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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 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


  • 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









PET/CT Fusion


Adaptive Planning

R & V

Linac/ Cyclotron




CT/ Simulator





Deform CT


Treatment Planning

4DCT Resort/Review








  • 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



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







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)


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

Add R&V


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


  • Once added, patient entry sits in Triage Manager – awaiting delegation and completion of necessary data

Add R&V


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


  • Completion of schedule information promotes patient to user worklists (actually there once physician or physicists is defined)

Add R&V


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


  • Workflow State

  • Workflow Deadline

    • Due >24 hrs

    • Due < 24 hrs

    • Overdue

  • Can overlay staff availability over calendar


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


  • 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
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)

Planning guidelines
Planning Guidelines

Patient/Service specific templates for common planning instructions

Linked to TPS, import DVH a ndcompares to planning goals


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

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


  • 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