Varian Informatics Tools - Randy Holt, PhD, DABR

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


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.


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


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


Front Office Productivity

At a glance windows

Most used informa-tion is grouped


Tx Planning Productivity

7.1.67 Some new

features Slight

productivity improvements

Big stability improvements


RTChart – MD Intent/Rx

Now being heavily used by MDs

Is key to the paperless chart.

Some issues in “Approval” and “Freezing”.


More Dosimetry Efficiency

Reference Point Arranger and Field Scheduler

Mostly carried in from TPS

1 minute vs. 10+ minutes in V6.2


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


What are a few wasted minutes worth?

30 minutes per staff member in an average sized department (20).

2500 hours per year


Treatment History Review

Dosimetry and Physics both spend time in here


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


Physics Review

Same Database = Same Values

Physics now only has to double check in one place


“Integrated” Treat ONE WINDOW

All info at a glance

Minimal, but complete features – i.e. no getting lost


“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


“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).


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


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.


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


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


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


Ant Prostate Seeds - Match

Manual match more effective - bladder contrast

5-10 seconds per view


Lat IMRT Prostate Seed Match


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)


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


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?


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)


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)


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.


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


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.


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.


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.


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.


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


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.


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.


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]

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