Radiation Oncology in the Age of Informatics

Nearly two thirds of cancer patients will receive some form of radiation therapy during their illness. While the marriage of informatics and radiation oncology is not changing treatment options for patients, it is providing the radiotherapy team with smarter, more efficient tools to help receive, transmit and store electronic information, flawlessly - ultimately improving the many steps involved in advanced treatments. Radiation oncology is an intense, demanding field that is currently suffering a shortage of radiation therapists. Informatics is lending a helping hand.

Workflow at the Rock Hill Radiation Therapy Center (RHRTC) has improved significantly since implementing an oncology image and information management system. Transitioning to an electronic charting environment, the online data repository holds 15 years of patient clinical data. Electronic images and information are now available to each member of the radiotherapy team with the click of a button.

RHRTC (Rock Hill, S.C.), a freestanding radiation treatment center affiliated with the Carolinas Healthcare System, offers treatments such as conventional and conformal radiotherapy and IMRT (intensity modulated radiation therapy). An average of 50 patients are treated daily on two linear accelerators (linacs) - Varian Medical Systems' Clinac 21EX and 23EX. The center also utilizes GE Healthcare's new QXI wide-bore CT scanner.

To efficiently manage the electronic data, RHRTC implemented Varian's VARiS Vision record and verify system, along with the company's Eclipse treatment planning software. The systems operate in a single database environment, says Roy Lowe, RT, medical physicist at RHRTC. This creates a single electronic chart for each patient that is easily accessible for the medical staff anytime, anywhere.

"For example, when a CT scan is acquired and saved, it is saved to the VARiS database server," explains Lowe. "When these images are picked up for treatment planning, the plan is developed on the server. The images are not pushed around like they normally would be in the past.

"In the past, we used one entity to acquire data, then we pushed them through the DICOM protocol to a treatment planning system. Once the plan was complete, using the DICOM protocol, we would have to push it to the record and verify system. Then that information was pushed to the linac to actually treat the patient," Lowe says.

Now when a treatment plan is developed and saved using VARiS, it is saved to the server for near real-time access. Doctors can immediately review any updated information in their office or in remote locations. Radiation therapists can instantly access updated digital reconstructed radiographs (DDRs) minutes before a patient receives treatment.

A new clinical assessment module, part of VARiS, contributes to streamlined working conditions, Lowe says. The module electronically documents and manages a patient's diagnosis, disease staging, evaluation and management, patient vital signs, lab results, patient counseling and education, and medications. A smart staging feature guides physicians through the staging process according to current clinical guidelines so that an optimal treatment approach can be determined.

Digital technology has improved the process of acquiring portal images. "After the patient is irradiated with the portal imager, the electronic portal image is immediately available," explains Lowe. "There is no film developed by the radiation therapist. This cuts down dramatically the time that the therapist spends dealing with films, cassettes and processing. Most importantly, it cuts down the amount of time the patient needs to lie on the table to be treated."


RT and IT unite

Digital image management and electronic charting systems developed for radiation therapy provide oncology centers and departments with the confidence to routinely carry out technically advanced treatments. In addition, they significantly improve patient throughput.

Informatics is not viewed as improving treatment options, but rather as a way to improve the many steps needed in developing and executing a successful treatment plan - making the process more efficient and perhaps less arduous.

In lieu of the intense, demanding nature of the field, the current shortage of radiation therapists and the large number of patients who receive some form of radiotherapy annually, this is important.

According to the 2002 Radiation Oncology Workforce study from the American Society for Therapeutic Radiology on Oncology (ASTRO), radiation therapy practices across the country are in need of about three healthcare professionals per practice. In particular, facilities are having a difficult time hiring radiation therapists to help physicians treat patients. On average, practices across the United States are experiencing a shortage of 18.3 percent for radiation therapists - representing a current nationwide need for approximately 1,800 additional radiation therapists.

ASTRO also reports that nearly two-thirds of all cancer patients will receive radiation therapy during their illness. In 2002, nearly 1.3 million patients were treated with radiation therapy, up 13 percent from 2001. Also in 2002, 90 percent of patients treated with radiation therapy received external beam treatments from a linac. An average linac is used for 4,500 to 6,500 treatments per year.

Uptime of radiation treatment machines is crucial, as is the seamless flow of electronic data that are transmitted from the imaging modalities, to the treatment planning workstation, to record and verify, to the delivery machine. The process has been made possible - and more efficient - with informatics and souped up digital linacs.

"Radiation oncology has been a fairly late adopter of IT," says Tim Solberg, PhD, director medical physics, department of radiation oncology, University of Los Angeles Medical Center. "One of the main things that hindered this in the past was that our equipment was just not open and amenable to collecting and distributing electronic information." Yet now, digital linacs are replacing analog linacs, allowing users to integrate with software systems that track and dictate the flow of patient information. Thus, manual workflow is being replaced with automatic processes.

Another important milestone has been the development of DICOM-RT. "In radiation oncology there are many more things of interest than just images, such as contours, dose and portal images," says Solberg. "The DICOM-RT extension incorporates all of the necessary elements of radiation oncology and is having a revolutionary impact similar to that of DICOM in radiology. The adoption of DICOM-RT by the linac and treatment planning vendors is essential for improvements in radiation oncology workflow."

RHRTC's Lowe concurs that the advent of DICOM RT has changed the radiotherapy world completely. "Essentially it has allowed a standardization protocol of data movement to exist between linear accelerators, record and verify systems and data acquisition media such as CT, PET and MRI scanners," he says. "But more importantly, it has allowed software functionality to become virtually seamless. This allows for a more streamlined process of treating patients with a higher level of accuracy and efficiency."


Nothing 'less' about it

In the "Environmental Scan of the Radiation Therapists' Workplace" study conducted by the American Society of Radiologic Technologists (ASRT), 80 percent of the 590 participants indicated that the quality of patient care has improved during the last five years even though the complexity of treatment has increased. Additionally, 50 percent of staff radiation therapists and 60 percent of radiation therapy administrators perceive that the number of patients treated in a week's time also has increased due to technological advances.

While UCLA's radiation oncology department did not increase patient referral, the modest-sized department that treats 1,000 patients annually with five linear accelerators is now performing more complex, specialized procedures upon moving toward a filmless and paperless environment. "Our patient referrals are somewhat different from centers out in the community," says Soldberg. "So we are not necessarily increasing our patient load, but the system makes more efficient the increasingly complicated things that we do."

UCLA offers state-of-the-art technology, including stereotactic radiosurgery, IMRT, image-guided radiation therapy, prostate brachytherapy, total body irradiation and intravascular brachytherapy. Two years ago, the department began evaluating different delivery technologies, but more importantly, solutions that vendors had for connectivity and integration, says Soldberg.

The department implemented Siemens Medical Solutions' new generation Oncor Avant-Garde linacs, in addition to Siemens' Lantis oncology management system and Coherence Dosimetrist workspaces. "The technologies for the first time gave us the availability of electronic patient charting, electronic billing, and record keeping so that delivery machines and software systems are capable of capturing, storing and distributing electronic images," Soldberg says. "All of that has significantly improved our efficiency and workflow."

With a centralized Lantis server, clients run on PCs and these are installed throughout the department for multi-access utilization. Six Coherence workspaces with the Dosimetrist module are installed throughout the medical center. At their convenience, a radiation oncologist, medical physicist or dosimetrist can utilize the workstation's treatment planning tools and at the same time access multi-modality images that provide complementary information in determining the optimal course of patient care.

"Because radiation oncology is getting more technologically advanced, there are aspects of it that require more and more resources," says Soldberg. "With the electronic transfer of information, we can improve efficiency in other areas. For example, an IMRT plan that we do now is transferred electronically to the treatment machine; there is no inputting of parameters. This also minimizes the possibility of mistakes."

"For us, it was a big learning curve going from essentially nothing to state of the art," continues Soldberg. "Even though the process has been pretty painless, it still takes a bit time to become [filmless and paperless] completely. But I would say that is our overall goal, and we are pretty close to being there."


Recipe for success

In addition to increased adoption of clinical technologies, radiation oncology sites are increasing their usage of electronic networks to send and receive digital images used in treatment planning, according to IMV Ltd.'s 2001/02 Radiation Oncology Market Summary report. While in 1998, 24 percent of the radiation oncology sites used electronic networks, IMV's new census determined that 60 percent of sites now use networks for sharing electronic images used in treatment planning.

Good Shepard Hospital of Barrington, Ill., uses a comprehensive electronic network to transmit and receive electronic oncology images and information. The center installed IMPAC's ViewStation medical image management system that provides online access to medical images as well as permits digital images - CT, MR, digital radiography, computed radiography and electronic portal - to be imported and associated with a patient's medical record.

Good Shepard is one of four radiation oncology centers affiliated with Advocate Health Care, an integrated delivery network. Jagan Venkatesan, medical physicist, headed the project that transitioned Good Shepard and its networked clinics from a paper chart to an electronic-based charting environment. Good Shepard already has 800 medical records online.

The process was a difficult one, because as Venkatesan puts it, there really is no cookbook to developing an electronic department. "You have to go through these hurtles and figure out the best way to integrate your clinical practice with what the software gives you to work with," he says.

In terms of workflow improvements, the new systems reduce the amount of human intervention between transferring the data from the treatment/planning machine to the record and verify system. From an administrative standpoint, the largest gain has been accessibility. The electronic chart and images are always available. Good Shepard's radiotherapy team also has gained multi-person accessibility to the same file at any given time.

When implementing a digital image management system, Venkatesan suggests a project champion "sell" the system to the department as well as prove to the physicians how it will make their workload easier and more efficient. "For us, we have a huge physician radiation oncology group that rotates between four sites," explains Venkatesan. "A physician may start a case in one site, but the next day when the plan is ready to be reviewed, he or she may be at a completely different site. Since all the data are centrally located, the physicians are able to access the data from any one of the sites.

"It gives the physicians tremendous flexibility as to being able to review plans, check up on their patients, and check a patient's fields or images in real-time over the network." In the future, Venkatesan envisions an integrated PDA system with Bluetooth wireless capability so that physicians can review plans, images and also synchronize their schedules instantaneously over the network.

"Is it making our treatments any better by going electronic?" poses Venkatesan. "Probably not. But is it making our workflow more efficient. And making sure that we are delivering more accurately? Definitely. By going electronic, we have not enhanced our treatment modality any more than we would have with a paper chart. But we have streamlined the process and made it more efficient, in addition to improving communication internally throughout each site."


Conclusion

Informatics is helping make more efficient advanced radiotherapy treatments. Radiation oncology sites harnessing the power of digital image and information management systems are experiencing improved and efficient workflow, and providing better patient care. Multi-modality images are used to develop optimal treatment plans, robust networks are improving their transmission and vendors are providing the necessary tools to import these digital images in a patient's electronic record. Both care provider and patient are positively impacted by the inclusion of informatics in radiotherapy.