ELECTRONIC MEDICAL RECORDS (EMR) STREAMLINE CH I PROCESS. Ping Xia, Ph.D. Head of Medical Physics Department of Radiation Oncology Cleveland Clinic

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1 ELECTRONIC MEDICAL RECORDS (EMR) STREAMLINE CH I PROCESS Ping Xia, Ph.D. Head of Medical Physics Department of Radiation Oncology Cleveland Clinic

2 Disclosure I have received research grants from Siemens and Phillips.

3 Outlines and Objectives Overview of paperless operation. Discussion of the development of new communication pathway. Discussion of new challenges in the paperless environment. Understand how to apply EMR to enhance clinical workflow. Understand new pitfalls of missing charts under the paperless environment.

4 Record and Verify Systems The initial intent of R&V system is simply to verify that the delivered MUs and MLC shapes are as planned and to record what we delivered. The R&V system is a significant invention in radiation therapy, drastically reducing human errors in our delivery. The treatment parameters are electronically transferred to R&V system, avoiding another source of human errors.

5 From R&V to Computer Controlled Treatment Before Computer controlled treatment, delivery of the radiation treatment mandated radiation therapists manually set between parameters per patient, including field size, collimator angle, and gantry angle.

6 Significant Treatment Errors Reduction Manual data entry had an error rate of 0.21% per segment. Computer controlled treatment delivery has an error rate of 0.085% per segment.

7 Advancements in Radiotherapy Along with MLC and computer optimization, computer controlled delivery enables us to deliver more complex treatments such as 3D conformal, IMRT, VMAT, etc.

8 Conventional Dose Distributions 49 Gy 45 Gy 35 Gy

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10 Intensity Modulated Volumetric Arc Therapy Increased beam directions from 7~9 to 90~180

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15 Checklist Manifesto

16 Dosimetry Quality Checklist

17 Physics New Plan Quality Checklist

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19 Adapt to Changes from Conventional Delivery to Modern Delivery From manual data entry and recording to electronic data transferring and recording. From everything on paper to everything electronically. From intuitive beam shapes to non intuitive beam shapes From a few beams to many beams.

20 Using EMR to improve RT Quality EMR contains all things happening at RO. Patients All procedures Planning data, treatment data Resources (simulators, Linacs)

21 Using EMR to improve RT Quality Using EMR Optimize management of Department Resources Even new start distribution (days, among machines). Tracking of patients through the treatment course. Manual and automated checks at critical junctures of the process. Tracking of delivery quality

22 EMR Is Less Forgiving Time stamps matter, not forgiving. The signature sequences must be followed. The charges must be billed on time. The documents must be generated with the same day as the charges are billed. IMRT QA must be done prior to the first treatment..

23 New Pitfalls of Missing charts Under the Paperless Environment???? Simulation Ready for Tumor vol. Tumor Vol. Ready Plan approved Phys. check completed??? IMRT QA completed Chart arrived on machine list Therapy check completed Ready for treatment

24 New Pitfalls of Missing charts Under the Paperless Environment The chain is broken if one does not hand over to the next step despite all the work is done. Later chart, later chart,. Rush makes mistakes.

25 Develop a Standard Language Develop a standard language used in R&V system and be compliant. Label IMRT plans as TP IMRT, Label SBRT plans as TP SBRT. The status of a new patient is designated as: S start, P portal day, O old patient with new treatment A adaptive plan to start,.

26 Enhance Clinical Workflow New Chart Status Start Hours Phys Dosi Sim Patient Name IMRT QA Document Status

27 Apply EMR to Enhance Clinical Workflow Availability of machine time

28 Development of New Communication Pathway Automatically to a group (IMRT QA group) to alert how many new IMRT plans are just completed and ready for IMRT QA and their due dates. a group (dosimetry and physics groups) how many new patients are going to start on each machine and what are the status of the charts. a group (e.g. physicians) how many verification images are needed to be approved, who are responsible, and due dates. a group (e.g. physics and dosimetry) which charts have not been checked for more than 4 fractions since last check.

29 Modern Electronic Gadgets

30 Summary EMR can increase workload, requiring more timely documentation. EMR can also improve efficiency if we use it effectively. Physicists will lead effort to use EMR to improve workflow and quality.

31 Summary