1. McLaren-Elekta Progress Report
This report is first in a series
describing projects related to the
implementation of Elekta cancer
management solutions at the Barbara
Ann Karmanos Cancer Institute.
PAGE 3
Journey to the Cloud
PAGE 6
Exceptional care everywhere
PAGE 8
Moving ahead united
PAGE 10
Model for the future
PAGE 12
The indispensable change agent
PAGE 14
A vigilant eye on quality
HIGHLIGHTS
Summer 2015

2. 2
In December 2013, McLaren Health Care entered a unique,
long-term strategic partnership with Elekta. McLaren,
having just welcomed the Barbara Ann Karmanos Cancer
Institute as our most recent subsidiary, knew that we had
a special opportunity to improve the treatment of cancer
patients throughout the state. As the largest provider of
cancer services in Michigan, we took our duty seriously.
It has been our solitary goal to offer the highest possible
quality of care, regardless of which of our 18 cancer centers
is providing the care. As our partnership was negotiated,
Elekta committed to deploy their best resources to help us
realize our goal.
Just over one year into our partnership, our joint teams have
deployed a single ambulatory medical oncology information
system at all of our Karmanos community-based sites.
Our radiation centers and medical oncology at Karmanos
Cancer Hospital will likewise follow suit. A single cancer
registry system also has been implemented and is hosted in
the Elekta cloud. Nearly 400 medical oncology and radiation
oncology care plans have been developed and implemented.
Several components of Elekta hardware also have been
installed, including the first Versa HD™ linear accelerator
in Detroit. Nearly every aspect of our clinical and research
integration has been advanced by the collaboration between
McLaren, Karmanos and Elekta and our many dedicated
employees. I thank everyone for their hard work.
A project of this magnitude is never without challenges and
change of this scale requires commitment, dedication and
perseverance. It’s worth remembering that everything we
do is for our patients. As McLaren Health Care continues its
journey to become an “always” organization, we commit to
“always” offering our best. I thank Elekta for contributing to
this important goal.
Philip A. Incarnati
President & CEO
McLaren Health Care
The Barbara Ann Karmanos
Cancer Institute and its
Community-Based Programs
are undergoing a tremendous
metamorphosis that will further
solidify the organization’s
reputation as among the
most advanced, quality-driven
cancer treatment centers in the nation. In addition to the all-
important harmonization of oncology practices Karmanos
has achieved for all of its 18 centers, the institution has
implemented Elekta’s flagship MOSAIQ® Oncology
Information System for its medical oncology programs and
is poised to transition to MOSAIQ for radiation oncology.
And, Karmanos Cancer Hospital in Detroit is at the forefront
of a system-wide migration to Elekta linear accelerators and
treatment planning systems.
Serving as McLaren Health Care’s key technological partner
in this transformation has been a considerable honor, given
that McLaren had other choices among cancer management
solutions providers. Forming such close partnerships has
been critical to Elekta’s success, and, we hope, the success
of our customers as well.The experience so far has been
as rewarding as it has been daunting and challenging –
requiring our very best human and technical resources to
help Karmanos bring these early phases to completion.
The future – over the next several years – brings the
implementation of additional Elekta solutions and
refinement of the new Elekta products the cancer treatment
network has installed. In addition to improving the
effectiveness of therapy, these new implementations will
further boost the quality of care and efficiency Karmanos
Cancer Institute delivers to benefit its patients – the focus of
everything our organizations do.
Tomas Puusepp
President & CEO, Elekta
"It’s worth remembering that
everything we do is for our patients."
- Philip A. Incarnati

3. 3
Dedication to Karmanos vision
results in oncology system-wide
EMR “go-live”
Regardless of the size of their role in“The Project,”
hundreds of people set aside their personal preferences
and routines, left their comfort zones and dedicated
themselves completely to a truly monumental goal: the
migration of the Karmanos Cancer Institute Community-
Based Programs’ paper-based medical oncology workflow
to MOSAIQ, a paperless, cloud-based electronic medical
record (EMR) system. In 2014 and 2015, after more than
six months of preparation, and under the supervision of
the Oncology Information System (OIS) Task Force, 10
sites underwent the transformation sequentially over 34
weeks of go-live roll-outs of Elekta’s MOSAIQ Oncology
Information System.
The transition to MOSAIQ was a key part of the health
system’s efforts – in keeping with the vision statement –
“To be a world leader in cancer care, research and
education through courage, commitment and
compassion.”According to Lauren Lawrence, Director,
Community-Based Programs, Karmanos Cancer Institute
(KCI), and co-chair of the OIS Task Force, the key to the
project’s success was creating not just a team, but also a
spirit of teamwork, from among a diverse group of KCI and
McLaren Health Care medical oncology practices.
“We united two different organizational cultures in KCI
and McLaren – their respective IT groups, professionals
in pharmacy, nursing and clerical OIS Task Force Working
Groups, and Elekta representatives,” she says.“They
brought their knowledge and expertise to the table and
collaborated on a common vision for the implementation
of the EMR. That’s what I’m most proud of – that we
were able to assemble this diverse team of experts and
accomplish the objective in such a short time frame.”
The two historic teams now represent one cancer program
extended throughout McLaren’s statewide network.
MOSAIQ supports the vision
For integrating a healthcare network of widely dispersed
clinics there is no substitute for the EMR. Implementing a
single, network-wide EMR was more than overcoming the
disadvantages of a paper-based workflow, it was a way to
ensure that providers could access all the patient’s data
from anywhere in the network, and, similarly, to enable
patients to move around in the network – to receive care at
the clinic best suited for their needs (i.e., specialized care,
follow-up, continuing care, etc.)
JANUARY 2014 – Medical
Oncology care plan summit
DECEMBER 2013 – Deal signed MARCH 2014 – First site (Macomb
Medical Oncology) moved to the cloud
(this has become the main
DB to accommodate the
pursuit of one DB for the
entire network)
OUR COLLABORATION
JOURNEY TO THE CLOUD

4. 44
“The EMR also would help us efficiently track and measure
the quality of care provided at each community-based
practice, by evaluating how closely they are adhering
to the care plans we designed [see "Exceptional care
everywhere"],” Lawrence observes.“If we can ascertain
that they’re all following the same care plans, we can
be assured that patients are receiving the same high
standard of care across the system.You cannot make that
determination easily when clinics are isolated in discrete
paper-based environments.”
The electronic linkage MOSAIQ provides between the
community-based practices and the academic/research-
based centers of Karmanos Cancer Hospital also is vital
for the dissemination of clinical trial protocols, she adds.
“That is huge,”Lawrence says.“It’s not only about ensuring
quality and standardization of care. Soon, through the EMR,
community-based clinics will have access to the latest
treatment protocols, enabling them to take care to the next
level. It all goes back to fulfilling our vision to be a world
leader in cancer care.”
All told, MOSAIQ is now employed by 500 medical
oncology end users, including doctors, nurses,
pharmacists and administrative staff.
Gearing up for go-lives
A massive amount of upfront work went into the paper-
based-to-MOSAIQ transition. The OIS Task Force team
members worked from January 2014 through late June
2014 on several important activities. The Pharmacy and
Nursing Work Groups validated and tested the 350+ care
plans developed following a multidisciplinary care plan
summit in January.
“Physicians, pharmacists, nurses and other healthcare
professionals went through the care plans line-by-line
to ensure the dosages and cycles were right and all the
components of the care plan were correct, and then they
tested every one of the care plans before they went into
production,” she recalls.
Meanwhile, the KCI IT team spent months evaluating the
IT infrastructure of the 10 community-based practices,
assessing their needs and acquiring and implementing
required hardware. In addition, IT staff from Elekta, KCI
and MHC (Anthelio) worked to develop several application
interfaces (e.g., ADT, laboratory, radiology and documents
outbound), all of which had to be tested at each site. And
the Clerical Work Group focused on ensuring all details
were completed related to revenue capture in MOSAIQ.
“Timelines were aggressive, so there was a great deal of
interdependency among the Work Groups,” Lawrence
says.“Constant communication between OIS Task Force
members and community site leaders was essential and,
because we were dispersed over the state, that meant
strings of emails backed up by strings of emails and
hundreds of conference calls.”
As a preamble to the MOSAIQ go-lives, on June 23,
2014, the discrete tumor registry databases of individual
community sites were merged and taken to the Cloud
under Elekta’s METRIQ cancer registry. The network’s
18 certified tumor registrars (CTR) now had a single
system for entering tumor data. When MOSAIQ Connect
is interfaced to METRIQ in the future, the EMR will be able
to feed information right into the data extraction fields that
the CTRs are presently collecting and abstracting.
JUNE 2014 – 7 METRIQ databases
merged and moved to the cloud
MARCH 2014 – Radiation Oncology
summit & project kick off
JUNE 2014 – first MOSAIQ
implementation – Bloomfield Hills
(paper to standardized E-workflow &
implementation of MO care plans)

5. 5
A new MOSAIQ site every
three weeks
With all the upfront work completed, the OIS Task Force
began a systematic, one-after-another process of MOSAIQ
go-live roll-outs, one every three weeks for 34 weeks, from
June 30, 2014 to February 20, 2015. The three weeks were
packed with activity:
Week 1: “Prep”Week (core document scanning, encounter
document types, load medication lists and allergies per
patient, loading patients into schedule, interface testing,
end-to-end testing, Current State Workflow review with
site manager and staff).
Week 2: Site staff training by Elekta team (front desk,
nursing, medical assistants, physicians, pharmacy, HIM/
ROI, charge capture/billing.
Week 3: Go-Live. Attended by Elekta team, KCI IT, Anthelio
IT Field Service (MHC), CBP oversight, experienced site
manager, the site manager of the next Go-Live site.
To keep the sequential roll-outs on track and troubleshoot
potential issues, the project management team held a
5:00 p.m. teleconference every weekday during the 34
weeks of implementation, a total of 170 meetings.
“If you were a representative of the site going live, you
were the primary issue that we talked about on the call,”
Lawrence recalls.“But if you had just gone live, you were
also on the call. And if you were the next site to go live, you
were listening in to see what to expect.”
The fourth week was the first week of post go-live support,
in which project management team members were on
hand to provide onsite help for users, shifting to service
desk support in the fifth week. Two months after the last
community-based practice transitioned to MOSAIQ, the
project is now in a “circle-back” phase to assess the extent
and correctness of MOSAIQ use among end users.
“We will identify which practice needs the most support
and a Karmanos team, an Elekta team and I will spend at
least a week onsite to see how they’re navigating through
MOSAIQ, where they need assistance, and how we can
make it more efficient for them,” Lawrence says.
Phase II of the MOSAIQ implementation project is now
underway and involves integrating, over the next several
months, advanced features into the OIS, include e-faxing
of reports to referring physicians, voice recognition
technology, IQ Scripts and bar code medication
administration.
An amazing journey
The transition of Karmanos Cancer Institute’s Community-
Based Programs from a paper-based medical oncology
workflow to the MOSAIQ EMR has been a tremendous
success for the organization, a testament to the power of
teamwork and leadership in the pursuit of a worthy vision.
“It has been an amazing journey – something that when
you look back, you say ‘Wow!’ It’s quite an accomplishment
for this organization to do this and bring all these people
together,” Lawrence says.“I give significant credit to
our President and CEO, Dr. Gerold Bepler and our Vice
President, Dr. Justin Klamerus, who are the visionaries
who supported us all the way throughout this mission. It
takes strong leadership behind the people that are doing
the implementation and they continue to guide us.”
AUGUST 2014 – third MOSAIQ MO
implementation – Clarkston
JULY 2014 – second MOSAIQ MO
implementation – Lapeer
SEPTEMBER 2014 – fourth MOSAIQ MO
implementation – Macomb
(upgrade to new future state, with
standard workflows and care plans)
What’s in MOSAIQ?
• CPOE
• 350 + chemotherapy care plans
• Nursing assessments
• Imaging and laboratory results
• 185 document types
• Diagnosis & problem list
• Medical list & allergies
• Alerts
• Other non-chemotherapy
order sets
• Survivorship care plans
• Patient education materials
• Provider E-Scribe templates by
disease site
• Social work, referral,
assessment, E-Scribe &
template
• Clinical trial identification
• E-Prescribing capabilities

6. 6
Stephen T. Smith
Medical oncology care plans
harmonize care practices at
Karmanos centers
While the system’s cancer centers are spread far
and wide throughout Michigan, Karmanos Cancer
Institute undertook a massive effort to ensure each was
indistinguishable from another – at least in terms of the
quality of care patients receive and how they receive it. As
part of its 2014-15 transition from a paper-based medical
oncology workflow to the MOSAIQ electronic medical
record. Karmanos formed task force teams to create a
new set of care plans – designed specifically for use with
MOSAIQ – that would fully standardize medical oncology
care delivery throughout the system.
“Developing these care plans was aimed at getting all the
centers consistently using the same practices to treat
patients, whether the patient is at our cancer hospital,
an academic medical center, or at any one of our 15
community sites,”says Stephen T. Smith, Director of
Pharmacy Services.“Working groups from MHC and KCI
collaborated to establish an evidence-based oncology
practice that assures therapeutically effective, safe, rational
and cost-effective therapies across the McLaren network.
The care plans were one critical aspect of that mission and
were a key component of the transition to MOSAIQ.”
Care plan summit
During January 2014, just as the clinical integration
between McLaren and Karmanos was starting, Drs.
Gerold Bepler and Justin Klamerus convened a care
plan summit that brought together Karmanos and
McLaren pharmacists, nurses, medical oncologists and
other healthcare providers. Their mission was to reach
a consensus on the contents of the most common care
plans used in medical oncology.
A care plan is essentially a treatment plan; an organized
set of orders, instructions, assessments and diagnostics
that are used to drive patient care to an accepted
evidence-based standard. An audit of care practices at
network sites revealed a wide variety of practices.
SEPTEMBER 2014 –
Northern conversion to
the cloud
SEPTEMBER 2014 –
MOSAIQ V.2.6 upgrade
(all databases – Main,
Northern, Detroit)
SEPTEMBER 2014 – Kick
off – Karmanos Quality
Index Development
("Gang of 8" sub group)
OCTOBER 2014 –
Kick off ARIA data
migration project
Their mission was to
reach a consensus on
the contents of the most
common care plans used in
medical oncology.
EXCEPTIONAL CARE
EVERYWHERE

7. 7
“Some sites were very detail-oriented, others were not,”
Smith says.“And, there was significant variability in
things like solution volumes, infusion times, response,
sequencing of drugs and other aspects.”
An example might be a chemotherapy drug added to 250
mL of solution and infused over 30 minutes versus the
same drug added to 500 mL and infused over 60 minutes.
“Both are acceptable, but to standardize care, you want it
done the same way every time,” he explains.
The starting point in care plan development was ensuring
adherence to evidence-based guidelines, such as those
provided by the National Comprehensive Cancer Network,
the Oncology Nursing Society, the American Society for
Health System Pharmacists, and the Quality Oncology
Initiative for Best Practice, in addition to Michigan’s Blue
Cross/Blue Shield pathways.
“My mantra, however, was that while these guidelines
are necessary, they aren’t granular enough – they’re
very general,” Smith observes.“We needed to drive down
to the next level of standardization, for example, the
nursing assessments and pharmacy instructions. The
care plans are not just a list of drugs, they are reflective
of required diagnostics, all the monitoring tools, and any
kind of assessment that need to be done by the nurse,
the pharmacist and the physician to help drive care to
standardization and reduce variation between practices.
And, the care plan should track these steps during the
patient’s day in the Infusion Center as well as throughout
the patient’s entire treatment.”
Collaborating with the nursing, pharmacy and provider
working groups were 14 multidisciplinary teams (MDT)
from Karmanos Cancer Hospital, which focused on specific
cancers.There were MDT’s for lung, genitourinary, breast,
gastrointestinal, head-and-neck, sarcoma, melanoma,
gynecology and malignant hematology cancers.
Reflecting the complexity of the care plan project and the
challenges of reaching consensus when dealing with a
diverse group of providers, the initiative consumed nearly
a year and hundreds of hours of effort, progressing even as
care plans were being integrated into MOSAIQ.
“It was daunting to get everyone focused and agreeing to
a single standard,” Smith remembers.“The details were
overwhelming; like what to use for supplements or adjunct
therapy, standardizing antihistamines and antiemetics.
There was a lot of passion in terms of what’s right and
what’s wrong. But, we always fell back on the medical
evidence, the medical literature and what’s best for the
patient to support what we were doing.”
Care plans working in MOSAIQ
Approximately 350 care plans are now resident in
MOSAIQ, available to the 10 sites that went live with the
OIS during June 30, 2014 to February 20, 2015.
“We are by no means done with care plan development,”
Smith notes.“The vast portion the community sites would
use – the NCCN commercial, approved protocols –
are probably 90 percent done. But, Karmanos Cancer
Hospital also provides specialized care in bone marrow
transplantations and also is engaged in close to 350 open
investigational drug protocols. By the time we’re done, we
will have about 800 care plans.
“Once again, the whole purpose of taking the time to
create these hundreds of care plans,” he adds,“is to
minimize variation, to create unique Karmanos Cancer
Institute standards. By having all of our sites adhere to a
single standard, we know that every patient in the system
is receiving the best possible state-of-the-art care.”
OCTOBER 2014 – RO care plan summitOCTOBER 2014 – First Versa HD
delivered to a KCI site – Detroit
NOVEMBER 2014 – fifth and sixth
MOSAIQ MO implementations –
Northern Petoskey & Gaylord
"By having all of our sites adhere to a single standard, we
know that every patient in the system is receiving the
best possible state-of-the-art care."
- Stephen T. Smith

8. 8
(l-r) Justin Klamerus, MD, MMM; Gerold Bepler, MD, Phd; Thomas Boike, MD; Praveen Dalmia
Karmanos network to
benefit patients by unifying
radiotherapy practices
Like its medical oncology counterparts, the 10 Karmanos
Cancer Institute radiation sites have harmonize their
care practices to ensure patients receive a consistent
high quality care from any program the patient visits.
The strategy to get there mirrored medical oncology
– establishment of care plans specifically created for
radiation oncology and designed for use with the network’s
MOSAIQ electronic medical record (EMR). In May 2015,
the McLaren Health Care/Elekta partnership launched a
single instance of MOSAIQ across all sites by merging their
existing MOSAIQ databases into one cloud environment,
while migrating away from their previous Varian EMR.
“While the community-based radiotherapy sites have all
been under the McLaren name, each had been functioning
as an island in terms of how each site performs its
radiotherapy tasks,” says Thomas Boike, MD, associate
medical director at Karmanos Cancer Institute at McLaren-
Northern Michigan and leader of the care plan project.
“With MOSAIQ and care plans, all those islands were
brought together to unify practices and enable the sharing
of knowledge, with the aim of benefiting our patients.”
RO care plan summit
Like the medical oncology care plans, the radiation
oncology care plans are evidence-based, leveraging
radiotherapy guidelines from the National Comprehensive
Cancer Network, the American Society of Therapeutic
Radiation Oncology, the American College of Radiology
appropriateness criteria, and data from the current
standard arms of NRG Oncology clinical trials.
These guidelines formed a starting point for radiotherapy
professionals to customize care plans for the network.
“There was, however, a wide range of acceptable practice
and so this was a new task for us,” Dr. Boike explains.
Therefore, in advance of a planned Radiation Oncology care
plan Summit, Dr. Boike and his radiation oncology project
team reached out to Dr. Marie-Andrée Fortin (Centre de
Santé et de Services Sociaux de Laval), Dr. Marc Posner
(Center for Advanced Radiation Medicine, Northwestern
Lake Forest Hospital) and application specialists Meghan
Dennis and Laura Deluca (Thunder Bay Regional Health
Sciences Centre, Ontario) to obtain information on their
use of care plans in the MOSAIQ environment.
“Knowing the functionality of the software was important,”
Dr. Boike says.“Working with the information they provided,
DECEMBER 2014 – Karmanos Quality Index
defined and approved
DECEMBER 2014 – Seventh and eighth
MO implementations – Bay City and
West Branch
DECEMBER 2014 – Framework
Research Agreement signed
MOVING AHEAD UNITED

9. 9
Dr. Kiran Devisetty, the project team, and I formulated what
we would cover during our care plan summit.”
In contrast to a medical oncology care plan – which
focuses mainly on chemotherapy drugs, dosages, and
treatment protocols – a disease-specific radiation
oncology care plan is a set of orders: simulation orders,
planning orders, treatment orders and follow-up orders.
On November 2, 2014, under the leadership of Dr.
Boike and Dr. Devisetty, and facilitated by Elekta, over
55 representatives from the radiation oncology sites –
including physicians, physicists, dosimetrists, therapists
and nurses, in addition to Elekta staff and McLaren and
Karmanos executives – convened in Flint for a one-day
care plan summit. The goal of the summit was to come to
consensus on disease-specific care plans for four major
disease sites: lung, genitourinary (i.e., prostate), breast
and brain.
“Setting the meeting date was the most challenging part
due to everyone’s busy clinic schedules during weekdays –
so it had to be a Sunday,” Dr. Boike says.“In terms of the
care plans, we found more consensus on what we were
already doing than areas of disagreement; the latter being
things like the difference between patient preparation
steps, such as ‘full bladder,’ versus ‘comfortably full
bladder,’ – we needed to agree on some common terms
for what we meant.”
Apart from care plans in MOSAIQ, the group also worked
to standardize several other practice aspects among the
sites, including radiation prescriptions (dose constraints,
dose objectives), MOSAIQ quality checklists, IQ Scripts
(automated task workflow in MOSAIQ), and MOSAIQ
eSCRIBE documents.
For several months after the November 2 summit, work
on care plans for other disease sites and malignancies
was carried out via WebEx conferences. These included
lymphoma, gastrointestinal cancers, gynecologic cancers
and head-and-neck cancers.
At completion, the final output of the care plan team was:
• 46 disease-specific care plans
• 147 radiation prescriptions
• >90 quality checklists
• >300 order sets used in care plans or ad hoc orders
• >220 IQ Scripts
• >100 standardized eSCRIBE documents
Big winner is the patient
While standardizing the radiation oncology practices will
undoubtedly improve the competitiveness of Karmanos
Cancer Institute in Michigan and the region, the main
beneficiary is the patient, according to Dr. Boike.
“These care plans are evidence-based and the consensus
of all of our radiation oncology professionals,” he says.
“As our radiotherapy programs put them into clinical use,
patients across the system will consistently receive the
same high quality care at any of the sites they visit. The
patient’s welfare and how they perceive their treatment
were at the heart of the development of the care plans.”
With the care plans residing in the MOSAIQ EMR, KCI will
also have an efficient way to disseminate new or updated
care plans to the system, and to track treatment outcomes
of multiple centers from a single database. In addition, if
higher toxicities are observed at one or two centers, this
will become apparent and “targeted interventions” can be
undertaken to address these issues.
“Conversely, we may see a‘positive outlier,’for instance,
a center with very low toxicity or shorter wait times for
treatment,”he adds.“We could determine what that
program is doing differently and apply that practice into all
the other centers and make that the new network standard.”
The Karmanos community-based programs will
experience further radiotherapy practice harmonization in
the coming months and years as the sites begin replacing
their Varian linear accelerators with Versa HD™, Elekta’s
most advanced treatment system.
“With all centers using care plans and treating on the
same advanced linear accelerators,” he says,“we will be
even better able to deliver the same quality treatment to
all patients and leverage the outcomes data from those
treatments.”
JANUARY 2015 – First brachytherapy
system in use at Detroit
JANUARY 2015 – Ninth MO
implementation – Central
FEBRUARY 2015 –Tenth MO
implementation – Greater Lansing

10. 10
(l-r) Michael Snyder, PhD, Robert Halford, Mara Jelich
Karmanos Cancer Hospital Detroit
first with Elekta linear accelerator
and treatment planning system
As Karmanos Cancer Institute’s Community-Based
Programs undergo sweeping changes in their radiation
oncology and medical oncology information systems
(OIS) – the adoption of or conversion to Elekta’s MOSAIQ
OIS – Detroit-based Karmanos Cancer Hospital (KCH) is
the first in the network to acquire and clinically operate
a robust suite of advanced Elekta radiotherapy systems.
Joining KCH’s existing MOSAIQ OIS – in use since 2007 –
these systems include the Versa HD™ linear accelerator,
Monaco® treatment planning system and Flexitron®
brachytherapy afterloading platform. Like MOSAIQ for
oncology information management, the Versa HD/Monaco
combination is the treatment delivery/treatment planning
configuration that will extend across all Karmanos sites
over the next 10 years.
After a meticulous three-month commissioning process
by its physics team, Karmanos Cancer Institute began
treating patients with Versa HD in early March 2015.
The system replaced a Varian linear accelerator that
KCI had been operating since 2001. Versa HD is Elekta’s
most advanced treatment system, equipped with ultra-
sophisticated beam shaping and high dose rate mode
technologies, giving clinicians the flexibility to deliver
conventional therapies to treat a wide range of small and
large tumors throughout the body, while also enabling
treatment of highly complex cancers that require extreme
targeting precision.
“Complex installations and implementations of major
new radiation therapy systems are never without their
challenges, and the Karmanos Cancer Hospital experience
with our new Elekta systems was not an exception,”
says Jay Burmeister, PhD, chief of physics at Karmanos.
“However, the Karmanos and Elekta physics teams worked
well together to address issues as they arose. Overall, it
went very well.”
On the Karmanos side, physicists Bob Halford, MS and
Michael Snyder, PhD invested months in the run-up to
the first patient treatment, gathering measurements of
Versa HD treatment beams and entering those data in the
Monaco treatment planning system, in addition to testing
the Versa HD image guided radiation therapy (IGRT)
technology.
“It’s a painstaking process,” Halford says.“We tested the
model in hundreds of plans and deliveries to continually
refine it, enabling Monaco to very accurately predict what
APRIL 2015 – First comprehensive test migration on the
Flint Database
MARCH 2015 – First patient treated on new Versa HD – Detroit + first
treatment planned using Monaco TPS
MODEL FOR THE FUTURE

11. 11
MAY 2015 – first implementation of
new RO future state (+ care plans) –
Northern Petoskey site.
Versa HD will deliver. We’re going to work closely with
Elekta and the KCI community-based sites to use the
experience we’ve gained to help these other facilities as
they commission their own Versa HD systems.”
As Versa HD patient volume builds to capacity over
the next several months, KCH clinicians are preparing
to implement intensity modulated radiation therapy
(IMRT) treatments. The center recently received external
validation of the accuracy of its Monaco/Versa HD IMRT
program by the Imaging and Radiation Oncology Core
(IROC).
“The results show that our IMRT dose calculation and
delivery accuracy are outstanding,” Dr. Burmeister reports.
Monaco treatment planning
Concurrent with their first clinical use of Versa HD, staff
also began using the Monaco treatment planning system
for the first time. Monaco is an advanced treatment
planning solution equipped with biological cost functions
with multi-criterial constrained optimization, a powerful
leaf sequence optimizer and the gold-standard Monte
Carlo dose calculation algorithm.
“We’re excited to test the Monte Carlo algorithm and
biological optimization,” he says.“These features will help
increase our dose calculation accuracy and allow us to
optimize treatment plans based on biological metrics,
rather than just physical dose distribution characteristics.
While there have been some workflow and efficiency
limitations during our implementation of the Monaco
system, we have been assured that upcoming versions of
Monaco will provide the enhanced tools and capabilities to
overcome these limitations.”
As the partnership with Elekta moves forward, the
Karmanos Cancer Institute is committed to implementing
a comprehensive treatment planning solution. Teams
from both organizations are engaged to ensure that future
products, with planned enhancements, continue to build
on the strengths of Monaco.
Linking up with MOSAIQ
A long-time user of Elekta’s MOSAIQ OIS, Karmanos is
eager to begin networking with the community-based sites
as they migrate from their Varian OIS to MOSAIQ, he adds.
“We will be able to track a lot of metrics that would be
impossible to track if the radiation oncology centers were
on different systems,” Dr. Burmeister observes.“If the goal
is for our cancer care network to deliver standardized care
across the entire system, we need a way to evaluate that.
When we are all networked by MOSAIQ, this will be much
easier to do.”
Judging by the visibility of Elekta personnel during the
equipment installation and implementation process, and
the close teamwork between Elekta and Karmanos teams,
Dr. Burmeister is looking forward to a more intensive
customer-provider relationship.
“This partnership is unlike any vendor relationship I’ve
ever been involved in,” he says.“The effort that Elekta is
putting into it tells me that we will have more input into
these processes, whereas if we are just another customer
to a vendor, then we are limited to the products and
services they choose to offer. So, my expectation as we
move forward is that we will be more involved in product
development, and alpha- and beta-testing.”
MAY 2015 – Final site goes live
on METRIQ (Detroit – currently
a SEER site)
"The results show that our IMRT dose calculation
and delivery accuracy are outstanding."
- Jay Burmeister, PhD
APRIL 2015 – Patient Portal
integration achieved – successful
transmission
of CCDA.

12. 12
(l-r) Gerold Bepler, MD, PhD; Justin Klamerus, MD, MMM
MOSAIQ Oncology Information
System unifies Karmanos
cancer care
by
Gerold Bepler, MD, PhD
President & Chief Executive Officer
Karmanos Cancer Institute
Justin Klamerus, MD, MMM
Chief Quality Officer & Vice President
Karmanos Cancer Institute
Several articles in this report stress how important our
implementation of the MOSAIQ electronic medical record
(EMR) has been in uniting the health system’s cancer
service line. A statement in the article Journey to the
Cloud, says it all: “For integrating a healthcare network
of widely dispersed clinics there is no substitute for the
EMR,” as a common, unifying information platform. In that
respect, implementing the OIS has been the indispensable
change agent driving our integration.
This isn’t hyperbole. While the unification of MHC’s
McLaren Cancer Institute and Karmanos Cancer Institute
would have happened regardless of the hardware
and software chosen, we are confident that it is the
connections made between our dedicated colleagues that
has made all the difference. As of this publication date,
we have brought over a dozen centers together through
MOSAIQ. As we prepare to implement MOSAIQ at our
Detroit and Farmington Hills locations, we are certain we
will see even deeper integration and standardization of
care and professional practice.
Michigan is a big state with a lot of geography separating
our network cancer sites. Because of this, many of our
programs functioned as independent, autonomous
centers. Historically, apart from initiatives such as patient
screening, patient education, community awareness
and community benefit events, the providers at McLaren
Cancer Institute sites hadn’t come together before to
cooperate on big projects. Synergy means that the whole
is greater than the simple sum of its parts. This couldn’t
be more evident than in the coming together of McLaren
and Karmanos to form the state’s largest cancer provider
network. The first, and perhaps most significant, product
of our integration is our comprehensive care plans in
medical oncology and radiation oncology. Beyond this
important product, it is the teamwork demonstrated to
accomplish this goal that should make us all proud.
In fact, the care plan summits were the first events in
which multi-disciplinary professionals of our network
got together in an organized way to share their collective
MAY 2015 – Pre –Alpha testing –
Elekta’s Operational Dashboard
against Mclaren database
THE INDISPENSABLE
CHANGE AGENT
JULY 2015 – Kick off MOSAIQ
database Merge planning
JULY 2015 – Second Versa HD
ships to Macomb site
JULY 2015 – Delivery of
second brachytherapy
system to Macomb

13. 13
ON DECK:
expertise and experience. In pursuit of the critically
important organizational goal of harmonizing and
standardizing their care practices, representatives at the
community centers and our downtown facility worked to
form a consensus on high-quality patient care.
This collaborative process didn’t end with the care plan
summits, of course; it was – as Winston Churchill once
said – the “end of the beginning.” For the medical oncology
care plans, what followed was a pretty intense twelve-
month period of validation, testing and site preparation
to go live with the implementation of MOSAIQ in the
community. In the last month, our future state of MOSAIQ
for radiation oncology has been implemented in Petoskey
and soon, Detroit and Farmington Hills. Later this summer
we will complete the important task of converting our ARIA
sites to Elekta’s MOSAIQ OIS.
Our program has seen significant change in the past
year. Change is not always easy. Changing an EMR or a
treatment planning system can certainly be a disruptive
change for our colleagues and the sites who must adapt
to the new technology. As leaders at Karmanos, we are
aware that every change we ask our teams to make must
be driven by the principle that we are enhancing the
quality and service we provide for our patients. We are
confident that the Elekta Strategic Partnership serves our
goal of delivering Better Treatment and Better Outcomes
for our patients. We have confidence in this because we
have seen what hard-working and dedicated professionals
can do when they come together to be better together.
“Better Together” is the founding philosophy of our cancer
network.
MOSAIQ will be the unifying IT platform that will drive
much of our great work in the years to come. We want
to personally thank all of the countless professionals
who dedicated time and energy to this successful
implementation in the community. In particular, we want to
thank our project leaders – Dr. Tom Boike, Jay Burmeister,
Kay Carolin, Praveen Dalmia, Paula DesJardins, Dr. Kiran
Devisetty, Lauren Lawrence, Scott McCarter, Joe Nugent,
Shari Pifer and Stephen Smith – for their commitment to
our shared vision. Our entire system owes each of you and
your teams' our deep gratitude. We also want to thank the
countless Elekta professionals who also share our vision.
Three years ago Elekta’s President & CEO Tomas Puusepp
promised to change the typical “vendor” relationship
we had had with our previous provider. Elekta could not
have delivered more completely on this commitment.
Driving the deliverables of our partnership has been Elekta
Executive in Residence, Joanne Lacourciere. Joanne
has been instrumental in our success and is the voice
of reason and logic, who also brings us back when we
stumble. On behalf of all of our colleagues and patients, we
thank Joanne.
Our partnership agreement with Elekta spans at least
another nine years. We have much work ahead. As we
forge ahead, it is right to pause and acknowledge the
successes of the last year. Thank you everyone for your
hard work!
SEPTEMBER 2015 – Final Flint
test data migration & approve
AUGUST 2015 – Convert
Detroit RO database to the
cloud
As leaders at Karmanos, we are aware that every change
we ask our teams to make must be driven by the principle
that we are enhancing the quality and service we provide
for our patients.
- Drs. Bepler and Klamerus
“Better Together” is the founding
philosophy of our cancer network.
AUGUST 2015 – Alpha
testing – Operational
Dashboard solution

14. 14
A VIGILANT EYE ON QUALITY
The Karmanos Quality Index (KQI) will enable real-time quality tracking and monitoring.
KCI’s first version of the Karmanos Quality Index will be the
first tool the network will use to track, measure, monitor
and report the performance of KCI cancer services.
The data from MOSAIQ and METRIQ tumor registry are
currently being integrated into Elekta Healthcare Analytics
(EHA) dashboards that permit real-time checks of 18 key
performance indicators (KPI) and quality measures that
will be used to track performance. (See table below).
“Becoming a high-reliability cancer network requires
that we must measure how we are doing,” says Justin
Klamerus, MD, MMM, Chief Quality Officer and Vice
President Karmanos Cancer Institute.“For far too long we
have relied on external agencies, such as the Commission
on Cancer or ASCO’s Quality Oncology Practice Initiative
to validate our quality. These external organizations
provide static assessments of our programs, not real-time
performance assessments that can be used to drive high-
reliability care. These programs and initiatives are great,
but they only give you a snapshot in time; they can’t give
you the information in time to make to a difference for the
patient.”
With the KQI data integrated in Elekta Healthcare Analytics
dashboards, KCI administrators, physicians and staff can
assess their performance in real time. The “Gang of Eight”
is a group of Karmanos and Elekta professionals who
selected the initial version of quality measures and KPIs.
Each year, the KQI will be adjusted to address the quality
strategic initiatives of the network and the health system.
“Although our programs perform very well on external
assessments, we will be using new tools that track
performance in a much more active way,” Dr. Klamerus
adds.“For sites that are underperforming it may be
difficult to see their performance against sites that are
out-performing them. My view is that the best way to
influence behavior is to acknowledge the standards,
provide education and then give meaningful feedback to
drive enhanced performance. I don’t believe anyone in
healthcare today doesn’t want to be better. The KQI will
give us information to reward excellence and also provide
insight into areas where we might need to fix problems and
address deficiencies.”
KPIs IOM Quality
Dimension
Pain intensity quantified Patient-centered
Advanced care directives Timely
Documentation of iron stores in
MDS patients receiving ESAs
Effectiveness
Ad-hoc changes to radiation
oncology care plans
Effectiveness
Treatment with bisphosphonates
in Multiple Myeloma
Effectiveness
Radiation received post breast
conserving surgery
Effectiveness
Combination chemotherapy
for hormone receptor negative
breast cancer
Effectiveness
Wait time from referral to consult Timely
Ad-hoc changes to medical
oncology care plans
Effectiveness
Adjuvant hormonal therapy for
high risk prostate cancer patients
Effectiveness
Receptor positive breast cancer Effectiveness
Tobacco Use: screening and
cessation intervention
Surgical margin positivity rate for
prostate cancer patients
Effectiveness
Unplanned emergency
department visits during a
treatment episode
Effectiveness
Colon: Adjuvant chemotherapy Effectiveness
Distress assessment Effectiveness
Survivorship care plan creation Patient-centered
Receiving chemotherapy in the
last 14 days of life
Patient-centered
Adjuvant chemotherapy for
NSCLC
Effectiveness
OCTOBER 2015 – Third Versa HD
delivered to Flint
NOVEMBER 2015 – Macomb pod
(Macomt, Clarkston) goes live on
new MOSAIQ future state
SEPTEMBER 2015 – Flint pod (Flint,
Lapeer and Owosso) goes live on new
MOSAIQ future state (including first
data migration from ARIA)

15. 15
During the summer of 2015, Karmanos will be validating the content of the KQI with data extracted from the network’s
MOSAIQ and METRIQ databases, showing providers and program administrators the types of data that can be extracted,
measured and analyzed in EHA. After addressing any quality concerns or process changes that arise during this audit, the
KQI is scheduled to go live on October 1, 2015.
“I think the KQI is going to give us a great deal of information and generate a lot of discussions going forward about how
we’re doing as a program and where we can improve,” he says.
"The US healthcare system is in the midst of an enormous transition to value-based care,” adds John Christodouleas, MD,
Elekta’s Vice President of Medical Affairs and Clinical Research and a member of the Karmanos Quality Task Force which
identified the initial set of quality measures to be used for KQI v.1.“The informatics infrastructure that Karmanos and
Elekta are building together will allow both organizations to lead the way."
Note: Dashboard screen shots are for demonstration purposes only and do not reflect actual performance data of KCI centers.
NOVEMBER 2015 – Central stie goes
live on new MOSAIQ future state
(3rd migration)

16. The partnership agreement between McLaren Health
Care/Karmanos Cancer Institute and Elekta calls
for the implementation of a comprehensive array of
Elekta products over a 10-year period. However, the
most significant planning, design, innovation and
implementation efforts will occur in the first three years.
Ask any one of the over 200 KCI staff and providers that
have contributed to our many projects to date and they
will agree that a tremendous amount of effort is behind
our successes so far and many more challenges and
opportunities await us in the coming months and years.
By the end of the 2015, KCI and Elekta will have made
demonstrable progress in our efforts to integrate KCI
centers on one common OIS solution that will create a
platform for quality and performance management. Key
projects include:
• The network-wide implementation of MOSAIQ across
the KCI radiation oncology sites, including Northern
(May 2015), Flint, Owosso, Lapeer (August 2015),
Macomb, Clarkston (September 2015) and Central
(October 2015).
• A single consolidated, cloud-hosted MOSAIQ
database, with distinct departments for each
treatment site.To achieve this goal, data from existing
ARIA (Varian) databases were migrated to MOSAIQ
and three separate MOSAIQ databases have been
merged into one.A single database approach will
permit more efficient software upgrades, network-wide
access to patient records for optimal patient care,
and the collection and extraction of data to help KCI
leadership understand and manage the performance
of the cancer system.
• A clearly articulated treatment planning strategy that
supports KCI’s care delivery goals and maintains or
advances operational efficiencies.
• Adoption of the METRIQ® cancer registry at KCI
Detroit, resulting in one integrated, cloud-hosted, KCI-
wide cancer registry. SEER will continue to be Detroit’s
primary cancer registry. Relevant data captured in
the SEER database will be exported to METRIQ. Any
additional data, not required by SEER, but essential
to KCI for the purposes of producing the Karmanos
Quality Index, will be collected in METRIQ.
• Implementation of new MOSAIQ features to support
optimal workflow and desired practice at KCI
Community-Based medical oncology sites. Some
of the new features include eSCRIBE templates and
voice recognition technology for more efficient and
consistent provider documentation, implementation
of IQ Scripts to automate important workflows,
implementation of e-fax technology for the auto-
distribution of clinical documentation to referring
physicians, and additional document interfaces with
hospital information systems to facilitate sharing of
patient information.
• The validation and clinical readiness of five new
MOSAIQ medical oncology features – inspired
by the KCI Detroit team – that are critical to the
implementation of MOSAIQ at the Karmanos Cancer
Hospital. The most important new features include
enhanced barcoding functionality for improved
pharmacy workflow in MOSAIQ, as well as the ability
to facilitate sequential chemotherapy for treatments
that are sensitive to the order and timing of
chemotherapy drugs.
• A dashboard solution that will produce data in support
of both the Karmanos Quality Index (which includes
18 performance measures), as well as up to 25
operational indicators that can be used to monitor
program efficiency. KCI will be a part of a pilot group
to test Elekta’s operational dashboards. KQI metrics
will be built and tested in a progressive manner,
culminating in a full roll-out of the comprehensive
dashboard tool by December 2015.
• Implementation of two new Elekta linear accelerators
in Flint and Macomb, as well as brachytherapy units in
Macomb and Northern.
2015 SO FAR:
Reviewing Accomplishments,
Looking Ahead