their general tasks that they have tended to delay learning all that they need to know about genetic testing, Whitworth says. “They are anticipating this a little like they are anticipating ICD-10: they know they are going to need to learn it.”

Even so, Whitworth says doctors are liable to react with appropriate caution and moderation to the information they receive, particularly in cases of genetic variants of unknown significance, which some other physicians worry can tempt doctors and patients to make drastic and unwarranted decisions about treatment.

Whitworth’s opponent in the Miami debate, Mike Dixon, MD, professor of surgery and consultant surgeon at the Edinburgh Breast Unit in the United Kingdom, brought up exactly that point, saying that doctors are under pressure to do something for women, especially when the wait-and-see method can lead to further trouble.

“I think that it’s very difficult for patients to tell them we don’t know what it is and then bring them in 2 years later and say, ‘You know what? We worked out that gene, so that mutation is pathogenic.’ In the interim, if the patient develops breast cancer, they may not be too happy. Given the propensity for people in the United States to plug for bilateral mastectomy, even with small breast cancers, I’m concerned that the hype of testing will result in some women having unnecessary mastectomies. There is certainly evidence of that already within the literature,” Dixon says.

While not necessarily the fault of an inaccurate NGS test, a poor quality biopsy, or an interpretation error, a prophylactic mastectomy that is not necessary can lead to substantial problems for some patients, Dixon says.

“If you look at studies of prophylactic mastectomies, one study showed that 69% of women having a prophylactic mastectomy experienced pain, for 36% the pain affected their sleep, for 22% it had an effect on their daily activities, and 75% reported less enjoyment of sexual activities. These are women undergoing prophylactic mastectomies, so this is not an operation without significant morbidity and therefore we have to be sure that it’s worthwhile.”

Dixon says that there remains a substantial knowledge vacuum in terms of what the mutations identified by panel testing of genes really signify. Until that is cleared up, physicians may be liable to act on insufficient knowledge.

“You need to know in the population what these mutations in different genes mean. You need to know how frequent some of these mutations are, but much more importantly, how frequent they are in patients with breast cancer. That will give us some insight into what these different mutations mean and that will allow us to be in a much better position to inform patients, if they have a mutation, what that means. We’re currently not in that position, so for me the technology is ahead of the knowledge, and we’re doing tests on women and we really don’t know yet how to interpret the results,” Dixon says.

Mansfield says that guidelines for physicians on how they should use NGS test information would be a good idea, but aren’t within the FDA’s scope. “I think a lot of physicians are so incredibly busy that they haven’t really had the time to sit down and study the technology and read all the papers. A set of guidelines could be pretty helpful for them.…When doctors get information from a test, maybe even information they weren’t expecting, we tend to think it should come along with an explanation of what the test provider thinks that result means and how much confidence they have in that interpretation. If it’s something they think might be a pathogenic mutation but they’re not sure, our philosophy is the test provider should be truthful about that.”

Schilsky says that limited panel tests remain the most useful for doctors who have a disease culprit in mind, whereas larger panel tests have the potential to become “fishing expeditions” that yield some comfort in terms of knowledge, but not much more.

“It’s generally the case when you have patients with a far-advanced cancer and no other known treatment options where the NGS sequencing is being done,” Schilsky says. “Generally speaking you don’t have a lot of treatment options to offer the patient anyway. You could pull something out of the air, or you could say, ‘Let’s get this test done,’ and even though the test is not perfect and may be confusing, it may still be informative and better than having no information whatsoever, which is the alternative, and I think many patients would rather have some information that the doctor could potentially act on than have no information at all.”

			Leslie T, Agar D, Fielding S, Miller S. Market trends in genetic services: impacting clinical care through better prediction, detection and care selection. 

. http://www.boozallen.com/media/file/GeneticTesting_VP.pdf. Published 2013. Accessed July 20, 2015.

			Grand View Research. Next generation sequencing market is anticipated to grow to $27.87 billion in 2022. http://globenewswire.com/news-release/2015/06/13/744356/10138308/en/Next-Generation-Sequencing-Market-Is-Anticipated-To-Grow-To-27-87-Billion-In-2022-New-Report-By-Grand-View-Research-Inc.html#sthash.VC45AXAc.dpuf. Published June 13, 2015. July 20, 20156.

			US Department of Health and Human Services, US Food and Drug Administration. Public Workshop - optimizing FDA’s regulatory oversight of next generation sequencing diagnostic tests public workshop, February 20, 2015. http://www.fda.gov/MedicalDevices/NewsEvents/WorkshopsConferences/ucm427296.htm. Accessed July 20, 2015.

Next-generation sequencing is an advance in medicine that has many physicians and researchers excited, but substantial concern remains about the usefulness of the data generated.

Many Concerned About Safety, True Value of Sequencing Tests

Linda Bosserman, MD, went on vacation recently with what she considered to be 50 hours of transcribing and other administrative work related to her oncology practice. She routinely puts in hours of work on documentation each night.

Bosserman thinks that having a medical scribe working alongside her each day, helping with the note-taking and computer entry portions of her job, would be ideal, except for the fact that she doesn’t believe medical scribes have enough training or capability to relieve oncologists of the type of complex documentation tasks they have to do.

Bosserman, a medical oncologist at City of Hope in Rancho Cucamonga in Southern California, believes that she’s not alone in her opinion. Based on her interactions with other doctors, she believes that scribes are rarely if ever used in the oncology profession. “The challenge in oncology is we’re trying to personalize cancer care with multiple cancers, multiple different stages, tumor types, and now this explosion of molecular diagnostics. That’s a huge amount of data you’ve got to pull together for every patient to figure out what the right treatment is and what their side effect management is. It’s hard to train people to know that much,” Bosserman says.

Bosserman, an efficiency expert who has served on numerous medical boards and committees and is a founding member of the Community Oncology Alliance, says scribes are becoming more commonplace in other areas of medicine. Scribes are becoming integral in emergency departments, and primary care doctors are reaping huge efficiency benefits by employing them, she says.

But oncologists can only stand by wistfully as their documentation needs grow and current electronic health record technology remains inadequate to the task of easing the workload, Bosserman says.

This worries her, as it indicates that oncologists have no source of relief, and that the profession is up against a serious problem: workplace overload.

“Burnout is associated with doing nonproductive work, administrative burden, authorizations, pre-authorizations, and notes,” she says. “The challenge in oncology is that you’re one-on-one with very sick patients, making decisions, and then you’ve got to go and capture all of this.”

Michael Murphy, MD, CEO of ScribeAmerica, takes exception to Bosserman’s view that scribes have not penetrated the oncology profession and are not capable of working with the complex data that have to be recorded. Founded in 2004, ScribeAmerica has seen huge organic growth as well as growth through acquisition. The group now employs 7300 scribes across the United States in 950 hospitals and other health centers, according to Murphy. While ScribeAmerica would not indicate how many of those scribes are employed by oncology practices, Murphy contends the use of scribes in oncology has been roughly similar to that in other medical branches.

“I can’t really tell you the ratio of [oncology] growth compared with other specialties,” Murphy says. “All of the specialties seem to be growing pretty dramatically over the last few years, but we’re with some of the largest oncology groups in the country—Texas Oncology, 21st Century Oncology. These are some of the behemoths around the country, and then we’re with a lot of other, small hematology/oncology practices that are private or within big medical groups. So, it’s probably been the same pace as the other specialties of growth,” he says.

The biggest growth in scribe employment has been in the urology, cardiology, and orthopedics lines, Murphy says, while endocrinology has been slow to develop due to the high complexity of the field. “Most of the time their [patient] visits are a half hour or longer, and sometimes they just can’t really see more patients because they’re spending so much time trying to figure out the different pathways.” The same documentation needs that have plagued the oncology profession are contributing to the rising use of scribes across the board, Murphy says, echoing Bosserman’s sense that burnout is one chief reason physicians would turn to scribes if they could. “The physicians, when they come to us, they’ve just about had it and they’re ready to hang it up. They’re frustrated, they’re really just angry and just burned out,” Murphy says.

Murphy estimates that scribes in his employ get about a month’s training before they are considered fully ready for working in a practice. There is some follow-up training included, he says. Speaking in general terms, not specifically about oncology practices, Murphy says that having scribes working one-on-one with them enables physicians to see from 5 to 8 more patients per day, and that physicians can cover the cost of scribes by seeing just 2 extra patients a day.

“A scribe is there to do everything in real time, in parallel, not only the exam, the visit, the documentation, but also help you with the 

 codes, the follow-up care, and the scheduling of appointments. A scribe is a true definition of a lean process. From what we’ve seen, if the physicians have had a productivity loss, we got that back plus an incremental number,” Murphy says.

But a month of training and a bit of follow-up instruction is not nearly enough, says Bosserman. “Sometimes my nurse practitioner and I will go in on a really complicated person together, and she’ll scribe the note while I’m talking to the patient. But that’s not a good use of a nurse practitioner’s time, because they’re highly trained clinicians.”

Bosserman believes the solution to rising administrative workloads is going to have to come from somewhere else. Whoever does solve the problem is likely to capture the best and the brightest among the oncologist population, she says, which makes it an issue of business survival too.

“Whoever develops more supportive electronic medical records and more supportive methodologies will be able to hire the best people,” she says. “That’s what they go to work to do—perform high level analytics, and then assess and educate patients and engage them in the best healthcare for their needs.”

However, Dr. Punit Chadha, medical oncologist and hematologist with Texas Oncology in Austin, Texas, is an example of an oncologist who does use scribes, and he says the payoff has been many hours of saved labor and much more time with patients. He began using scribes 8 months ago and now has several working in his practice.

“Patients are my first priority,” Chadha says. “I started using a scribe so that I could spend more face-to-face time with each patient and not be staring at a computer screen during each visit. The scribe allows for real-time transcription so that the note is in the chart and is sent to the referring physician much sooner than if it had been dictated.”

Chadha also personally checks a lot of their work to make sure it is reliable, he says.

“The scribe works side by side with me to document each patient visit. He or she comes in the exam room with a laptop during each visit. I introduce the patient and the scribe to each other and confirm that the patient is OK with having the scribe in the exam room, and then we carry on with the visit. The end result is that a progress note is completed in real time and ready for me to review immediately after each visit.”

Chadha says that he supplements the training scribes receive prior to joining his practice by having them work closely with the physicians on-site.

“Each scribe has training in clinic flow, medical terminology specific to hematology and oncology, physical exam findings, documentation, billing, meaningful use, and pathophysiology related to oncology prior to coming on-site,” Chadha says. “Once onsite, it takes 1 to 2 months for the scribe to learn the physician’s style. Depending on the background of the scribe, it also takes several months to gain a solid understanding of the hematology/oncology world from a scribe’s perspective. There are limitations to what a scribe can do. They are not allowed to take or enter medical orders in our electronic medical record, touch patients, etc. All scribe tasks are done at the direction of the physician. Their primary role is to work side by side with the physician to record each patient visit.”

Aside from the debate over the effectiveness of scribes in the oncology profession, a report in JAMA earlier this year raised the issue of the general capability of scribes, along with serious concerns about whether they would be susceptible to manipulation by physicians who asked them to do order entry.

“Another risk is unintentional or intentional functional creep in how medical scribes are used,” the report stated. “Although the Joint Commission prohibition on use of scribes for order entry is unequivocal, some physicians still advocate use of medical scribes for computerized physician order entry. The Joint Commission cannot monitor whether medical scribes are used for order entry by US physicians. Patients rely on physicians to understand what constitutes unsafe use of technology in delivering healthcare, including clinical information technology.”

Chadha says scribes in his practice do not assume tasks above their station. He describes them as “incredibly valuable.” “Although some might say that using a scribe provides a mechanism for physicians to become more disconnected from the medical record, having a scribe actually gives me more time to review notes and patient records. I review each patient note prior to it becoming a part of the chart as I’ve always done,” he says.

	1. Gellert G, Ramirez R, Webster SL. The rise of the medical scribe industry: implications for the advancement of electronic health records. 

. 2015;313(13):1315-1316. http://jama.jamanetwork.com/article.aspx?articleid=2084910. Accessed July 17, 2015.

Oncologists can only stand by wistfully as their documentation needs grow and current electronic health record technology remains inadequate to the task of easing the workload.

Scribe Value in Easing Burnout Is an Ongoing Debate

As medical director of radiation oncology at Lowell General Hospital in Massachusetts, Matthew Katz, MD, is well attuned to trends in breast cancer treatment.

He and his colleagues have adopted the practice of using shorter radiation courses—for example, treating lumpectomy patients when appropriate with a slightly higher dose for 3 to 4 weeks rather than a standard dose for 5 to 6 weeks. They have patients with left-sided breast cancers use deep inspiration breath hold to inflate the lungs, moving the heart momentarily to reduce its radiation exposure. And they’re interested in identifying older women who can avoid post surgical radiation that is unlikely to lengthen their lives.

But the area that most distinguishes Katz may be his interest in understanding the subtle nuances of doctor-patient communication that contribute to patients’ decision making and their experiences of treatment. That has led him to focus on supportive conversations in his practice and to venture into the wilderness of online social media to learn more about how patients view their treatment.

Katz said he’s tried to apply what he has learned to moments that are particularly stressful, such as routine scans after treatment has ended that can produce “scanxiety” about recurrence.

“It's just trying to be better at listening and reinforcing women's feelings, and trying to elicit them when they're discussing some of the stresses,” he said. “People need us to be there not just to fix things, but to be there for support. ‘Doctor' means teacher in Latin. So if we're not able to listen and interact well and educate our patients, I don't think we're doing our job.”

Katz said the opportunity to have more direct patient contact contributed to his decision to go into community practice in 2004. After his training he worked at Massachusetts General Hospital in Boston for a year and then joined Radiation Oncology Associates, a 17-doctor practice that provides services at Lowell General and other hospitals in New Hampshire and Massachusetts. He has also taught at Harvard and University of Massachusetts medical schools.

At Lowell General, Katz treats the gamut of cancers and works with multidisciplinary teams focusing on breast, genitourinary, and head and neck cancers. Massachusetts has a relatively large elderly population and its cancer rates are significantly higher than the national figures, though overall mortality is lower.

Breast cancer rates are particularly high in New England. Connecticut has 137 cases a year per 100,000 women, with Massachusetts at 136, New Hampshire 134, Rhode Island 130, and Vermont 129.

Considering the range of treatment options available to cancer patients and the crucial role they themselves play in deciding which course to follow, Katz has long been interested in understanding how patients understand their disease and treatment, and in helping educate them so they can make informed choices. As part of that effort he created and posted online a detailed 83-slide guide to breast cancer and radiation therapy to help patients make decisions.

At the same time, he noted that providing clear information does not always result in a patient going with what a doctor considers the medically advisable choice. For example, many older women choose to undergo radiation after a lumpectomy in order to prevent recurrence of their cancer, even though studies show it will provide little survival benefit. Katz compared that choice with the decision to have a prophylactic mastectomy.

“It may not improve their physical health, but their mental health may improve,” he said. “It's a controversial area, but you always have to look at whether patients are making health decisions with the necessary evidence in front of them to make that choice.”

To get a better sense of how non-experts talk about cancer, Katz started communicating with the general public about the disease. In 2006 he began answering questions about oncology on Yahoo! Answers, a site that allows anyone to ask about anything, and anyone to answer.

“I was able to get a better idea of how people speak in plain language, and get a sense for the way I would say things that are medically important without it going over people's heads,” Katz said.

He moved for a time to Digg, a news-sharing site, but since 2010 has been active on Twitter, where he uses the nickname @subatomicdoc and posts a steady stream of article links and comments related to oncology, medicine in general, and other topics that pique his interest.

Twitter is a largely unstructured site where useful information can be difficult to find, especially for new users. About 3 years ago cancer survivors and advocates began organizing their discussions using hashtags like #BCSM, for breast cancer social media, and Katz joined in, providing information and answering questions.

“I found it extremely valuable to me because I could learn from other people something that I could expect my patients were also feeling, but might not share with me,” Katz said. “Because of some of the limitations of time that I have with each patient as I see them, I felt I could learn how to be better at asking certain questions at the right time.”

Katz is careful to note that doctors may not discuss patients’ confidential health information in open online chats. But from the various Twitter users who participated, he got pointers about what to ask and what to listen for, showing that “If I picked up on it and listened well enough in the exam room, I might be able to ask the right question to help one of my patients, having learned from someone else who was willing to share his or her experience,” he said.

BCSM soon swelled into something like a social movement, with weekly chats, national press coverage, and a nonprofit that provides evidence-based information to people affected by breast cancer. 

Katz said he has participated in similar discussions using hashtags such as LCSM, for lung cancer, and GYNCSM, for gynecological cancers, and he has proposed what he calls a “folksonomy” of more than 60 hashtags for different cancer sites. He is the lead author of a paper on disease-specific hashtags, and created a poster on the topic that he put online and displayed at this year’s ASCO annual meeting.

To encourage other radiation oncologists to connect with one another and discuss ways to improve cancer care, he also started a website called Radiation Nation that features short articles on anti-cancer therapies, patient education, survivorship, physician collaboration, and other topics. A recent piece he wrote asks, “Is there life after cancer?” and discusses the evolving definition of being a survivor.

Katz said he would like to see more doctors engaging in social media.

“It's a communication and education tool, and it's a powerful one, so we need to learn how to use it well,” he said. “There's what we can do in clinic, that is a private matter that we're used to dealing with, but then there's also public conversation. If doctors are not involved in public conversations about health, where patients are learning about it, then that may be something that we need to be doing more of in the future.”

Katz’s educational and outreach work extends beyond Twitter and Radiation Nation. He previously served as chair of communications for the American Society for Radiation Oncology and as an external advisor for the Mayo Clinic Center for Social Media.

He’s also contributed to published studies; created a personal website, Subatomicdoc.com, that explains his personal philosophy and offers manifestos on digital rights and citizenship; and written dozens of online articles for various sites about social media, the experience of practicing medicine, and related topics. In a 2012 piece he pushed back against the popular metaphor of cancer as the body being at war with itself.

“The war metaphor is a bad one,” Katz said. “In the setting of cancer, people usually use the war metaphor when in fact it's still part of our body.”

To show a different way of thinking about cancer, he inserted medical terminology into a meditation by 17th-century metaphysical poet John Donne about death and the church.

“There are a lot of very powerful kinds of writings people really respond well to. [The Donne piece] was trying to find a way to tinker with something and tap into it, in essence by doing what you would call a mashup,” he said.

“You don't need to completely reinvent the wheel. You can use something that's been very successful at getting through to people, and make it accessible in a way that could be useful,” he said. “It's just experimenting and tinkering around.”

			American Cancer Society. Cancer facts and figures 2015. http://www.cancer.org/acs/groups/content/@editorial/documents/document/acspc-044552.pdf. Accessed July 13, 2015.

			Katz M. Early stage breast cancer. http://www.slideshare.net/subatomicdoc/early-stage-breast-cancer. Published October 2011. Accessed July 13, 2015.

			Szabo L. Breast cancer survivor group is a social movement. USA Today. http://www.usatoday.com/story/news/nation/2012/10/23/breast-cancer-group-support/1637633/. Published October 23, 2012. Accessed July 13, 2015.

			Katz M, Utengen A, Anderson PF, et al. Disease-specific hashtags for online communication about cancer care.. 

			Katz M. Through the lens of molecular medicine: John Donne, illness, and cancer. Oncology Times. http://journals.lww.com/oncology-times/blog/voices/pages/post.aspx?PostID=37. Published January 24, 2012. Accessed July 13, 2015.

As medical director of radiation oncology at Lowell General Hospital in Massachusetts, Matthew Katz, MD, is well attuned to trends in breast cancer treatment. 

Patient Support Not Just a Buzzword for New England Doc

The rise of electronic medical reporting and value-based standards and measures for improved medical care is supported by the best of intentions, but the implication is that physicians now spend more time behind the computer terminal and less time with patients. They may have less time for each patient and they may be seeing far fewer patients each day.

If this represented a mere revenue loss, physicians might not be so unhappy about it. But the fact is that physicians report spending more and more time in the office each day. Some people, therefore, are not terribly surprised that so many smaller, less well funded practices are closing their doors or merging with larger institutions, or that it has become difficult to attract new physicians to the field of oncology.

, we investigated the possibility of medical scribes being one leg of a solution to this problem. We spoke with Linda Bosserman, MD, a medical oncologist at City of Hope in Rancho Cucamonga in Southern California, who prides herself on being an efficiency expert. Even for her, though, there is no way around the administrative chores that all oncologists face. When she packed up her bags recently for a one-week vacation, next to the toothbrush and the shampoo in her luggage she put what she estimated to be 50 hours of dictation work.

She would love to be able to use medical scribes in her practice to take over some of the mundane chores, but she doesn’t see how that’s possible given the degree of complexity of her work, which has been made more difficult by electronic reporting standards.

“The efficiencies are just becoming a major burden to the oncologist,” she says. “The burnout rate is skyrocketing and people are retiring early. They just don’t want to spend time in meaningless work.”

 makes clear, the jury is still out on whether these helpers have a significant role to play in helping oncologists and hematologists get more done and derive more enjoyment from the profession. Michael Murphy, MD, CEO of ScribeAmerica, contends that scribe use is dramatically rising across most medical sectors, including oncology, though he would not provide numbers to support that assertion. He says scribes save time and money, enabling physicians to see more patients. Murphy’s organization employs roughly 7300 scribes, each of whom receives a month’s worth of training before starting regular employment. They receive periodic training updates after that, Murphy says.

Is that enough for an oncology practice? Bosserman says no, and contends that she’s not shooting from the hip. She’s given the matter thorough consideration, because she, like other physicians, needs a solution to the problem of increasing workload and tighter budgets. However, one physician who says he has made scribes work for him is Punit Chadha, MD, a medical oncologist and hematologist with Texas Oncology in Austin. Chadha began using them in his office 8 months ago and hasn’t looked back. The training doesn’t stop once they are dispatched from ScribeAmerica, he says. They work side-by-side with physicians in his office to learn the ropes, and their work is closely reviewed for accuracy. “Many of the scribes are also premed students, or have a strong science background,” Chadha told 

The rise of electronic medical reporting and value-based standards and measures for improved medical care is supported by the best of intentions, but the implication is that physicians now spend more time behind the computer terminal and less time with patients.

August 2015 | Oncology Business News®