As radiation oncology sites press forward into image-guided therapy, the need for integrated IT intensifies.

	VolumeView cone-beam CT image showing coronal, sagittal and transverse views acquired by Elekta Synergy.

Throughout the 1980s and early 1990s, radiation oncology seemed to operate in idle. Technology advances were few and far between, providing ample time for practices to adjust as needed. The advent of 3D radiation therapy, IMRT and IGRT in the late 1990s, however, ushered in a new era characterized by rapidly evolving technology and a more prominent role for patient images and data. Over the next decade, imaging emerged as a data-glut as sites graduated from x-ray to CT imaging for treatment planning and positioning. Today, the field continues to evolve as sites consider next-generation techniques like adaptive radiation therapy, which centers on real-time treatment planning while the patient is on the table. Insiders predict that adaptive radiation therapy will translate into petabytes of patient data annually. In addition, workflow is increasingly collaborative and image-dependent. The upshot? Radiation oncology requires seamless, robust IT infrastructure. This month, we’re looking at how a pair of cutting-edge practices has assembled the various IT components to create an integrated infrastructure that support workflow and high-quality patient care.


IT integration on the edge

“Lots of centers have invested in individual IT components like an EMR, image servers and treatment planning systems; however, few have tied all of the pieces together,” says Fred Fangman, director of radiation oncology at MIMA Cancer Center in Melbourne, Fla. MIMA has not only tied the pieces together via IT interfaces between treatment planning, treatment delivery and information management systems but also leaped into anytime/anywhere virtual radiation oncology by investing in Tablet PCs and image-enabled cell phones.

Eight months after launching a paperless initiative, the practice is 95 percent paperless. It’s a significant accomplishment for a two-physician department affiliated with a 120-physician comprehensive physician group. Varian Medical Systems ARIA Oncology Information System is the hub of  the radiation oncology department. The software provides a repository for images, clinical documentation, scheduling, treatment plans and follow-ups. “Radiation oncologists generate everything electronically now and also sign off in ARIA. ARIA enabled the transition to paperless,” says Fangman. ARIA workstations are located throughout the facility including exam rooms, and a robust wireless infrastructure supports the endeavor. Tablet PCs and image-enabled cell phones let physicians view images and data on the go—and anywhere. The system weds high tech and high touch. Radiation oncologists use Motion Computing Tablets to show patients images—and progress—on a regular basis. When therapists acquire treatment planning images, they email them to physicians’ cell phones equipped with resolution and zooming capabilities that suffice for a quick check and approval.

The focus on IT-enabled workflow proved particularly valuable earlier this year when the practice deployed Varian RapidArc volumetric modulated arc therapy, a new treatment technique that reduces treatment time. Prior to RapidArc, a typical MIMA prostate treatment took about 15 minutes. RapidArc slashes treatment time to seven minutes, allowing the radiation oncology department to serve multiple additional patients every day. “We couldn’t do it without IT support. Radiation oncologists cannot be at the treatment console 40 times a day to view images for each patient we treat. ARIA, the wireless network, Tablet PCs and cell phones make it possible to increase volume and provide high-quality patient care,” concludes Fangman.


Inside the best-of-breed pioneer

Radiation Oncology Services (ROS) of Riverdale, Ga., is committed to community-based, state-of-the-art assessment and treatment. The practice treats 2,000 patients annually at four freestanding radiation oncology centers. Chief Operating Officer Andy Tillman explains, “We embrace a best-in-class approach to infrastructure and use treatment delivery systems from all major vendors: Elekta, IMPAC Medical Systems, Siemens Medical Solutions and Varian Medical Systems. This approach presents unique challenges in moving data from one system to another.” In addition, ROS contends with standard industry challenges. Particularly vexing is the exponential increase in patient data, says IT Director Greg Wilson, forcing the practice to adapt its network and storage solutions. With radiation oncology changing so rapidly, collaboration between clinical users and vendors is essential.

Cone-beam CT is a case in point. Over the last two years, ROS deployed a pair of Elekta XVI linear accelerators with cone-beam CT. Each CT-based treatment course represents 250 megabytes of data. Currently, the practice stores raw data on the Elekta system during treatment and backs up images on an external hard drive. Wilson aims to streamline the process later this year when Elekta adds a RAID drive to the XVI linac.

Other changes deliver critical workflow and patient care benefits. For example, three years ago, a multidisciplinary team comprised of IT staff, clinicians and administrators realized that a single database approach could facilitate paperless, filmless workflow. The practice decided to transition from four distinct IMPAC EMRs to a single IMPAC database running over a wide area network. “If radiation oncology practices aren’t paperless, staff spends an incredible amount of time looking for patient information because the chart could be at the front desk, in the treatment area or at the nurses’ station,” says Tillman.

The single database approach improves both patient care and workflow. The clinical team is no longer tied to the treatment console for access to imaging data and medical records. Instead, images and information are available throughout the practice. Physicians don’t need to interrupt workflow to review images at the console, and collaboration is enhanced because physicians can review cases with colleagues at sites throughout the practice.


Pioneering advice

• Physician buy-in is the essential first step, says Tillman. Physicians need to understand the rationale for and benefits of tech changes; otherwise, expect an uphill struggle.
• The organization must match its commitment to technical infrastructure with a commitment to human resources to keep systems working optimally and guide the plan for IT-enabled medicine, says Fangman.
• Network with colleagues and adopt an open-door policy about sharing ideas, says Wilson. For example, ROS visited a St. Louis practice to learn more about billing software. Because the hosts shared prolifically, the ROS team walked away with a much larger (and more beneficial) project: the single database model.
• Train, train and train again. With IMPAC, ROS employed a varied approach, beginning with vendor training about the basic of IT-based charts, progressing to internal training about specific processes and including a hefty dose of super-users for ongoing monitoring and re-education.

Paperless payoff

Filmless, paperless radiation oncology workflow is rapidly becoming the primary radiation oncology workflow model. All constituents benefit from the approach. The paperless model extends the reach of radiation oncologists, freeing sites to treat more patients and tap into state-of-the-art imaging and treatment protocols that offer patients optimal care. And as volume increases the bottom line improves. 21st century radiation oncology is new and improved. It hinges on IT integration, however, as images and data must flow smoothly throughout the practice.