Remember the day? Depending on where you are from you may even be still doing this. Or you are lucky enough to never experience it. Blue pens meant one energy, maybe 6MV, black meant another like 15MV, Brown was for electrons, a big red B was for bolus, orange for IJ’s on the field size and a W was stuck in there for the wedge. We dealt with trying to read everyone else's writing, especially the MD’s prescription on the front of the chart.
Henry Kaplan, MD 1956 stanford Been in the field for 13 years if you count my clinical years. I had never gotten a chance to work on a cobalt as some of you may have. I have dealt with the thumb wheels on an old 4 before though. Just look at the last ten years how advanced machines, computers driven technology and treatments have come
In just the past 10 years our field has seen incredible leaps and bounds into more computer driven treatmens. Tomotherapy, Cyberknife, frameless SRS, OBI, MLC, MMLC, IMRT, IGRT, SBRT, CBRT, EFGHIJKLMNOP Arc Therapy, Dose escalation, Dynamic Wedges, EMR, Record and Verify systems, CT SIM’s, using the CT to plan all cases including electrons, less clinical set-ups on the machine. Gone is the day of the film processor, now we are filming our ports with OBI or digital CR systems such as Kodak or Fuji. Most if not all of this is based on a computer.
.EMR is considered an electronic Paper chart that is used in a department and does not travel out easily software systems were first developed in the 1970’s. Hospitals created their own systems to alleviate errors. Memorial Sloan-Kettering Cancer Center was one of the first radiation therapy departments that published their experience with a centralized radiation therapy record and verify system. But still in the 2000’s there were places that still did not utilize it. Now as technology is improving so was the need to improve the software. It has gone from just r&v to an oncology management system. Many places use an EMR for department using the record and verify system.. Import physics/dosimetry plans. Notes. Port Films are approved and stored, set-up, shifts. now they are being approved as EHR’s ARIA and Mosaic are certified under the HITECH act to satisfy the meaningful use criteria. So what is an EHR. They are built to share information with other health care providers, such as laboratories and specialists, contain information from all the clinicians involved in the patient’s care . The National Alliance for Health Information Technology stated that EHR data “can be created, managed, and consulted by authorized clinicians and staff across more than one healthcare organization.” Problems with Hippa connecting an EMR to allow it to be EHR. HL7 interface Health Level Seven ( HL7 ), is a non-profit organization involved in the development of international healthcare informatics interoperability standards HL7 and its members provide a framework (and related standards) for the exchange, integration, sharing, and retrieval of electronic health information VA emr system. The VHA manages the largest medical system in the United States,  providing care to over 8 million veterans, employing 180,000 medical personnel and operating 163 hospitals, over 800 clinics, and 135 nursing homes throughoughout the continental U.S., Alaska, and Hawaii on a single electronic healthcare information network.  National Center for Health Services Research and Development of the U.S. Public Health Service (NCHSR&D/PHS). (The NCHSR&D is now known as the Agency for Healthcare Research and Quality (AHRQ).) 1971 U.S. Navy's clinic at the Brunswick Naval Air Station launched in 1978 20 VA’s. In 1981 was called Decentralized Hospital Computer Program (DHCP) and written into law as the medical-information systems development program of the VA “ Doctors and hospitals that haven't made the move to electronic health records will receive lower payments from Medicare and Medicaid after 2015.” incentives and penalties Recovery Act to speed the move from paper to electronic health records.
Also now there is the popularity of the computer cloud. I am sure many of you have apple products, how many of us have heard about iCloud, or even the Amazon version Amazon Cloud. The National Institute of Standards and Technology defines Cloud computing as a model for enabling ubiquitous, convenient, on-demand network access to a shared pool of configurable computing resources (e.g., networks, servers, storage, applications, and services) that can be rapidly provisioned and released with minimal management effort or service provider interaction. what did you say? It is basically storing information up in the air and being able to access it without it being in your computer clogging it up. Saving memory on your end in a way. Use in rad therapy
Patient care, share information with other departments hospitals securely dose distribution,, dose escalation for better tumor response. side effects Longer life increase in pancreatic with the use of cyberknife
For completely paperless systems. Pt info at touch of the keyboard all can be stored in the r&v system, doing QI electronically chart checks and storage. Turn around from physics dosimetry. Films to doctors and approved igrt prostates
Remember when we lost communication with the record and verify system. It looked like it would be a while before they were going to get it running again and we are already a ½ hour behind and had 5 patients in the waiting room and the doctor needs them treated. We had the ability to treat offline. There were blocks and everything was written in the chart so you could set everything by hand. Now you lose contact and you are down. One of the worst cases I ran into was the server for the record and verify system crashing and frying the raids losing all information. We scrabbled for a few days re-planning IMRT patients to be treated with blocks, cutting blocks at a feverish pace. There was a failure in the back-up system and it looked like all information was lost. We needed to create a new database and put all patients back into it. Eventually the original data base was recovered. Trusting the computer is always right. Chart checks, if something was acidetally changed how would anyone know. Do you know how many MU’s you are looking at per imrt segment, do you even have time to see how many mu’s were given. 600 dose rate, 1000 dose rate e-, and now looking at 2000 dose rate for SRS patient treatments. “ growing realization among those who work with this new technology that some safety procedures are outdated.”(new york times) cuts and understaffing
Learn SIM on CT Ximitron not retaley available, how to use a pendant, set field sizes for each patient, go into the room between each field to turn gantry and look at field on skin. Digital age, computer knowledge is greater Whole brain is CT’d even during emergency most cases, electrons planned, no flash to look at or MLC to look at on IMRT patient’s. I do a yearly competency with my staff, it is a requirement at the VA. It is just me observing them, working on the machine with them and making sure that they have the skills. There are some places around the country, though, that have new hires to go through competencies when they are hired. The employee maybe started at a lower level therapist position and given a certain amount of time to complete competencies to show what they know and learn how the center may set-up certain treatments, i.e. breast set-up different. They are then bumped up a level as a staff therapist etc. When I first graduated Cleveland, now manager yes. Vendor has a large responsibility in training staff to use the new equipment. Case in the New york times later. Many places do not get the adequate training due to cost of training. Maybe one or two are trained and now they must teach others. The VA has been hit hard over the last 4+ years. From incidence in East orange overdose of 36 due to lack of proper safeguard and training to the brachytherapy issue in Philly. Bi annual conference discuss things and we are the first to be tested on things before it is made mandatory for all. ACR NHPP NRC Joint Commission very scrutinized department and we have been strong in all aspects QA issues “a hospital in Springfield, Mo., Cox Health, disclosed that because of an error in setting up a new piece of equipment, 76 patients — the vast majority with brain cancer — had been overradiated during a five-year period ending in 2009. “ (www.nytimes.com)
Schools are using tech for teaching and informing students of everything. Blackboard, text messages, emails. I was excited when I could email a paper to a teacher. Now Uploading homework. Even classes have some of the information prerecorded and the student is responsible to watch or listen to it for different sections. As spoken about before, why teach on the ximatron? Blocks wedges in some cases and even posterior neck electrons. It is great for them to see but they really don’t care do they. Attitude about when am I going to ever use this, like physics. Writing in a chart you really did that. Sit back and watch the MLCS move. Love to push through all popup. Culture is teaching us speed speed speed. What do you mean I have no chart to look at. I can’t read this image on the computer screen. Why not just give it more MU’s to see it better. I have five computer screens to look at What should I be looking at? The mouse click here is the opposite, want to read every warning and pop-up, newer grads get annoyed, just click through Newer technology leads to a possibility of people not wanting to learn it. Ah I only have a few years left to work. I hate computers. You run the beam, I will just level and go in and out of the room. They are now being left behind in the field. What happens the day that you need to do more because of a sickness and someone else covers the machine?
Most of us should have heard about the NY times series. It was very scary and intense for people that are not in our field and worrysome for those in our field. It put names and faces to these mistakes and that is difficult to swallow. IMRT training, missing wedge, field size not reitierated by the company BRAINLAB, now during training it is gone over and over again. Responsibility of the department and vender We are in some cases Learning on the fly. Not something we know from school. Other modalities are having problems with technology also. CT scan in california on a childs brain, tech didn’t know the equipment well enough and just kept rescanning the same small area over and over because they couldn’t figure out why they were only getting a small portion reconstructing. Again a lack of training and uderstanding of new equipment
BrainLab error field size outside shielding Wedge not used for 27 treatments 3 days with out mlc’s on imrt Error with small cell lung SBRT
ASTRO Tim R. Williams, M.D . Chairman of ASTRO White papers go over safety and timelyness of procedures. IMRT, Time consumming, may need more time, real time changes need to have a strong standard of procedure and forced time outs ASRT ASRT President Diane Mayo, R.T.(R)(CT) NESRT We must also look at our regional representative to assist in state issue. We have ASRT for national, but things like Mass wanting us to have CT licenses for simulation. This is fought by our local groups. Spread the word and lets make NESRT a stronger society for us to lean on.
Human error probability, we look at the incidents divided by the number of treatment. So we say, for example we are treating about 30 patients on a machine. That would be 150 treatments in a week, 600 in a month and 3600 in 6 months (approximately). During that six month stretch one incident occurs. That would be 1/3600 which then equals 0.03% probability of an error. So then we turn it around and say that the reliability factor, number of successful treatments divided by number of treatments would be 3599/3600 which comes to 99.97%. This was also discussed in the letter to the New York Times in response to their article in 2010 by Tim R. Williams, M.D . chairman of ASTRO. (Astro.org)
Integrating the Healthcare Enterprise IHE has it’s own wiki page wiki.ihe.net Integrating the Healthcare Enterprise-Radiation Oncology (IHE-RO) is an ASTRO-sponsored initiative for improving the functionality of the radiation oncology clinic. Created in 2004, it is composed of members of the radiation oncology team, administrators and industry representatives that work together to ensure a safe and efficient radiation oncology clinic. The IHE-RO task force develops IHE Integration Profiles, which specify how industry standards are to be used to address specific clinical problems and ambiguities. These integration profiles are then tested at ASTRO’s annual Connectathon, where vendors meet to test the connectivity of their products. (www.astro.org) we want everything to talk correctly. Pass from one vendors system to another smooth no glitches that can cause errors in treatment. In the wiki page, find use cases and import use cases for solutions. Shows ones that have been dealt with and integrated and those that are being assesed The Alberta Heritage Foundation for Medical Research Health Technology Accessment/ HTA Initiative #22 A Reference Guide for Learning from Incidents in Radiation Treatment Collect data of incident reports and what to do with them Hopital based next then Radiation Oncology Safety Information System
We all know that everyday we treat there is the potential for a mistreatment of any kind. We need to be diligent in our efforts to provide the best care we can We as therapists are know as the last line of the treatment. We run some of the last QA before the pateint is treated. A good system is the reporting of Discrepencies or near misses. This allows the department to see where polices and procedures may need to be updated, or trends that seem to be occuring often. But sometimes things happen, Discovering an error can be upsetting, and embarrassing. We need to think of the patient first when something is to happen. But in order for that to happen the department really needs to have a culture that makes it comfortable to report. Having a culture were someone becomes afraid for their job if they make a mistake, even if it is a near miss, that is discovered through filming which is part of the therapists job. it will not allow this. Obviously as a manager I do have to look at trends in incidences to see what the problems maybe and work with the therapist if there are issues. When an incident occurs it goes through a chain, some of us are familiar with what our own facility does. There maybe a computerized system that starts off with the therapist and goes to each entitly to look at and sign. Or a paper procedure. First we inform the doctor so that they can be aware, then physics so that the two can discuss what should be done with the patient. The physicist has the therapist fill out the incident report, I then send the report to the the Quaulity Management department/Risk managers. They will call if there are more questions. The total dose delivered differs from the prescribed dose by 20% or more; 2. The calculated weekly administered dose differs from the weekly prescribed dose by more than 30%; or 3. For a planned treatment course of three or fewer fractions and the calculated total administered dose differs from the total prescribed dose by more than 10% of the total prescribed dose; orThe fractionated dose delivered differs from the prescribed dose, for a single fraction, by 50% or more. An administration of a dose or dosage to the wrong individual A dose to the skin or an organ or tissue other than the treatment site that exceeds by 0.5 Sv (50 rem) to an organ or tissue and 50% of the dose expected from the administration defined in the written directive. 1. The registrant's name; Usually RSO 2. The name of the prescribing physician; 3. A brief description of the event; 4. Why the event occurred; 5. The effect, if any, on the individual(s) who received the administration; 6. Actions, if any, that have been taken, or are planned, to prevent recurrence; 7. Certification that the registrant notified the individual (or the individual's responsible relative or guardian), and if not, why not. No patient info Report agency next business day no later 15 days to submit report 24 hr to notify Dr and notifies the patient
A voluntary international incident reporting informational system. It was established in 2001 under the auspices of the professional body "European Society of Therapeutic Radiology and Oncology" (ESTRO), and has successfully established an international voluntary incident and near incident reporting system, a supporting website and an annual teaching course on Patient Safety in Radiation Oncology.Centers send in info on an incident and an annual teaching course on Patient Safety in Radiation Oncology. Enabling the clinics to share reports on incidents with other clinics as well as with other stakeholders such as scientific and professional bodies Collecting and analysing information on the occurrence, detection, severity and correction of radiotherapy related incidents Disseminating these results and generally promoting awareness of incidents and a safety culture in radiation oncology. an effort to raise awareness of the potential for harm in radiation therapy, to facilitate learning from the experience of others, and thereby to minimise the probability and severity of possible future incidents.
Technology: The Good, the Bad and the Ugly
The Good, The Bad, And The UglyJason Morneau RT(T)Chief Therapist Boston VAMC http://geofflivingston.com/2011/02/21/the-good-the- bad-and-the-ugly-of-online-cause-marketing/
Briefly discuss technological advances in treatmentEMR vs. EHRThe positive and negative outcomes of technologyOverview of human errorPublicized treatment errors/incidencesDiscuss the use of online incident reporting services.
EMR vs. EHR Electronic Medical Record Electronic Version of a Paper Chart Record and Verify Systems ARIA/Varian MOSAIC/ELEKTA Electronic Health Record What is it? HL7 Developed in the start of 1970’s 1971 tested at Brunswick Naval Air Station 1978 launched at 20 VA’s 1981 named DHCP and put into law Finland Hospital first outside US www.wikipedia.com www.healthit.gov/buzz-blog/electronic-health-and-medical-records/emr-vs-ehr-difference/ www.elekta.com www.varian.com http://www.uwlax.edu/md/studentresources/Documents/Heath%20Revised%20Manuscript.pdf
• Recovery and Reinvestment Act of 2009 Health Information Technology for Economic and Clinical Health Act or HITECH Act President Obama wanted all hospitals paperless by 2014 $17 Billion of funds available in incentives Medicare and Medicaid want it by 2015 What is Meaningful Use? http://www.elekta.com/healthcare-professionals
1. Use of CPOE (computerized provider order entry) formedication orders;2. Drug to drug and drug allergy interaction checks;3. E-Prescribing (eligible professionals only);4. Recordation of demographics and smoking status, andchanges in vital signs;5. An up-to-date problem list;6. Active medication list and medication allergy lists;7. One clinical decision support rule;8. CQM as specified by the Secretary;9. Providing patients with an electronic copy of theirhealth information (eligible professionals and hospitals)and discharge instructions (hospitals only);10. Providing clinical summaries for patients for eachoffice visit (eligible professionals only); and Protectingelectronic health information.
• Medicaid- – Physicians whose caseloads include at least 30% Medicaid patients are eligible to receive up to $63,750 over the course of 6 years• Medicare – – Physicians seeing Medicare patients can receive up to $44K over the course of 5 years• Eligible professionals who cannot demonstrate that they are meaningful – January 1, 2015, will receive an adjustment to their Medicare fee schedule of 99% for 2015, 98% for 2016, and 97% for 2017 and each subsequent year. www.gfrlaw.com
Eligible professionals who cannot demonstrate that they are meaningful users of certified EHR by January 1, 2015, will receive an adjustment to their Medicare fee schedule of 99% for 2015, 98% for 2016, and 97% for 2017 and each subsequent year.
Technology Positives and Negatives“WITH GREAT POWER THERE MUST ALSO COME - -GREAT RESPONSIBILITY! “-Stan Lee Amazing Fantasy #15(August 1962)
Better patient care Share patient information securely Dose distribution and escalation Decrease side effects Living longer Improved QA Treating the untreatable Decrease in treatment time
More organized and timely Thank you computer No more missing charts Neat charts/save room Faster Turn around time MD approval of films
The computer Slow or stuck computers Server issues Trusting the computer is always right. Outdated procedures, QA
Education and Training Under staffed departments New generation of students Clinical based vs. Technical based knowledge Dirty Word “Competency” Proper QA/Commissioning of the machines
New grads are experiencing a whole new world of learning. Education has come into the digital age The need to teach things from the past as well pastThe veterans are trying to keep up with a whole new world. AHHHH you want me to what? Getting left behind
New York Times articles A series of articles “The Radiation Boom.” by Walt Bogdanich Cases looked at in Radiation Therapy IMRT plan missing for 3 treatments Missing filter for 27 treatments Field Size issue Cases in other modalities.
• Release of statements – ASTRO • Letter to the New York Times January 25, 2010 Tim R. Williams MD. • Radiation therapy 99.99 percent safe and effective • The White Papers – ASRT • ASRT Responds to New York Times Article Jan. 27, 2010, Diane Mayo, R.T.(R)CT) – NESRT • We must look to and support our regional representation www.asrt.org www.astro.org
Definition:Human error, the propensity forcertain common mistakes bypeople; the making of an error as anatural result of being human(www.dictionary.com)
30 patient=150 treatments per week = 600 treatments a month and 3600 in 6 months.1 incident occurs1/3600=0.003% probability of an error or 99.997% reliability factor.(Swain, 1963)
IHE-RO was established in 2004 www.wiki.ihe.net Vendor equipment connectivity issuesPatient Safety Organizations GE PSORadiation Oncology reporting systems Hospital based AHFMR/HTA ROSIS www.ihe.ca/documents/HTA-FR22.pdf www.astro.org/Practice-Management/IHE-RO/In/www.rosis.infodex.aspx
What do we as therapists need to doThe development of the reporting cultureThe trail of the incidence reportIncidence vs. Reportable medical event DPH 105 CMR Section 120.435
Voluntary incident reporting systemDiscussed last year at the VA Radiation Oncology Meetingswww.rosis.info