Upload
terrybear11
View
203
Download
7
Tags:
Embed Size (px)
Citation preview
Varian Informatics Tools:Radiation Oncology Clinical Productivity
Analysis with an Integrated Planning, Record and Verify and Treatment System
Randy Holt, Ph.D., DABR
North Valley Radiation Oncology
Enloe Medical Center, Chico, CA
HOLT: 12/03 VARIAN ANNUAL CSS MEETING 2
“Ideal” System for Outcomes Management and Review
As proposed by Kerry Rowe, PhD
Integrated Information System, Treatment Preparation and Treatment Delivery System
Collects data in a central database, collates analysis effort Promotes on-going outcome monitoring and review Provides single glance historical and current patterns. Would allow comparison of outcomes between facilities/clinicians in
relation to the existing standard of care or established benchmarks Would allow corrective adjustments for patient factors Would lead to standardized clinical practice and decreased
treatment variations
HOLT: 12/03 VARIAN ANNUAL CSS MEETING 3
Varian Varis/Vision 6.5/7.0Two major items for discussion
Direct impact of Integrated Systems on productivity: Improved software leads to reduced costs, improved QA, and improved treatment.
Mining and utilizing the exponentially increasing flood of information to improve productivity.
HOLT: 12/03 VARIAN ANNUAL CSS MEETING 4
Single Vendor Model Enloe Medical Center
600C with EPID, EDW21EX with EPID, EDW, MLCSatellite 2100C with EDWBrachytherapy, LDR, HDR CT sim, 2 Eclipse, 2 BV1 BrachyVision w/ GM+ HDR8 Vision review stationsCurrent average of 47 patients/day, 28%
IMRT
HOLT: 12/03 VARIAN ANNUAL CSS MEETING 5
6.5 upgrade
Went live with Clinical Evaluation (Beta) 4/1/03 – release version 10/6/03.
Upgraded from Varis 6.5 to Varis 7.0 in January. Full overhaul of all systems
All staff affected - Dosimetry, Front Office, MDs, RTTS, Physics
HOLT: 12/03 VARIAN ANNUAL CSS MEETING 6
Front Office Productivity
At a glance windows
Most used informa-tion is grouped
HOLT: 12/03 VARIAN ANNUAL CSS MEETING 7
Tx Planning Productivity
7.1.67 Some new
features Slight
productivity improvements
Big stability improvements
HOLT: 12/03 VARIAN ANNUAL CSS MEETING 8
RTChart – MD Intent/Rx
Now being heavily used by MDs
Is key to the paperless chart.
Some issues in “Approval” and “Freezing”.
HOLT: 12/03 VARIAN ANNUAL CSS MEETING 9
More Dosimetry Efficiency
Reference Point Arranger and Field Scheduler
Mostly carried in from TPS
1 minute vs. 10+ minutes in V6.2
HOLT: 12/03 VARIAN ANNUAL CSS MEETING 10
Common User Interfaces
Power-user Action MS Windows Apple Macintosh
Move Window Grab Title Bar Grab any Window edge
Resize Window Grab any window edge
Grab corner
Dismiss a message box
Enter or Space bar
Mouse click only
Alt-F4 Close Windows Raises the Volume
HOLT: 12/03 VARIAN ANNUAL CSS MEETING 11
What are a few wasted minutes worth?
30 minutes per staff member in an average sized department (20).
2500 hours per year
HOLT: 12/03 VARIAN ANNUAL CSS MEETING 12
Treatment History Review
Dosimetry and Physics both spend time in here
HOLT: 12/03 VARIAN ANNUAL CSS MEETING 13
Previous (1.4, 6.1, 6.2)
Current
Physics Review Steps
Plan TransferGen 6 or RTPlink or hand entry
R&VDouble Check all values
Treat
Plan Double Check Plan TreatApprove
HOLT: 12/03 VARIAN ANNUAL CSS MEETING 14
Physics Review
Same Database = Same Values
Physics now only has to double check in one place
HOLT: 12/03 VARIAN ANNUAL CSS MEETING 15
“Integrated” Treat ONE WINDOW
All info at a glance
Minimal, but complete features – i.e. no getting lost
HOLT: 12/03 VARIAN ANNUAL CSS MEETING 16
“Integrated” Treat 7-field IMRT
plans used to take 20 minutes per patient, including Setup Orthogonal
Portal images, Table shifts, Treat.
Now take 12-13 minutes per patient
HOLT: 12/03 VARIAN ANNUAL CSS MEETING 17
“Integrated” Treat 7 minutes per
patient * 10 IMRT patients per day * 250 days per year * two therapists * $60/hr with benefits = about 35K per year.
Not to mention associated staff (front office, etc).
HOLT: 12/03 VARIAN ANNUAL CSS MEETING 18
EPI Review – MD tasks
Filters : All, New, Approved, etc
Navigation buttons for quick sequential review
Image Note and Patient Note Attachments
Quick action buttons: Approval, Retake, etc
All done on MD workstation Speed/ease critical for Daily IMRT ports
HOLT: 12/03 VARIAN ANNUAL CSS MEETING 19
ASTRO Estimate of Staff Shortages
Avg Rad Onc Dept is 13.8 FTE personsIncluding RTT, CMD, RN, MS, PhD, MD
Avg Openings is 2.6 FTE persons
National Staff Shortage of 18.9% 2002 Radiation Oncology Workforce Study: American Society
for Therapeutic Radiology and Oncology.Int J Radiat Oncol Biol Phys. 2003 Jun 1;56(2):309-18.
HOLT: 12/03 VARIAN ANNUAL CSS MEETING 20
Enloe ROC Productivity
Hospital wide tracking of “Productivity”
Tracked metrics for 6 months to establish baseline values
Then Admin raised the bar by 5% for all departments
HOLT: 12/03 VARIAN ANNUAL CSS MEETING 21
Enloe Productivity 7/02 – 10/03
0.8
0.9
1
1.1
1.2
1.3
7/1/2002 9/30/2002 12/30/2002 3/31/2003 7/1/2003 9/30/2003
Actual FTE Cost per RVU / Budgeted (expected) FTE Cost per RVU
6.5 upgrade
HOLT: 12/03 VARIAN ANNUAL CSS MEETING 22
Clinical Interlude:Characterizing and Reducing the Daily
Setup Error for IMRT
Daily Verification – EPID orthogonal pairs
ANT EPID
RT LAT EPID
Provides INF/SUP and R/L LAT info
Provides ANT/POST and INF/SUP info
HOLT: 12/03 VARIAN ANNUAL CSS MEETING 23
Ant Prostate Seeds - Match
Manual match more effective - bladder contrast
5-10 seconds per view
HOLT: 12/03 VARIAN ANNUAL CSS MEETING 24
Lat IMRT Prostate Seed Match
HOLT: 12/03 VARIAN ANNUAL CSS MEETING 25
Match Results - Interpretation Required Shifts presented as Couch
Movements
In-room Monitor for Couch Position used
e.g. original LAT = 100.0, then desired LAT = 99.7original LNG = 100.0, then desired LNG = 100.5
Independent of Patient Position (Supine, Prone, etc)
Beams not aligned with couch accounted for producing three axis couch moves (tangents, RAO, etc)
HOLT: 12/03 VARIAN ANNUAL CSS MEETING 26
Total Magnitude of Daily Setup Shifts
Following Orthogonal EPI Matching - 5 patients for 15 days
Mean daily
moves -
Seeds: 6.6 mm
Bony: 4.2 mm 0
0.2
0.4
0.6
0.8
1
1.2
0 10 20 30 40 50 60 70 80
Me
an
Sh
ift
(cm
)
Seed Markers
Bony Anatomy
HOLT: 12/03 VARIAN ANNUAL CSS MEETING 27
Prostate 10mm Margin vs. 8mm Margin
0
10
20
30
40
50
60
70
80
90
100
0 20 40 60 80 100 120Dose (%)
Vo
lum
e (%
)
10mm-Bladder10mm - PTV10mm - Rectum8mm-Bladder8mm-PTV8mm-Rectum
So, what’s a couple of mm between glands?
HOLT: 12/03 VARIAN ANNUAL CSS MEETING 28
Indicated Shifts - Prostate Seed Patient #1
-9
-6
-3
0
3
6
9
12
15
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26
Treatment #
Sh
ift
(mm
)
LAT LNG (anterior image)
VRT LNG (lateral image)
HOLT: 12/03 VARIAN ANNUAL CSS MEETING 29
Daily Match Error - H&N Patient
-7
-4
-1
2
5
8
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21
Treatment #
Sh
ift
(mm
)
VRT LNG(LAT) LAT LNG(AP)
HOLT: 12/03 VARIAN ANNUAL CSS MEETING 30
Examples of Mining Varis for Improved Productivity
Applications to Radiation Oncology.A) Retakes in CT-SimB) Optimal planning for time-slot over-runs
Per diem, floating staff levels of 7-10% of total full time staff are critical to cost management. Pre-scheduled open time blocks are critical to cost containment of over-long delay periods.
Dexter, F Anesthesiol Clin North America. 2003 Jun;21(2):387-402.
HOLT: 12/03 VARIAN ANNUAL CSS MEETING 31
Optimal Scheduling and Staffing
To use the Dexter staffing model – we need to know Average time slotActual average duration Standard deviation of under-usage/over-usageCost (per hour) of after-hours staffing
Introduce a delay time, run 2-variable scenarios:Time of day, and Duration of delay period
HOLT: 12/03 VARIAN ANNUAL CSS MEETING 32
Breakfast is the most important meal…Within 95% confidence limits, can show that most
efficient delay time period is a) exactly centered in the workday and b) of a duration of 3.5 to 4*STDev of time-slot overrun
Result: New Departmental Scheduling ScenarioNominally, eliminate all (routine or emergency)
scheduling from 1200 –1220Time period and duration changes depending on planned
hours of operation.
…but Lunch is the most cost-effective meal.
HOLT: 12/03 VARIAN ANNUAL CSS MEETING 33
Applications of Informatics to Operating Theatre Productivity
At least four months of data is required for decision making - Tampering with staffing levels and scheduling techniques more than three times per year is unjustified statistically, and very unjustified from staff morale.
Epstein, RH : J Perianesth Nurs. 2002 Apr;17(2):84-8.
HOLT: 12/03 VARIAN ANNUAL CSS MEETING 34
Reducing Retakes in Sim Data-base mining in Varis – Info-maker based. DB queries found: One CT-sim out of every 22 require re-simulation Cost of retake is the cost of throwing away the first Sim:
1 hour of CT time, 72 CT slices (tube cost), 1.25 hours of sim-tech, ½ hour of MD contouring time, 0.5 hours of dosimetry time, 0.25 hours of physics time. Approx total cost of $450.
About 40% due to using stock setup techniques, i.e. ~ 2% of patients don’t “fit the mold”
About 60% due to sim-tech CT error, mostly from taking too few slices to properly plan a treatment.
HOLT: 12/03 VARIAN ANNUAL CSS MEETING 35
Sign on my PhD Advisors Door:“If you have time to do it over again, why didn’t
you have time to do it right the first time?”
Given 1000 CT sims per year, annual cost of retakes ~ $20K QAC investigation analysis proposed two solutions:
1) Sim tech to be required to take an additional 5 minutes per patient to preemptively double check patient Setup with CT scout views.
2) Add another 5 slices to top and bottom of standard CT protocols to avoid Sim tech to be required to take an additional 5 minutes per patient to preemptively double check patient Setup with CT scout views.
Potential cost increase of ~ $18 / Sim, about 18K per year.
Cost of re-takes on morale and disruption of flow…not quantifiable.
HOLT: 12/03 VARIAN ANNUAL CSS MEETING 36
Future Productivity Investigations Filling empty time slots with discount cases is cost-
effective only for discounts less than 15% (approximately 80% of the profit margin).
Dexter, F. Anesth Analg. 2001 May;92(5):1215-21.
Information from both billing and IS to make staffing decisions is not necessary. One or the other is adequate.
Dexter, F: AORN J. 2003 Apr;77(4):825-30.
If all ORs optimized utilization of existing staff, there would be no OR nursing shortage.
Dexter, F Anesthesiol Clin North America. 2003 Jun;21(2):387-402
HOLT: 12/03 VARIAN ANNUAL CSS MEETING 37
Summary
Integrated TPS/RV/Treat (Varis/Vison 7.0) shows immediate reduction of costs.Improved treatment and staff morale is a
freebie.Potential of virtually eliminating staff
shortages.
Additional tools for information analysis project additional reductions.
HOLT: 12/03 VARIAN ANNUAL CSS MEETING 38
Summary
Biggest Potential Impacts on Physics and Information Specialists: More information than we know what to do
with.The Cost of trying to Reduce Costs (analyst
time) must also be taken into account.
HOLT: 12/03 VARIAN ANNUAL CSS MEETING 39
Acknowledgments
Many thanks to Patricia McBride, Varis/Vision GroupFranklin P. Dexter III, M.D., PhD., University of IowaAll the great gang at
Enloe Medical [email protected]