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Twenty-five years ago, my daughter was applying for admission to various colleges and universities.  One that she was accepted to was The University of Redlands.  Prior to starting her freshman year, students and their parents were invited to participate in a discussion of a book with faculty members.  The book was Robert M. Pirsig’s Zen and The Art of Motorcycle Maintenance.  Even though she ultimately didn’t attend Redlands, I read the book anyway and found it very thought provoking and inspirational.

One of the central themes is the author’s struggle with the concept of Quality.  In this process he resurrects the word “gumption”, an old Scottish word which he likes “because it describes exactly what happens to someone who connects with Quality.  He gets filled with gumption.”  The word implies what the Greeks called enthousiasmos, our “enthusiasm,” meaning “filled with theos,” or God, or Quality.  “If you’re going to repair a motorcycle, an adequate supply of gumption is the first and most important tool.”

Seems to me the word Quality is used so routinely in Healthcare that it has become part of the wallpaper.  Everyone is providing Quality care.  I saw a notice recently that an insurance company had purchased a large medical group for the purpose of providing (you guessed it) Quality care.  So how do we identify quality?  The old response was:  “I know it when I see it.”  Obviously too subjective.  The most reasonable definition I saw in Merriam-Webster online was “grade” or “degree of excellence.”  Better, but still subjective.  When I poll my partners, the usual response is that by practicing Evidence-Based Oncology, usually defined by NCCN Guidelines, we are, therefore, a quality group.  Also, payors base authorization and reimbursement decisions on adherence to these guidelines.  Since recommendations are ranked by level of evidence cited in literature reviews, quantitative data is provided.

Now that we have a working definition of Quality Cancer Care, how to demonstrate that, in fact, we are providing such care is the next challenge.  I think all agree we can’t provide supportive data without an EHR.  It would be very difficult to collect all necessary information and abstract appropriate data points from paper charts.  Not impossible, but tedious and error-prone.  Recognizing that this is a necessity, the number of oncology practices that are computerized, even including those who are actively considering it, is still pretty low.  According to a recent article entitled “Impact of EHR’s on Oncology Practice:  Enhancing the Value of Cancer Care” (Value-Based Cancer Care, vol 21 no 5, August, 2011, pp 32-33), that number is 25% of 12,000 US oncologists.  So why, with all the advantages mentioned in this article, haven’t more oncologists signed up?  In my experience the answer is the systems require a lot of work, they are not intuitive, and cost is prohibitive.  Focusing in on one obstacle, “the leading oncology-specific EHR’s implemented in the marketplace today” are client-server applications.  Responsibility  for upgrades and maintenance fall to the practice.  “But only the oncologists who are on a web-based platform are on a HITECH-certified version today” and thus eligible for incentives to digitize. These systems have to be upgraded at more cost.  Catch-22.

In conclusion, “Oncology practices need to continue on this path, sharing best practices with each other, and steadily improve leveraging information systems whenever possible to provide the highest-quality cancer care for their patients.”  There’s that word again.  Pirsig uses the motorcycle as an example of technology.  When fixing machines, things always come up that “drain off gumption, destroy enthusiasm and leave you so discouraged you want to forget the whole business.”  The trick is to avoid these “gumption traps.”

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