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Varian Informatics Tools: Radiation Oncology Clinical Productivity Analysis with an Integrated Planning, Record and Veri

HOLT: 12/03. VARIAN ANNUAL CSS MEETING. 2. ?Ideal" System for Outcomes Management and Review As proposed by Kerry Rowe, PhD . Integrated Information System, Treatment Preparation and Treatment Delivery System Collects data in a central database, collates analysis effortPromotes on-going outcome

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Varian Informatics Tools: Radiation Oncology Clinical Productivity Analysis with an Integrated Planning, Record and Veri

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    1. Varian Informatics Tools: Radiation Oncology Clinical Productivity Analysis with an Integrated Planning, Record and Verify and Treatment System   Randy Holt, Ph.D., DABR North Valley Radiation Oncology Enloe Medical Center, Chico, CA

    2. HOLT: 12/03 VARIAN ANNUAL CSS MEETING 2 “Ideal” System for Outcomes Management and Review As proposed by Kerry Rowe, PhD Integrated Information System, Treatment Preparation and Treatment Delivery System Collects data in a central database, collates analysis effort Promotes on-going outcome monitoring and review Provides single glance historical and current patterns. Would allow comparison of outcomes between facilities/clinicians in relation to the existing standard of care or established benchmarks Would allow corrective adjustments for patient factors Would lead to standardized clinical practice and decreased treatment variations

    3. HOLT: 12/03 VARIAN ANNUAL CSS MEETING 3 Varian Varis/Vision 6.5/7.0 Two major items for discussion Direct impact of Integrated Systems on productivity: Improved software leads to reduced costs, improved QA, and improved treatment. Mining and utilizing the exponentially increasing flood of information to improve productivity.

    4. HOLT: 12/03 VARIAN ANNUAL CSS MEETING 4 Single Vendor Model Enloe Medical Center 600C with EPID, EDW 21EX with EPID, EDW, MLC Satellite 2100C with EDW Brachytherapy, LDR, HDR CT sim, 2 Eclipse, 2 BV

    5. HOLT: 12/03 VARIAN ANNUAL CSS MEETING 5 6.5 upgrade Went live with Clinical Evaluation (Beta) 4/1/03 – release version 10/6/03. Upgraded from Varis 6.5 to Varis 7.0 in January. Full overhaul of all systems All staff affected - Dosimetry, Front Office, MDs, RTTS, Physics

    6. HOLT: 12/03 VARIAN ANNUAL CSS MEETING 6 Front Office Productivity

    7. HOLT: 12/03 VARIAN ANNUAL CSS MEETING 7 Tx Planning Productivity

    8. HOLT: 12/03 VARIAN ANNUAL CSS MEETING 8 RTChart – MD Intent/Rx

    9. HOLT: 12/03 VARIAN ANNUAL CSS MEETING 9 More Dosimetry Efficiency

    10. HOLT: 12/03 VARIAN ANNUAL CSS MEETING 10 Common User Interfaces On the Macintosh, when you want to move a window, you can grab any edge with the mouse and move it. On Windows, you must grab the title bar. If you try to grab an edge, the window will be reshaped. Try to widen a window by dragging the right edge. Frustratingly, the whole window moves, rather than resizing as expected. On Windows, when a message box pops up, you can hit enter or the space bar to dismiss the message box.  On the Mac, space doesn't work. You usually need to click with the mouse. On the Macintosh, when you want to move a window, you can grab any edge with the mouse and move it. On Windows, you must grab the title bar. If you try to grab an edge, the window will be reshaped. Try to widen a window by dragging the right edge. Frustratingly, the whole window moves, rather than resizing as expected. On Windows, when a message box pops up, you can hit enter or the space bar to dismiss the message box.  On the Mac, space doesn't work. You usually need to click with the mouse.

    11. HOLT: 12/03 VARIAN ANNUAL CSS MEETING 11 What are a few wasted minutes worth? 30 minutes per staff member in an average sized department (20). 2500 hours per year

    12. HOLT: 12/03 VARIAN ANNUAL CSS MEETING 12 Treatment History Review

    13. HOLT: 12/03 VARIAN ANNUAL CSS MEETING 13 Previous (1.4, 6.1, 6.2) Current Physics Review Steps

    14. HOLT: 12/03 VARIAN ANNUAL CSS MEETING 14 Physics Review

    15. HOLT: 12/03 VARIAN ANNUAL CSS MEETING 15 “Integrated” Treat

    16. HOLT: 12/03 VARIAN ANNUAL CSS MEETING 16 “Integrated” Treat

    17. HOLT: 12/03 VARIAN ANNUAL CSS MEETING 17 “Integrated” Treat

    18. HOLT: 12/03 VARIAN ANNUAL CSS MEETING 18 EPI Review – MD tasks Filters : All, New, Approved, etc Navigation buttons for quick sequential review

    19. HOLT: 12/03 VARIAN ANNUAL CSS MEETING 19 ASTRO Estimate of Staff Shortages Avg Rad Onc Dept is 13.8 FTE persons Including RTT, CMD, RN, MS, PhD, MD Avg Openings is 2.6 FTE persons National Staff Shortage of 18.9% 2002 Radiation Oncology Workforce Study: American Society for Therapeutic Radiology and Oncology. Int J Radiat Oncol Biol Phys. 2003 Jun 1;56(2):309-18.

    20. HOLT: 12/03 VARIAN ANNUAL CSS MEETING 20 Enloe ROC Productivity

    21. HOLT: 12/03 VARIAN ANNUAL CSS MEETING 21 Enloe Productivity 7/02 – 10/03

    22. HOLT: 12/03 VARIAN ANNUAL CSS MEETING 22 Clinical Interlude: Characterizing and Reducing the Daily Setup Error for IMRT Daily Verification – EPID orthogonal pairs

    23. HOLT: 12/03 VARIAN ANNUAL CSS MEETING 23 Ant Prostate Seeds - Match

    24. HOLT: 12/03 VARIAN ANNUAL CSS MEETING 24 Lat IMRT Prostate Seed Match

    25. HOLT: 12/03 VARIAN ANNUAL CSS MEETING 25 Match Results - Interpretation Required Shifts presented as Couch Movements In-room Monitor for Couch Position used e.g. original LAT = 100.0, then desired LAT = 99.7 original LNG = 100.0, then desired LNG = 100.5 Independent of Patient Position (Supine, Prone, etc) Beams not aligned with couch accounted for producing three axis couch moves (tangents, RAO, etc)

    26. HOLT: 12/03 VARIAN ANNUAL CSS MEETING 26 Total Magnitude of Daily Setup Shifts Following Orthogonal EPI Matching - 5 patients for 15 days

    27. HOLT: 12/03 VARIAN ANNUAL CSS MEETING 27 So, what’s a couple of mm between glands?

    28. HOLT: 12/03 VARIAN ANNUAL CSS MEETING 28 Indicated Shifts - Prostate Seed Patient #1

    29. HOLT: 12/03 VARIAN ANNUAL CSS MEETING 29 Daily Match Error - H&N Patient

    30. HOLT: 12/03 VARIAN ANNUAL CSS MEETING 30 Examples of Mining Varis for Improved Productivity Applications to Radiation Oncology. A) Retakes in CT-Sim B) Optimal planning for time-slot over-runs Per diem, floating staff levels of 7-10% of total full time staff are critical to cost management. Pre-scheduled open time blocks are critical to cost containment of over-long delay periods. Dexter, F Anesthesiol Clin North America. 2003 Jun;21(2):387-402.

    31. HOLT: 12/03 VARIAN ANNUAL CSS MEETING 31 Optimal Scheduling and Staffing To use the Dexter staffing model – we need to know Average time slot Actual average duration Standard deviation of under-usage/over-usage Cost (per hour) of after-hours staffing Introduce a delay time, run 2-variable scenarios: Time of day, and Duration of delay period

    32. HOLT: 12/03 VARIAN ANNUAL CSS MEETING 32 Breakfast is the most important meal… Within 95% confidence limits, can show that most efficient delay time period is a) exactly centered in the workday and b) of a duration of 3.5 to 4*STDev of time-slot overrun Result: New Departmental Scheduling Scenario Nominally, eliminate all (routine or emergency) scheduling from 1200 –1220 Time period and duration changes depending on planned hours of operation.

    33. HOLT: 12/03 VARIAN ANNUAL CSS MEETING 33 Applications of Informatics to Operating Theatre Productivity At least four months of data is required for decision making - Tampering with staffing levels and scheduling techniques more than three times per year is unjustified statistically, and very unjustified from staff morale. Epstein, RH : J Perianesth Nurs. 2002 Apr;17(2):84-8.

    34. HOLT: 12/03 VARIAN ANNUAL CSS MEETING 34 Reducing Retakes in Sim Data-base mining in Varis – Info-maker based. DB queries found: One CT-sim out of every 22 require re-simulation Cost of retake is the cost of throwing away the first Sim: 1 hour of CT time, 72 CT slices (tube cost), 1.25 hours of sim-tech, ˝ hour of MD contouring time, 0.5 hours of dosimetry time, 0.25 hours of physics time. Approx total cost of $450. About 40% due to using stock setup techniques, i.e. ~ 2% of patients don’t “fit the mold” About 60% due to sim-tech CT error, mostly from taking too few slices to properly plan a treatment.

    35. HOLT: 12/03 VARIAN ANNUAL CSS MEETING 35 Sign on my PhD Advisors Door: “If you have time to do it over again, why didn’t you have time to do it right the first time?” Given 1000 CT sims per year, annual cost of retakes ~ $20K QAC investigation analysis proposed two solutions: 1) Sim tech to be required to take an additional 5 minutes per patient to preemptively double check patient Setup with CT scout views. 2) Add another 5 slices to top and bottom of standard CT protocols to avoid Sim tech to be required to take an additional 5 minutes per patient to preemptively double check patient Setup with CT scout views. Potential cost increase of ~ $18 / Sim, about 18K per year. Cost of re-takes on morale and disruption of flow…not quantifiable.

    36. HOLT: 12/03 VARIAN ANNUAL CSS MEETING 36 Future Productivity Investigations Filling empty time slots with discount cases is cost-effective only for discounts less than 15% (approximately 80% of the profit margin). Dexter, F. Anesth Analg. 2001 May;92(5):1215-21. Information from both billing and IS to make staffing decisions is not necessary. One or the other is adequate. Dexter, F: AORN J. 2003 Apr;77(4):825-30. If all ORs optimized utilization of existing staff, there would be no OR nursing shortage. Dexter, F Anesthesiol Clin North America. 2003 Jun;21(2):387-402

    37. HOLT: 12/03 VARIAN ANNUAL CSS MEETING 37 Summary Integrated TPS/RV/Treat (Varis/Vison 7.0) shows immediate reduction of costs. Improved treatment and staff morale is a freebie. Potential of virtually eliminating staff shortages. Additional tools for information analysis project additional reductions.

    38. HOLT: 12/03 VARIAN ANNUAL CSS MEETING 38 Summary Biggest Potential Impacts on Physics and Information Specialists: More information than we know what to do with. The Cost of trying to Reduce Costs (analyst time) must also be taken into account.

    39. HOLT: 12/03 VARIAN ANNUAL CSS MEETING 39 Acknowledgments

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