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
 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
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

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
Data
Billing
Billing
Data
Data
CBCT
Linac/
Cyclotron
Billing
PET/CT
Fusion
Adaptive
Planning
Billing
Data
Data
CT/
Simulator
IMRT QA
Billing
Billing
Rescan
Deform
CT
Data
R&V
Data
Treatmen
t Planning
4DCT
Resort/
Review
Billing
Data
Data
Billing
Data
Billing
Billing
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
Shower
Eat
Feed dog
Walk kid
Go to work
Fill 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
Physicist
Physician
Workflow
•Patient Intake
•CT Scan
•Contours
•Prescription
•Treatment Plan
•Plan Approval
•Plan Check
•Chart Rounds
•Insurance Approval
•…
Admin
Nurse
Therapist
Dosimetrist
Clinical Objects
Manage Staff Resources directed towards patient care
(There’s a good bit to keep track of)
Patient
QA
•Workflow
•Planning
Guidelines
•Plan Review
•Staff Responsibility
•Schedule
(CT,VSIM,START)
•Deadlines
•Patient specific
document
management
•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)
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
Stored 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
Add
R&V
Intake
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)
Add
R&V
Intake
Add
WB
Pre Tx
Review
(p+ only)
Triage
Manager
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
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
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 4DCT
Can select phase, amplitude or phase directed amplitude
resorting
Monte Carlo based optimization algorithm
Flash Plan Review
Polk, James (0000011)
Staff Availability
Machine Data (PDF)
Planning Guidelines
Patient/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 Schema
QA
Plan Index
Measurement Date
TPS ID
Planning System
Result
Patient Documents
Plan Index
Description
Saved Location
Icon
Plan (Course)
Plan Index
Service
Site Description
Instructions
Modality
Attending MD
Treatment Planner
Schedule (CT,VSIM,START)
Boost(y/n)
Locations
Location ID
Name
Site (MGH, NWH, EH)
Imaging
Treatment
Tx Modes
Modality ID
Name
Site
Workflow
Plan Index
Name
Rank
Bitmask id
Completed userid
Completed when
Workflow Template
Modality ID
Name
Rank
Bitmask id
Expiration
Reference Date
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