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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. Outline. Historical context General philosophy

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

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Radiation oncology whiteboard data and workflow manager for enhanced communication and task management

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


Outline

Outline

  • Historical context

  • General philosophy

  • Technical Implementation

  • Operation/Features


My biggest problem in 2006 was not caffeine

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

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

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 b e a n a pp f or t hat

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


Common point of access to information

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

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


Checklists

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


Workflow i am a checklist hypocrite

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 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)


Clinical objects

Clinical Objects

Manage Staff Resources directed towards patient care

(There’s a good bit to keep track of)


Operation

Operation

  • Patient added to whiteboard at intake or after (all patients entered by time of CT)

Add R&V

Intake

Add WB


Proton intake form

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


Operation1

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)


Triage manager

Triage Manager

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


Operation2

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)


Workflow 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

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


Workflow

Workflow

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


Patient detail

Patient Detail


Reminders

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

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

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

Insurance Authorization for IMRT & SBRT

List generated from SBRT and IMRT patients only


Data analysis

Data Analysis

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


Embedded applications

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

4DCT Resorting

Allows for visual editing of resorted 4DCT

Can select phase, amplitude or phase directed amplitude resorting

Monte Carlo based optimization algorithm


Flash plan review

Flash Plan Review

Polk, James (0000011)


Staff availability

Staff Availability


Machine data pdf

Machine Data (PDF)


Planning guidelines

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


Morning qa

Morning QA


Linac output constancy

Linac Output Constancy

View Morning QA, Problem Reporting Log and Constancy data simultaneously


Therapist page

Therapist Page

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


Linac elekta qa

Linac (Elekta) QA


Measurement equipment

Measurement Equipment


Technical implementation

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 schema

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


Hardware software topology

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

External Application Interfaces

  • Record &Verify ODBC

  • Treatment Planning Systems – CMS Xio, Raystation

    • SSH, SCP (file synchronization)

  • DICOM (Images)


Next to last slide

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

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


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