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Radiation Oncology Whiteboard Data and Workflow manager for enhanced communication and task management John Wolfgang PhD Massachusetts General Hospital.

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Presentation on theme: "Radiation Oncology Whiteboard Data and Workflow manager for enhanced communication and task management John Wolfgang PhD Massachusetts General Hospital."— Presentation transcript:

1 Radiation Oncology Whiteboard Data and Workflow manager for enhanced communication and task management John Wolfgang PhD Massachusetts General Hospital Department of Radiation Oncology NEAAPM Winter Meeting John Wolfgang February 1, 2013

2 Outline Historical context General philosophy Technical Implementation
Operation/Features

3 My Biggest Problem in 2006 Was Not Caffeine
The Conversation ME: “The patient is scheduled to start the day after tomorrow, but I am still waiting on contours.” THEM: “Right. There was [insert vague excuse here] that prevented them from getting done. I will get them to you tonight – the patient really needs to start on time, can you do the plan for me?” THEM: “I’ll buy you coffee…” ME: “Sure…”

4 It was Communication Patient Care historically involves many peer-to- peer exchanges of information Many points of exchange are often “multi-cast” where information must be passed to multiple care givers simultaneously Medium for information exchange involved hallways, elevators, vaults, cryptic excel spreadsheets, dark rooms full of CT Workstations – worse yet, …. Communication such as this not conducive to best patient care

5 How to improve… We had more than a few meetings about these issues – some even have clever b-school names like “LEAN” Usually, the meetings went nowhere

6 There Must Be An App For That
Topology of MGH Radiation Oncology Department Distributed department MGH Main Campus (Cox, Yawkey, Lunder, FBPTC) Emerson Newton-Wellesley Multi-vendor environment Many isolated data locations Increasing number of data sources Small departments utilize a simple whiteboard to track patient status Not just impractical in our setting, but limiting

7 Common Point of Access to Information
Radiation Oncology Whiteboard (2007) Web-enabled portal for access to patient workflow data Complimentary to MOSAIQ Collection of data outside the scope provided by MOSAIQ Combine, sort and display data in new, useful ways Integrate existing and new applications Reduce number of “hidden” spreadsheets/applications Share data between “islands” and MOSAIQ

8 Pre-Whiteboard Operational View
CBCT Data Billing Linac/ Cyclotron Data Billing PET/CT Fusion Data Billing Adaptive Planning CT/ Simulator Data Billing IMRT QA Data Billing Rescan Data Billing Deform CT Data Billing 4DCT Resort/Review Data Billing R & V Data Billing Treatment Planning Data Billing

9 Checklists The Checklist Manifesto: How to Get Things Right, Atul Gawande “The biggest clinical invention in thirty years” (The Independent) The awful truth about (me and) checklists - Stuff I am supposed to do in the morning Shower Eat Feed dog Walk kid Go to work Fill out checklist

10 Workflow (I am a checklist hypocrite)
List of activities to be executed during patient treatment course Workflow templates defined by treatment “modality” – IMRT, 3D, Protons, etc Individual patient workflows are customizable Workflow items have due dates based on patient schedule (start date, sim date) Completion of workflow activities can trigger other processes (internal or external) Not just a passive list of events

11 Communication becomes asynchronous, not serial (peer-to-peer)
Workflow Based View Physicist Physician Workflow Patient Intake CT Scan Contours Prescription Treatment Plan Plan Approval Plan Check Chart Rounds Insurance Approval Admin Therapist Nurse Dosimetrist Task delegation, patient status and current activity are transparent to all Communication becomes asynchronous, not serial (peer-to-peer)

12 Clinical Objects Manage Staff Resources directed towards patient care
(There’s a good bit to keep track of) Patient Workflow Planning Guidelines Plan Review Staff Responsibility Schedule (CT,VSIM,START) Deadlines Patient specific document management QA Patient specific Physical Measurements (e.g. IMRT QA) Morning constancy check (linac, simulator, others pending) Monthly constancy check (linac) Machine specific document management Personnel Assignments (patient) Workflow reminder (by schedule) Event Alert (by workflow completion) Availability (departmental responsibility chart) Coverage (staff away)

13 Operation Patient added to whiteboard at intake or after (all patients entered by time of CT) Add R&V Intake Add WB

14 Proton Intake Form Stored in Whiteboard
Form for Pre-tx Proton Rounds Completed by physician for later peer review Whiteboard entry can be prior to R&V system

15 Operation Once added, patient entry sits in Triage Manager – awaiting delegation and completion of necessary data Add R&V Intake Add WB Pre Tx Review (p+ only) Triage Manager

16 Triage Manager Track patients that have not been assigned a start date, physicist or physician

17 Operation Completion of schedule information promotes patient to user worklists (actually there once physician or physicists is defined) Add R&V Intake Add WB Pre Tx Review (p+ only) Triage Manager Workflow Manager

18 Workflow Manager Ordered list of patients for which selection criteria (current user) has been delegated responsibility View presents workflow state, special alerts, available documents

19 Patient Calendar Color by: Event Type CT,VSIM,START,BOOST
Workflow State Workflow Deadline Due >24 hrs Due < 24 hrs Overdue Can overlay staff availability over calendar

20 Workflow User “clicks-off” completed tasks to which they have been assigned

21 Patient Detail

22 Reminders A “Reminder” is a notice (page/ ) distributed by whiteboard alerting user regarding a pending deadline regarding a workflow item User customizable Deadline relative to schedule event (start, sim) Overdue notice sent when task deadline expires MGH Implementation “Contours & Prescription” task Failure to complete results in MD financial penalty Patient appts cancelled, physician required to reschedule

23 Alerts/Actions An “alert” is a notice ( /page) regarding a change of workflow state for a given patient User customizable based on combination of modality, user, workflow item, location MGH Implementation example Proton physicist of the day receives page when a proton plan becomes available for a physics check Action does not necessarily need to be a /page message

24 Role Specific Views Not all members of department require direct association with patient workflow Need view reflecting a specific workflow event for a subpopulation of patients Some members of department are focused on workflow event, location or modality rather than specific patients

25 Insurance Authorization for IMRT & SBRT
List generated from SBRT and IMRT patients only

26 Data Analysis Review workflow timing data, population data to help identify and solve workflow issues

27 Embedded Applications
4DCT Resorting Remote Plan Review IMRT/SBRT QA reporting Morning QA Digital Signage for Patient Waiting Areas Linac Monthly Output QA Staff Responsibility and Availability chart

28 4DCT Resorting Allows for visual editing of resorted 4DCT
Can select phase, amplitude or phase directed amplitude resorting Monte Carlo based optimization algorithm

29 Flash Plan Review Polk, James ( )

30 Staff Availability

31 Machine Data (PDF)

32 Planning Guidelines Patient/Service specific templates for common planning instructions Linked to TPS, import DVH a nd compares to planning goals GUIDLINE CONSTRAINTS LINKED REPRESENTED ON DVH PLOT

33 Morning QA

34 Linac Output Constancy
View Morning QA, Problem Reporting Log and Constancy data simultaneously

35 Therapist Page Physician Status Check Schedule, Accelerator “on-time” status

36 Linac (Elekta) QA

37 Measurement Equipment

38 Technical Implementation
Current DB size (in memory) is ~100 MB 26000 patient plan entries (initial + boost) 16000 patients workflow steps Small efficient database = fast response

39 Simplified Schema Plan (Course) Plan Index Service Site Description
Instructions Modality Attending MD Treatment Planner Schedule (CT,VSIM,START) Boost(y/n) Workflow Plan Index Name Rank Bitmask id Completed userid Completed when QA Plan Index Measurement Date TPS ID Planning System Result Locations Location ID Name Site (MGH, NWH, EH) Imaging Treatment Workflow Template Modality ID Name Rank Bitmask id Expiration Reference Date Patient Documents Plan Index Description Saved Location Icon Tx Modes Modality ID Name Site

40 Hardware/Software Topology
Single Server (Blade) Dual Quad Core – 32 GB Ram SAN Storage Remote Datacenter Inside Partners Firewall Generation 1 Virtual Fedora Core 5 MySQL, PHP, perl, java Generation 2 Windows Server 2008 R2 SQL Server 2008 PHP, Active state perl, java

41 External Application Interfaces
Record &Verify ODBC Treatment Planning Systems – CMS Xio, Raystation SSH, SCP (file synchronization) DICOM (Images)

42 Next to Last Slide Centralized point of communication presents many opportunities for clinical improvement Transparency of information (esp, patient workflow) Leveraging of information from different data sources (linac output, engineering log, therapist log, morning qa) Communication not only with staff, but with patients as well Communication and complete transparency of information, in my opinion, is the best and easiest path to a safer clinic

43 Contributors Developers Consultants/Advocates Franklin Lonberg, PhD
Ryan Connolly, RT(T) Anne McKay Daniel Griffin Christoph Speier Scott Mauceri Consultants/Advocates Maida Williams Broudo Lois Greer Christine Michelini Ted Hong Philip Graceffa


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