Post on 25-Feb-2016
description
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