1. India center’s upgrade to MOSAIQ® OIS transforms
workflow, boosting patient safety and efficiency
CUSTOMER PERSPECTIVE
Fortis Memorial Research Institute leaves paper patient
RT chart behind and goes completely paperless
Fortis is India’s first radiotherapy department
with all-electronic workflow featuring MOSAIQ OIS
For two years, health care providers at Fortis Memorial
Research Institute (FMRI), in Gurgaon (Haryana) had
tolerated their often confusing paper-based radiation
therapy workflow. Although they had been using MOSAIQ®
Desktop (v 2.3) to record and verify treatments since
2012, every other aspect of the practice depended on the
manual processing of a piece of paper – everything from
scheduling and tracking the patient through the treatment
process to the creation and filing of many different
patient-related documents. In addition to the inefficiencies
and greater chance for human error associated with an
exclusively paper-driven environment, the department
was steadily losing space to the accumulation of physical
RT charts. The 2014 upgrade to MOSAIQ® Oncology
Information System (OIS) version 2.5 has – over the last
12 months – streamlined FMRI’s workflow dramatically,
resulting in better safety, efficiency, and communication.
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FMRI is a premier referral hospital for the Asia-Pacific and Middle East
regions and beyond.
A paperless vision
With 288 inpatient beds on an 11-acre campus, multi-
specialty hospital Fortis Memorial Research Institute is a
premier referral center, drawing patients from throughout
Asia and the Middle East.
Since the inception of the FMRI department of radiation
oncology in 2012, staff had been cataloguing their patients’
RT charts in two-ring binders and shelving them in
cabinets. Although neatly tabbed into five sections, each
patient chart contains 40 to 50 pages of documents. The
rows of chart binders take up space even today.
However, it had been a long-held vision of Bidhu Mohanti,
MD, Head and Director of FMRI’s Department of Radiation
Oncology, to create a completely paperless department.
His vision – with support from the department’s
oncologists, medical physicists, therapists, radiation
oncology nurses and hospital administration, in addition
to arrival of MOSAIQ v 2.5 and Elekta’s training support
– led to among the most significant transformations in a
department that is witnessing rapid growth.
The challenge for Dr. Mohanti, Anusheel Munshi,
MD, Additional Director of the department and chief
physicist, Tharmar Ganesh, PhD, was to persuade FMRI
administration and even radiation oncology department
staff of the value of an OIS, a technology whose use in India
is virtually non-existent.
“People weren’t fully aware about the full capability of
MOSAIQ as an OIS and how it could coordinate the entire
radiotherapy workflow, rather than just serve as a simple
record-and-verify system,” Dr. Ganesh says.“First, we
needed to educate them that the challenge of radiation
therapy is not simply the volume of paper required, but
also that it is a complex workflow. It requires a lot of
information inputs from one step, and then each step
generating its own output, which will be taken as input
in subsequent steps. Rather than trying to manage this
complicated workflow on paper, we had to show them
that all of the steps, and the timing of each step, could be
managed electronically in a single system, MOSAIQ. And,
also that by doing so we could improve patient safety and
deliver better patient care.”
They shared their ideas and plans with Elekta Singapore
representatives for their input on how the RT department
would migrate to a paperless environment.
“After understanding the department needs and
requirements, we brainstormed with department staff
and FMRI administration on how to implement MOSAIQ
and determine additional hardware and software needed
to reach their goals,” says Kai Yan Wong, Elekta Business
Development Director, Software Systems, in the Asia-
Pacific region.
3. 3
Plans in place
Fortis and Elekta agreed on an implementation schedule
that would have FMRI go live with MOSAIQ OIS by the end
of October 2014. As a first step, an Elekta Singapore team,
during June 16-20, 2014, made the first of three visits to
FMRI to train staff on MOSAIQ.
In the fourth week of October 2014, FMRI converted
from MOSAIQ Desktop (v 2.3) to MOSAIQ OIS (v 2.5),
upgraded its 12 MOSAIQ workstations to Windows 64-bit
and installed MOSAIQ on them, and relocated the MOSAIQ
server from the department to the hospital’s data server
room. The department also purchased a new printer-
scanner to convert and upload paper documents into
MOSAIQ.
“Although the conversion was successful, there were
significant challenges throughout the process,” Dr. Mohanti
acknowledges.“Many of the staff voiced strong concerns
whether it was feasible at all. In addition, getting everyone
trained on MOSAIQ was a serious hurdle, because not all
had attended the training classes.
“Even with instruction, it took time for others to catch up
with the new workflow and to understand how to use all
the MOSAIQ features,” he continues.“These challenges
created a very hectic environment in the department in
the first several days – there were a lot of people asking
for clarification of issues.”
Despite these difficulties, FMRI staff began to appreciate
the value of their new MOSAIQ workflow.
With its MOSAIQ go-live, Fortis became the first radiation
therapy department in India to migrate to a completely
paperless operation using MOSAIQ.
An electronic mirror image of the paper chart
The customizability of MOSAIQ enabled FMRI staff to
create an electronic RT chart that mirrored the physical RT
chart in terms of the original tabbed sections.
Once this was done, FMRI staff were officially free from the
task (required per AAPM TG-40 report) of photocopying
and filing several paper documents, including billing
sheets, vital signs, investigation reports (e.gs., labs,
endoscopy, pathology), EORTC-QLC-C30 (i.e., quality
of life scoring), TPS printouts, morbidity scores and
discharge summary (i.e., chemotherapy or surgical
oncology department). These amounted to an average
of 40-50 pages of documents in the physical RT chart.
4. 4
“We scan all of these documents and attach them
to the patient’s EMR in MOSAIQ,” says Silas George,
Chief Technologist. His technologist colleagues, Saneg
Krishnankutty and Jeen Sathya add that previously,
physicians had to flip through several pages of a patient
record, which made it difficult to locate a particular report.
In contrast, all of the documents can be neatly arranged
into user-definable document types in MOSAIQ and are
readily available at the click of mouse button.
In an FMRI patient’s RT chart today, there are just two
paper consent forms – one for RT treatment course and
another for CT scanning with contrast – and one paper
sheet for recording daily shifts.
Clinical Notes
A well-used screen in MOSAIQ is Clinical Notes, which
relieves doctors of the necessity to handwrite and file the
frequent clinical notes per patient that can come from
several different areas and subjects, such as oncology
history, radiology, pathology and clinical audit/physics/
RTT. These are now entered electronically and categorized
in MOSAIQ.
No more chart chasing
In addition to reducing FMRI’s paper documents and
enabling access to them in a single, easy-to-navigate
application, MOSAIQ eliminated the need to locate RT
charts in the department.
“MOSAIQ OIS has so wonderfully streamlined and
seamlessly integrated the entire clinical and physics
workflow in our department,” observes radiation
oncologist Anusheel Munshi, MD, Additional Director of
the department.“This system provides an amazing array
of features, including appointment scheduling, patient-
related information, image verification, real-time patient
status on our machines and much more. For us, with the
inception of the paperless era, patient files and bundles
of papers have become a thing of the past. It is like having
the entire departmental patient information digitally, with
anywhere, anytime access.”
MOSAIQ OIS provides an
amazing array of features,
including scheduling
appointments, patient-related
information, image verification,
real-time patient status on our
machines and much more.
For us, with the ushering in of
a paperless era, patient files
with bundles of papers have
become a thing of past. We
now have all patient information
available digitally with
anywhere, anytime access.
Anusheel Munshi, MD
Radiation Oncologist
MOSAIQ was easy to
implement clinically, because
it is organized and flexible,
and offers solutions for every
need. In fact, once we had
the infrastructure in place, it
took us less than a couple of
days to implement Phase I of
our paperless program. The
changeover was smooth and
without any hiccups.
Tharmar Ganesh, PhD
Chief Medical Physicist
5. 5
MOSAIQ Home page
Another related time-saver is the MOSAIQ Home page,
which has removed the requirement for staff to walk to
the Treatment Planning room and use a whiteboard to
check off when they have completed an assigned task
(e.g., CT done, Fusion done, Contours completed,
Planning completed, etc.)
“The Home page is the common space in which the
department’s entire workflow is monitored and the
individual’s pending tasks are reviewed,” says Shaleen
Agrawal, MD, radiation oncologist.“That saves frequent
walks to the Treatment Planning Room, which, depending
on where you are, can be 50 or 60 meters away.”
On the Home page, it also is obvious when patients have
arrived at the hospital, at what time they have been taken
inside for treatment and when they complete treatment.
This is facilitated significantly by the use of a barcode
scanner integrated with MOSAIQ. The OIS assigns
patients a barcode that is affixed to their appointment
card. When patients arrive in the department for their
daily appointment, they no longer have to search for
department staff. Instead, when they scan their barcode
they automatically “announce” their arrival to everyone
in the department.
“Earlier, I had only a rough idea when the patient was
expected, so if I wanted to know, I would have to come out
of my room or call someone,” says radiation oncologist
Vikas Roshan, MD.“Now, when patients arrive, they are
queued and their progress through the process is visible
on my MOSAIQ schedule.”
Weekly chart audit
Having all patient records stored electronically has greatly
eased the weekly chart audit of new patients and those
who have completed their treatment course. Before
MOSAIQ OIS, the audit required transporting physical
charts for review.
“If there were 12 news cases and 10 patients completing
treatment, that meant we had to bring 22 physical RT
charts from the linear accelerator console rooms to the
conference room, which is several meters away,” notes
radiation oncologist Sayan Paul, MD.“So we needed a
person to bring all these charts and discuss all these files
cluttered on the table. Afterward, they would have to be
segregated and brought back to their respective treatment
machine. With MOSAIQ OIS, we do not require physical
RT charts anymore in the chart review room. Instead, we
just have one workstation running MOSAIQ and through
the Patient Worklist Option inside MOSAIQ, and using
appropriate filters, we have access to the complete patient
record of any required patient, thus obviating the need for
the physical chart.”
Daily schedules
Pre-MOSAIQ OIS, he adds, daily schedules were done
on the two MOSAIQ Desktop sequencers at the two linac
consoles. However, they were replicated manually in an
Excel sheet for distribution to consultant and staff doctors,
Patient Review Room, Front Desk and TPS Room. This
manual entry in the Excel document was prone to errors.
In addition to the time it took to prepare the Excel sheet,
there could be wrong patient ID’s and spelling mistakes
MOSAIQ allows the FMRI team to access patient information with anywhere. anytime convenience.
6. 6
in patient names, according to members of the front desk
staff and radiotherapy technologists, the latter previously
responsible for this daily task. They were able to eliminate
this Excel document almost immediately after MOSAIQ
go-live.
Assessments
All clinical assessments (e.g., vital signs, Temozolomide
administration, morbidity scoring) previously done on
paper forms are now MOSAIQ electronic assessments
complete with graphs to better track trends. In fact,
radiation oncology nurses have their own workstation at
which they enter the first two assessments listed above.
eScribe documents
The availability of eScribe document templates, such as
physics calculations, in-vivo dosimetry results and plan
requests with dose optimization criteria, also saves time.
Medical physicists Biplab Sarkar and Kanan Jassal
relate that they are using this feature for plan requests
by radiation oncologists. They note that pre-defined
templates are available for different sites with all the dose
constraints. Instead of writing the dose constraints and
dose objectives on a separate register, oncologists are
now using the eScribe feature to put in their requests.
Since the constraints and objectives are already there,
they have to do no editing or very little editing before
finalizing them and attaching them to the EMR, they
observe. Sarkar and Jassal also use eScribe for recording
manual calculations, such as electron treatment field
calculations. This has improved the documentation
process.
Inventory statistics
With MOSAIQ, FMRI staff also can gather usage statistics
on inventory, such as VacLok bags, thermoplastic sheets
and how many blood bags and blood product irradiations
have been done.
“We have 16 VacLok bags, for example, so we can keep
track of how many times a particular VacLok bag has been
used in the last month or the last three or six months,”
Somnath Guria, RTT, explains.“That can help us determine
what the useful life of a VacLok bag should be. If the
average is 900 uses and one goes bad after 300 uses,
then maybe there’s a bag handling issue that needs
to be addressed.”
MOSAIQ scores not only in
organizing the patient's workflow,
but also in streamlining and
managing the department's
activities and resources. Features
such as 'Reports’ – with over 200
built-in templates that can generate
data in a few seconds, which
otherwise would have taken several
days – make it an indispensable
item in any modern radiation
oncology department. MOSAIQ
offers tremendous data mining
capability, and as we progress
further in our paperless journey,
we expect to benefit a lot through
its features.
Tharmar Ganesh, PhD
Chief Medical Physicist
7. 77
Saving space, saving cost
From MOSAIQ go-live on November 1, 2014 to March 3,
2015, FMRI staff have scanned and uploaded to MOSAIQ
8,643 pages of RT chart documents, representing the
paper forms of all new patients and the complete records
of patients reporting for follow-up care. That translates
to over 17 reams (500 sheets/ream) of paper at 5 cm per
ream, or 86.5 cm (i.e., nearly 3 feet) of storage width saved
– at a minimum, considering that this doesn’t account for
the width of the 2-ring binders containing the charts.
Although not tracked, FMRI also has saved significant
paper and color ink printer cartridge costs.
On the horizon
FMRI’s first priority was to get out from under the
mountain of paper produced in the radiation therapy
workflow. In doing so, the department has greatly
enhanced staff productivity, reduced the likelihood of
errors and enabled providers to deliver better patient care.
Moving forward, the department’s goals are to more fully
exploit the extensive functionality of MOSAIQ and to use
the information electronically catalogued in
MOSAIQ to begin mining this data and generating
SAP® Crystal Reports®.
“There are already about 200 reports built into MOSAIQ,
but to tailor a report with the unique parameters of our
workflow, we will need to develop a Crystal Report,”
Dr. Mohanti says.“We expect that in the coming
months some of us will receive Crystal Reports training.”
In addition, while FMRI is using many of the most useful
MOSAIQ capabilities, Drs. Mohanti and Ganesh appreciate
that the department has only scratched the surface of the
OIS’s potential.
“I know that there are many centers outside of India that
are are exploiting the comprehensive range of MOSAIQ
functionality,” Dr. Mohanti observes.“We would like to visit
those departments to see how they’re using MOSAIQ in
innovative ways. We can learn from them, which will help
us take MOSAIQ to an even higher level in our department.”
FMRI radiotherapy staff now work with an all-electronic workflow
