Revving Up Radiation Oncology Workflow


Radiation oncology is a specialty in transition. Increasingly it is depending more heavily on images, and dealing with decentralization of services. Yet the key issues that disrupt radiation oncology workflow also are universal in healthcare, says Tim McKeough, chief operating officer of Arizona Oncology Services of Phoenix.

There are basic clinical office challenges. Patient names are hand-entered multiple times, and the exchange of paper across a large department can be problematic. The results are ugly. Billing is delayed; claims are denied; and both staff and patients spend far too much time waiting.

At the same time, radiation oncology is becoming decentralized and more hospitals and large imaging centers are opening satellite clinics, which necessitates new systems and processes to facilitate communication and image sharing across multiple sites.

Finally, the widespread adoption of IMRT (intensity-modulated radiation therapy) and emerging acceptance of IGRT (image-guided radiation therapy) demand new workflow models that allow practices to efficiently integrate new treatment options that heavily depend on imaging (and image review). “IMRT requires 20 to 30 minute appointments, stringing out the schedule. If there’s one hitch, we have problems for the rest of the day, and there’s no way to catch up,” explains Brent Applegate, radiation oncology manager for Ironwood Cancer and Research Centers in Chandler, Ariz.

This month, Health Imaging & IT visits with a few sites that have deployed an array of solutions to tame the radiation oncology workflow beast.

Practice management pays

Arizona Oncology Services is the largest physician-owned radiation oncology service in the Southwest and operates eight clinics and six hospital clinics. Several years ago, COO McKeough aimed to deploy a system to streamline the practice. “Basic office paper stuff is exacerbated in radiation oncology because every patient is a referral,” explains McKeough. Radiation oncology uses an abundance of insurance codes and many clinical players exchange paper tickets before billing. Staff often couldn’t locate tickets resulting in double charges and late and missed bills. On the clinical front, scheduling a session could be three-step process. Brachytherapy, for example, requires that the room and physician must be scheduled. The practice also lacked a system to notify therapists when patients arrived, causing a fair amount of back and forth for therapists.

In April 2002 Arizona Oncology deployed NextGen Healthcare Information Systems practice management and EMR system. The new system eliminates paper fee tickets. Instead therapists use a workstation in the dosimetry room to select from a few codes based on the type of appointment, enabling same day billing.

“It’s a huge step forward for cash flow,” confirms McKeough. Double billing has dropped, and full-time chargers have been redeployed to other duties. Plus, the practice has grown. Although conventional wisdom pairs nearly one additional accounts receivable person with every new physician, Arizona Oncology Services has added eight physicians and only two accounts receivable staffers since deploying NextGen. The practice also worked with NextGen to write a custom patient estimate program. Prior to treatment, probable patient codes are loaded into the system and merged with insurance contracts. At the click of a button, a financial counselor presents the patient with a clear estimate of his or her responsibility. “The upfront estimate is good customer service, we’re sending fewer statements and we’re handling fewer calls from angry, confused patients,” notes McKeough.

The practice prepped for the new system by upgrading network connections between its sites, making sure that each site had enough computers in the right locations. The initial network upgrade consisted of system-wide T1 lines to increase speed, reliability and system performance. A second upgrade to a fiber connection delivers 30MB per second between clinics to enable central management of all systems and rapid transfer of CT images and treatment plans from clinic to clinic. The practice also purchased an entire new line of computers, adding workstations so that each department had at least one station. Multiple workstations were deployed in busier locations like the front desk, nurse station and physics room to eliminate bottlenecks. 

Uniting remote facilities

In the good old days, radiation oncology was hospital-based, and the patients came to the hospital for treatment. But times are a-changing. For example, Waukesha Memorial Hospital is Wisconsin now operates three satellite radiation oncology clinics. One-stop shopping is great for the patient, says Chief Physicist Eric Hendee, but physicians must be able to communicate across all three sites. For example, a single radiation oncologist may have patients scheduled at two sites simultaneously. The physician must be able to review the plan and images to keep patient flow moving.

Waukesha Memorial Hospital relies on Philips Medical Systems Pinnacle3 treatment planning system and P3MD physician workstation to enable a virtual department. Physicians have complete access to all treatment plans and images not only at the three clinics but from anywhere in the world. “It’s a tremendous workflow booster,” confirms Hendee. The department is completely paperless; physicians check charts and review treatment plans and QA remotely. Hendee says the elimination of paper could translate into productivity gains in the 25 percent range.

Hendee believes the model is a win-win as the hospital is increasing efficiency and productivity as it improves patient care. “We can use fewer people to do the same amount of work and have reduced the number of physicists from three to two while gaining the ability to serve more patients with increased throughput,” concludes Hendee.

Mary Bird Perkins Cancer Center, a three site practice based in Baton Rouge, La., faces a similar situation. Physicians and staff rotate among three locations. “Treatment plans, diagnostic images and EMR data must be immediately available and portable over our wide area network,” explains  Chief Executive Officer Todd Stevens.

The center relies on Impac Medical Systems’ radiation oncology suite as its enterprise management system and Philips Pinnacle treatment planning system. The systems allow physicians to view images and patient plans across all sites and from home via a virtual private network (VPN). “Their work follows them; they don’t need to get in a car to follow it,” sums Stevens. In addition, the lone dosimetrists at two smaller sites can transfer work to the Baton Rouge site when the patient census is too high to handle, enabling the practice to balance the peaks and valleys of radiation oncology work.

Staff aren’t the only beneficiaries of the system. Many of the region’s radiation oncology sites were not operational following hurricanes Katrina and Rita. “We’ve had a fairly significant increase in patient volume without a linear increase in staff. We attribute our ability to accommodate additional patients to our electronic patient data management systems,” explains Stevens.

Wedding workflow & advanced applications

Sometimes facilities on the bleeding and leading edges of technology deployment pay a stiff price in terms of workflow. They may be guinea pigs facing a steep learning curve. In other cases, the pioneers set the pace, developing processes and tapping into technology to ensure smooth implementations for the masses. Take for example Emory University Clinic of Atlanta.

The facility was one of the first in the nation to deploy IMRT and was the first IGRT site in the U.S. Emory relies on a pair of Varian Medical Systems Clinac 23 EX linear accelerators retrofit with the On-Board Imaging (OBI) and RPM gating systems, two Trilogy systems with OBI cone-beam CT capabilities, an Acuity simulator with cone-beam CT and ARIA information system and software as the backbone of the department. Patients are scheduled in 15-minute blocks, and the department hums with processes and systems that maximize staff time.

“We use the On-Board Imaging with nearly every patient every day. It’s impractical to have physicians set up these patients for the linear accelerators,” explains Radiation Therapist Tony Webb. At Emory, radiation therapists run the On-Board Imager, and physicians check images remotely on the workstation. “They can look over our shoulders without actually being here,” says Webb. He believes the key to workflow success is deploying complementary solutions. This allows sites to build upon previous knowledge and readily develop new skills. “Our transition from IMRT to IGRT was simple because staff was used to the equipment and could build on what they already knew,” states Webb.

Ironwood Cancer and Research Centers streamlines the IGRT process with a new Elekta Synergy platform with XVI (x-ray volume imaging) cone beam CT and portal imaging. “It helps speed up IMRT by providing a quick pre-treatment scan to localize the beams,” explains Applegate. Currently, radiation oncologists view the initial and weekly images at the CT workstation, but an upgrade scheduled for this fall will tie the scanner to an Impac image management system and export images to physicians’ desktops.

Some treatment options require creative scheduling. One physician at Ironwood Cancer and Research Centers, for example, offers high dose rate brachytherapy to breast cancer patients. The facility does not have a separate brachytherapy suite, so all treatments must be scheduled in a linear accelerator treatment room. The regimen consists of two daily treatments scheduled six hours apart. “It really pushes our schedule,” confirms Applegate. The center meets patient needs without disrupting workflow by scheduling radiation therapists from 5:30 a.m. to 6:30 p.m.

Merging state-of-the-art technology & the human touch

Sonora Regional Radiation Oncology of California consists of a new 4,500 square foot center that nearly triples the size of the practice’s previous building. It’s equipped with state-of-the-art systems including Siemens Medical Solutions COHERENCE oncology workspace, Impac practice management and Philips Pinnacle treatment planning system. The systems allow the practice to provide fairly sophisticated IMRT and IGRT — in a very streamlined fashion.

“Siemens iMAX 2 software delivers IMRT 30 percent faster than before,” reports Medical Director Gary Young, MD. In addition, Young says Pinnacle speeds the IMRT planning and revision process.

Coherence workspace delivers other benefits as well. For example, the system enables the practice to offer daily IGRT. “This is important in prostate cancer treatment because the prostate moves from day to day within the pelvis and IMRT margins are tight. Our urologists place permanent fiducial markers into the prostate before treatment planning.  We visualize the fiducials with portal imaging and compare the location with the reference images. Before each treatment, we take a portal image and determine the exact table shift with Coherence,” explains Young. Coherence streamlines workflow by allowing the radiation oncologist to verify the accuracy of shifts from the office as he reviews portal images.

Despite the state-of-the-art environment, the practice does not allow technology to substitute for face-to-face communication. Young holds a daily morning meeting before patients arrive. “The meeting streamlines our day. We discuss every patient and address items that can’t be computerized like social and nutritional issues,” says Young. The 15-minute commitment is efficient, says Young, because practitioners don’t interrupt the workflow to tackle issues that can be handled in the meeting.

Workflow wisdom

Workflow is a tricky process that hinges on a delicate balance of technology and human resources. Facilities that have solved the workflow puzzle offer some advice for their colleagues.

  • Employ an informatics system, says Applegate. It keeps data organized and provides one-click availability of critical information. “Look for an open, flexible planning system,” adds Hendee. Hendee says the flexibility of Philips Pinnacle planning system provides the necessary base for remote connections. Be sure to check out the infrastructure of systems under consideration, says McKeough. “I want systems that talk to each other and products that interface with what we have in place.” Open systems are critical from both a business and clinical perspective, says Young. Systems that use a standard DICOM format minimize integration problems and enable image and data sharing across and beyond the enterprise. 
  • Remember that the network is the backbone of the entire system.  Bandwidth should be sufficient to support digital images and information. Initially Ironwood found it difficult to swallow the price tag of a fiber optic line; however, the T1 line connecting its two sites has not provided bandwidth necessary for efficient transfer of digital data between its clinics. A fiber optic line is in the works. 
  • If the practice operates multiple sites, employ a consistent approach in all sites, says Stevens. This allows the practice to easily shift human resources to meet patient needs. 
  • IT transcends products and includes staff. Deploying new technology and processes requires IT support, says Hendee. Make sure the IT department under­stands the specific needs of radiation oncology.

Ultimately, streamlined workflow evolves from a balance of new systems and technologies designed to interact and interoperate, staff training and efficient office/practice management. Caregivers and auxiliary staff benefit as clear and efficient practices optimize their time and work, enabling them to effectively handle more patients. Patients benefit as each staff member can focus on their primary task of patient care.