Radiation Oncology Whiteboard

Data and Workflow manager for enhanced communication and task management

John Wolfgang PhDMassachusetts General Hospital

Department of Radiation OncologyNEAAPM Winter Meeting

John WolfgangFebruary 1, 2013

Outline Historical context General philosophy Technical Implementation Operation/Features

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…”

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, email….

Communication such as this not conducive to best patient care

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

There Must Be An App For That

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

Topology of MGH Radiation Oncology Department

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

Pre-Whiteboard Operational View

Adaptive Planning

Rescan

Data

Billing

CT/ SimulatorData

Billing

R & V

DataBilling

4DCT Resort/Review

Data Billing

Treatment

Planning

Data

Billing

Deform CT

Data

Billing

IMRT QA

Data

Billing

PET/CT Fusion

Data

Billing

CBCT

DataBilling

Linac/ Cyclotron

DataBilling

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

ShowerEatFeed dogWalk kidGo to workFill out checklist

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

Workflow Based View

Workflow•Patient Intake•CT Scan•Contours•Prescription•Treatment Plan•Plan Approval•Plan Check•Chart Rounds• Insurance Approval•…

Physician

Therapist

DosimetristNurse

Admin

Physicist

Task delegation, patient status and current activity are transparent to allCommunication becomes asynchronous, not serial (peer-to-peer)

Clinical Objects

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)

Manage Staff Resources directed towards patient care

(There’s a good bit to keep track of)

Operation Patient added to whiteboard at intake or

after (all patients entered by time of CT)

Intake

Add R&V

Add WB

Proton Intake FormStored in Whiteboard

Form for Pre-tx Proton Rounds

Completed by physician for later peer review

Whiteboard entry can be prior to R&V system

Operation Once added, patient entry sits in Triage

Manager – awaiting delegation and completion of necessary data

Intake

Add R&V

Add WB

Pre Tx Review

(p+ only)Triage

Manager

Triage Manager

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

Operation Completion of schedule information

promotes patient to user worklists (actually there once physician or physicists is defined)

Intake

Add R&V

Add WB

Pre Tx Review

(p+ only)Triage

ManagerWorkflow Manager

Workflow Manager

Ordered list of patients for which selection criteria (current user) has been delegated responsibility

View presents workflow state, special alerts, available documents

Patient Calendar

Color by:Event Type

CT,VSIM,START,BOOST

Workflow StateWorkflow Deadline

Due >24 hrsDue < 24 hrsOverdue

Can overlay staff availability over calendar

Workflow

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

Patient Detail

Reminders A “Reminder” is a notice (page/email)

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

Alerts/Actions An “alert” is a notice (email/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 email/page message

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

Insurance Authorization for

IMRT & SBRT

List generated from SBRT and IMRT patients only

Data Analysis Review workflow

timing data, population data to help identify and solve workflow issues

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

4DCT Resorting

Allows for visual editing of resorted 4DCTCan select phase, amplitude or phase directed amplitude resortingMonte Carlo based optimization algorithm

Flash Plan Review Polk, James (0000011)

Staff Availability

Machine Data (PDF)

Planning GuidelinesPatient/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

Morning QA

Linac Output Constancy

View Morning QA, Problem Reporting Log and Constancy data simultaneously

Therapist Page

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

Linac (Elekta) QA

Measurement Equipment

Technical Implementation

Current DB size (in memory) is ~100 MB 26000 patient plan entries (initial + boost) 16000 patients 220000 workflow steps

Small efficient database = fast response

Simplified SchemaPlan (Course)

Plan IndexServiceSite DescriptionInstructionsModalityAttending MDTreatment PlannerSchedule (CT,VSIM,START)Boost(y/n)

WorkflowPlan IndexNameRankBitmask idCompleted useridCompleted when

QAPlan IndexMeasurement DateTPS IDPlanning SystemResult

Patient DocumentsPlan IndexDescriptionSaved LocationIcon

Workflow TemplateModality IDNameRankBitmask idExpirationReference Date

Tx ModesModality IDNameSite

LocationsLocation IDNameSite (MGH, NWH, EH)ImagingTreatment

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

External Application Interfaces

Record &Verify ODBC Treatment Planning Systems – CMS Xio,

Raystation SSH, SCP (file synchronization)

DICOM (Images)

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

Contributors Developers

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