Radiation Oncology Whiteboard Data and Workflow manager for enhanced communication and task management

1. Radiation Oncology WhiteboardData 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, email…. • 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 Data Data Data Data Data Billing Data Billing PET/CT Fusion CBCT Adaptive Planning R & V Linac/ Cyclotron Billing Data Billing CT/ Simulator IMRT QA Data Billing Rescan Deform CT Billing Treatment Planning 4DCT Resort/Review Data Billing Data Billing Billing Billing

9. Checklists • The Checklist Manifesto: How to Get Things Right, AtulGawande • “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. Workflow Based View Physician Therapist Dosimetrist Nurse Admin Physicist 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)

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 RoundsCompleted by physician for later peer reviewWhiteboard 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 Triage Manager Pre Tx Review (p+ only)

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 Triage Manager Workflow Manager Pre Tx Review (p+ only)

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/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

23. 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

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 (0000011)

30. Staff Availability

31. Machine Data (PDF)

32. Planning Guidelines Patient/Service specific templates for common planning instructions Linked to TPS, import DVH a ndcompares 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 • 220000 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 • Franklin Lonberg, PhD • Ryan Connolly, RT(T) • Anne McKay • Daniel Griffin • ChristophSpeier • Scott Mauceri • Consultants/Advocates • Maida Williams Broudo • Lois Greer • Christine Michelini • Ted Hong • Philip Graceffa