MOSAIQ Clinical WorkFlow Manager

MOSAIQ Clinical
WorkFlow Manager
Business Process
Management using the
IMPAC Electronic Medical
Record integrated with RTP
applications as services for
Quality Assurance

Introduction
• Radiation Therapy Planning (RTP) is a reproducible
process that can be integrated with the MOSAIQ EMR

RTP Workflow Management
• RTP is a process
– that requires Macro “States” (Create, Ready for Approval, Re-
Plan, etc.) of Patient and Plan data to be managed
• Process efficiency and reproducibility gains
– should result if planning activities & tasks are automated
• To support Adaptive Planning
– an even higher level of Process Automation will be required
• Therefore
– platform independent workflow management (WFM) is THE core
component of MOSAIQ RTP

RTP workflow
• The efficiency of the RTP process can be increased by
– Planning of sequential activities or tasks
– Updated knowledge of task status until completion
– User and Group work-lists
– Task notifications, reminders, alerts – particularly when missed or
overdue
• User frustration can be reduced by
– Reducing the number of mouse clicks when responding to the
same question every time a new patient plan is created
– Examples that could be managed by decision rules
– Placing the isocenter location at the center of the PTV geometric
bounding volume
– Selection of protocol and treatment technique from available slots

Reproducible RTP
• Treatment Planning is often based upon protocols, either
national (i.e. RTOG, EORTC) or local
– A protocol links activities with data and can be automated
– Each clinic can define their own protocols

Protocol based RTP
• MOSAIQ will support template-driven RTP from the EMR
– Templates for
– Image study acquisition
– Registration method & metric
– Manual contouring (delineation) by the Physician
– Margining rules (population averages, patient-specific)
– Automatic segmentation (ABAS)
– Prescription (simple, complex, IMRT)
– Virtual simulation workflow
– Treatment planning workflow
– Plan comparison
– Plan evaluation
– Review & Approval tasks
– Quality Assurance of patient plan

Standards in Radiation Oncology
• New and evolving standards in RO require managing the
data flow between systems
• The IHE-RO initiative is defining profiles and actors to
support a multi-vendor approach
• Using MOSAIQ as a single centralized database supports
the implementation of standards in an “open systems”
environment

Standards compliance RTP
• To support the IHE-RO profiles & actors, MOSAIQ RTP
– Provides modules as services which correspond to IHE-RO
definitions
– Contour (MOSAIQ Anatomy)
– Geometric Planning (MOSAIQ Simulate)
– Dose Calculation (MOSAIQ Dose)
– Optimization (MOSAIQ Optimize)
– Plan Review (MOSAIQ Evaluate)
• To support the HIPAA requirements
– MOSAIQ tracks who viewed/edited patient data, when, and where
• To support the IEC 62083 states
– MOSAIQ can ensure Anatomy & Plan approvals

Workflow Concept
Activity 1
Activity 3
Activity 4
Activity 2
• Import Volume
• Create Contours
• Review/Approve Contours
• Compute Dose
• Review Dose
Actor::Contourer
Actor::Contour
Reviewer
Actor::Dose
Evaluator
Actor::Dose
Reviewer
Agent::ABAS
Agent::Anatomy
Agent::Evaluate
Agent::MSQ Dose
Viewer

Clinical Workflow Manager
Patient Activity 1 Activity 2 Activity 3
Doe, Jane X
Jones, Bob X
Smith, John X

Data integrity and fidelity
• The amount and complexity of data in RO is ever
increasing
– Multi-modality image data (CT, MR, PET, US, SPECT, etc)
– Complex IMRT and VMAT treatment plans
– Images from 2D and 3D ….. now 4D IGRT
• Data dependencies
– Update dose and DVH with change of Structure contour(s)

Centralized data management
• MOSAIQ is a paperless and filmless patient EMR that can
– store a single copy of any and all patient data in 1 location
– manage the distribution of data to systems from difference
vendors
– alert and resolve data conflicts
– example, manually drawn contours with automatic segmentation
results (CMS ABAS)
– send data to a workstation to meet performance requirements
– Example - chart rounds (act as a local cache)
– archive all data after therapy completion to a location such as the
MOSAIQ Oncology PACS

Quality Assurance
• A process that involves more than a single actor with data
moving between systems from different vendors is
hazardous if it relies only on human interaction and is
therefore probably not fault tolerant

Benefit – Quality Assurance
• Before the treatment plan is delivered to the patient
– it must be reviewed and approved by a Physician
– checked by a Medical Physicist
– exported to the MOSAIQ EMR for delivery
– and in some cases, patient plan specific Q.A. must be made
• Workflow management in the EMR can offer
– comparison of the DICOM RT PLAN from the RTP system with
the treatment intent
– this should reduce/remove mapping errors between systems
– This is a closed loop approach – start and finish plan in EMR
– Automated list of changed fields per week for checks

RTP Research
• Academic (University clinics) centers often wish to try
new processes and clinical trials using commercial
products
• Tailoring these systems to new requirements has in the
past required significant software engineering skills
– popular example is Pinnacle3 scripting

Process flow customization
• The Clinical WorkFlow Manager in MOSAIQ
– will recognize that not all clinics are the same, work the same
way, and have the same clinical goals
– will offer clinics the possibility to start with an existing Protocol
and modify the process steps to meet local needs
– data can be input without a requirement to understand the SQL
database schema or software engineering
– Examples could be ASCII text or XML strings

CART Nordic collaborative project

Data communication flow
• CART process flow diagram integrates
– Basic Patient Data
– Laboratory results
– Diagnostic images
– Therapeutic images
– Treatment reference data
– Treatment documentation data
– Radiation reference data
• CART process starts with fluoroscopic simulation and
ends with treatment delivery
– Delivery system with IGRT provides adaptive therapy strategy

Conclusions
• Treatment Planning Systems can be connected to a
centralized Electronic Medical Record to support process
management (clinic workflow)
– There are many benefits to this integration, including:
– Reproducible treatment planning from protocols and templates
– A single storage location for all patient and plan data
– Comparison of created treatment plans with physician intent
– Efficiency of staff with knowledge of planned tasks and activities
– Knowledge of the state of data (i.e. approval)
– This workflow efficiency will be required to support increased
workload for Adaptive RT (Dose Guided RT) feedback loops

Adaptive Radiation Therapy Framework:
Anatomy and Dose Tracking
• Presented at IMPAC Radiation Oncology User Meeting,
ASTRO 2007 by:
• Qiuwen Wu, Ph.D.
– Staff Physicist
– William Beaumont Hospital
– Royal Oak, MI, USA

Clinical Infrastructure for Image Guided
Adaptive Radiation Therapy (IGART)
• Online Volumetric Image/Correction Monitoring
– Volumetric Imaging of patient at treatment position
– Couch position & MLC beam aperture correction
– Real time capture of machine geometry and output (MU & MLC)
• Anatomy Tracking/Feedback
– Auto deformable organ registration/segmentation
– Parametric and sample estimation for anatomical variation
• Dose Tracking/Feedback
– Daily and cumulative dose construction and estimation
– Treatment evaluation and plan modification decisions
• Adaptive Modification
– Online or offline 4D adaptive planning
– Treatment schedule control and adjustment

Patient Anatomy/Dose Tracking &
Feedback Control Process for IGART
4D
Adaptive
Planning
Ref Plan
Treatment
Evaluation &
Modification
Decisions
(CBCT Linacs)
Patient Setup
Dose Delivery
Machine
MU/MLC
Output
Treatment Dose
(daily &
cumulative)
Construction
CB Image
Position
Correction
Segmentation
&
Registration

WBH IGART Prototype
CT, MRI, PET
Scanners
Data Storage
HD: 30TB
1 Gbps network
Linac
CB
Imager
Derived Data
(Contour,
Displacement,
Plan, Dose, ...)
Data Monitor
Job Controller
Job Queues
and Dispatch to
Target Server
Specific
(High priority)
Job Request
Treatment/Plan
Modification
Segmentation/Registration
...
...
Job i
Job i+1
...
Treatment Dose Construction
...
Job i
Job i+1
...
4D Adaptive Planning
...
Job i
Job i+1
...
User Review
Evaluation Job Execution
Log
QA
Evaluation
Station

Imaging & Treatment Calendar
• A schedule for localization imaging, treatment delivery,
then for the activity of potential plan adaption

Summary
• Image guidance generates vast amount of information
stored in electronic medical records. It is challenging to
effectively use these information
• Patient anatomy/dose tracking and feedback control
process provides a foundation and an integrated solution
to manage adaptive radiotherapy for optimal individual
patient treatment
• This process also provides a systematic means for
treatment evaluation, quality assurance, proper tumor
registry and clinical outcome analysis