Electronic Oncology Systems the Management and the Safety Measures Hansen Chen, Director, TDSI
Radiation Oncology Department People Place Equipments Procedures Patients Hansen Chen 2
Radiation Oncology Staff People Oncologist Physicist Dosimetrist Engineer Sim Tech Administrator Therapist Nurse Clerical Billing Hansen Chen 3
Department Layout Place Linac Vault CT Vault Exam Room Brachy Suite Front Desk Tx Plan Offices Hansen Chen 4
Machines and Systems Equipment External Beam Machines CT Simulators Brachytherapy Machines Treatment Plan Systems Oncology Info Systems IT Infrastructure Calibration Devices Treatment Accessories Oncology PACS Hansen Chen 5
Clinical Procedures External Beam IMRT Image Guided Radiotherapy Procedure CT Simulation MammoSite APBI Stereotactic Radiosurgery HDR Brachytherapy Stereotactic Body Radiotherapy Prostate Seeds Implant Hansen Chen 6
Patient Visit Flow (ex. IMRT) Patient Consult CT Scan Virtual Sim Tx Plan Follow-up Tx Delivery Portal Film Physics QA Hansen Chen 7
Yes, It s s Quite Complicated Operation! People Place Equipment Procedure Hansen Chen 8
Mitigation of Potential Errors More Manpower More Checking Procedures More Equipments Use of Computer Technologies Buy More Liability Insurance Hansen Chen 9
What Computer Can Do Jaw Jaw Treatment Treatment Setup Setup Message Message Downloaded Downloaded (TSD (TSD- - JAW) JAW) Patient Patient ID: ID: A050809 A050809 Course: Course: 1, 1, Field: Field: '001A', '001A', Fraction Fraction 0, 0, Attempt: Attempt: 1 Oper. Oper. Mode: Mode: 1, 1, Seg. Seg. Total: Total: 20, 20, Seg. Seg. number: number: 1, 1, Seg. Seg. Attribute: Attribute: 0x00301000 0x00301000 Mode: Mode: X-ray, X-ray, Energy Energy 6, 6, Technique: Technique: Fixed Fixed Dose: Dose: 50.0 50.0 MU, MU, Dose Dose Rate: Rate: 0 MU/Min MU/Min # Used: Used: 1, 1, Accessory Accessory A: A: RETIC, RETIC, Accessory Accessory B: B:,Accessory,Accessory C: C: Collimator: Collimator: 90.0, 90.0, Gantry: Gantry: 0.0, 0.0, Arc: Arc: 0.0, 0.0, Direction: Direction: CCW CCW Field Field Type: Type: 0 Jaw Jaw X1: X1: 5.0, 5.0, Jaw Jaw X2: X2: 100.1 100.1 Jaw Jaw Y1: Y1: 5.0, 5.0, Jaw Jaw Y2: Y2: 100.1 100.1 MLC MLC X1: X1: 10.2, 10.2, 10.5, 10.5, 8.7, 8.7, 6.3, 6.3, 7.2, 7.2, 8.1, 8.1, 9.5, 9.5, 9.5, 9.5, 9.6, 9.6, 9.8, 9.8, 10.6, 10.6, 11.3 11.3 MLC MLC X2: X2: 7.2, 7.2, 6.5, 6.5, 8.7, 8.7, 6.3, 6.3, 7.2, 7.2, 8.1, 8.1, 9.5, 9.5, 9.5, 9.5, 9.6, 9.6, 9.8, 9.8, 6.9, 6.9, 9.3 9.3 Table Table Longitudinal: Longitudinal: 0.0, 0.0, Lateral: Lateral: 0.0, 0.0, Vertical: Vertical: 0.0 0.0 Isocentric: Isocentric: 0.0, 0.0, Eccentric: Eccentric: 0.0 0.0 Relative Relative Table Table Longitudinal: Longitudinal: 0.0, 0.0, Lateral: Lateral: 0.0, 0.0, Vertical: Vertical: 0.0 0.0 Isocentric: Isocentric: 0.0, 0.0, Eccentric: Eccentric: 0.0 0.0 Epid Epid Acquisition: Acquisition: 0 Epid Epid Table Table Longitudinal: Longitudinal: 0.0, 0.0, Lateral: Lateral: 0.0, 0.0, Vertical: Vertical: 0.0 0.0 VW VW Original Original MU: MU: 0.000000, 0.000000, VW VW Dynamic Dynamic Jaw: Jaw: 0.00 0.00 Data Data Valid Valid 32-Bit 32-Bit Mask: Mask: 0x0000f1ef 0x0000f1ef Hansen Chen 10
What Computer Can NOT Do Preparing the Data Jaw Jaw Treatment Treatment Setup Setup Message Message Downloaded Downloaded (TSD (TSD- - JAW) JAW) Patient Patient ID: ID: A050809 A050809 Course: Course: 1, 1, Field: Field: '001A', '001A', Fraction Fraction 0, 0, Attempt: Attempt: 1 Oper. Oper. Mode: Mode: 1, 1, Seg. Seg. Total: Total: 20, 20, Seg. Seg. number: number: 1, 1, Seg. Seg. Attribute: Attribute: Potential Error 0x00301000 0x00301000 in Data Entry Mode: Mode: X-ray, X-ray, Energy Energy 6, 6, Technique: Technique: Fixed Fixed Dose: Dose: 50.0 50.0 MU, MU, Dose Dose Rate: Rate: 0 MU/Min MU/Min # Used: Used: 1, 1, Accessory Accessory A: A: RETIC, RETIC, Accessory Accessory B: B:,Accessory,Accessory C: C: Collimator: Collimator: 90.0, 90.0, Gantry: Gantry: 0.0, 0.0, Arc: Arc: 0.0, 0.0, Direction: Direction: CCW CCW Field Field Type: Type: 0 Jaw Jaw X1: X1: 5.0, 5.0, Jaw Jaw X2: X2: 100.1 100.1 Jaw Jaw Y1: Y1: 5.0, 5.0, Jaw Jaw Y2: Y2: 100.1 100.1 MLC MLC X1: X1: 10.2, 10.2, 10.5, 10.5, 8.7, 8.7, 6.3, 6.3, 7.2, 7.2, 8.1, 8.1, 9.5, 9.5, 9.5, 9.5, 9.6, 9.6, 9.8, 9.8, 10.6, 10.6, 11.3 11.3 MLC MLC X2: X2: 7.2, 7.2, 6.5, 6.5, 8.7, 8.7, 6.3, 6.3, 7.2, 7.2, 8.1, 8.1, 9.5, 9.5, 9.5, 9.5, 9.6, 9.6, 9.8, 9.8, 6.9, 6.9, 9.3 9.3 Table Table Longitudinal: Longitudinal: 0.0, 0.0, Lateral: Lateral: 0.0, 0.0, Vertical: Vertical: 0.0 0.0 Isocentric: Isocentric: 0.0, 0.0, Eccentric: Eccentric: 0.0 0.0 Relative Relative Table Table Longitudinal: Longitudinal: 0.0, 0.0, Lateral: Lateral: 0.0, 0.0, Vertical: Vertical: 0.0 0.0 Isocentric: Isocentric: 0.0, 0.0, Eccentric: Eccentric: 0.0 0.0 Epid Epid Acquisition: Acquisition: 0 Epid Epid Table Table Longitudinal: Longitudinal: 0.0, 0.0, Lateral: Lateral: 0.0, 0.0, Vertical: Vertical: 0.0 0.0 VW VW Original Original MU: MU: 0.000000, 0.000000, VW VW Dynamic Dynamic Jaw: Jaw: 0.00 0.00 Data Data Valid Valid 32-Bit 32-Bit Mask: Mask: 0x0000f1ef 0x0000f1ef Hansen Chen 11
Electronic Oncology Systems (EOS) Treatment Plan System Oncology Information System Treatment Delivery System Treatment Verification System Hansen Chen 12
EOS System Design Guidelines Patient Safety Electronic Oncology Quality of Care Operation & Care Cost Time & Efforts Hansen Chen 13
Electronic Oncology Systems Management IT Infrastructure Servers and Clients Data Safety in Storage Backup and Archive Data Safety in Communication Data Integrity in Transmission & Execution Systems Monitoring Responsibilities Policy & Procedures Policy & Procedures System Malfunction etc Hansen Chen 14
EOS IT Infrastructure Centralized Computing System Redundancy Hansen Chen 15
Systems Infrastructure Before Columbia Campus Cornell Campus License + Service Hansen Chen 16
Centralized System Infrastructure Columbia Campus Cornell Campus Hansen Chen 17
Systems Redundancy Clustered Data Servers SAN (Storage Area Network) Hansen Chen 18
Application Deployment Servers Citrix Server Farms SunRay Server Array Hansen Chen 19
Citrix ITA Thin Client Access Hansen Chen 20
Oncology Information System Topology Hansen Chen 21
Pinnacle SunRay Thin Client Hansen Chen 22
Pinnacle SmartEnterprise Topology Philips Philips Pinnacle Pinnacle Server Server Cluster Cluster x 2 810 810 Server Server 810 810 Client 810 Client 810 Client Client Philips Philips Pinnacle Pinnacle Compute Compute Modules Modules x 2 Server End Cornell Campus Teaching Units Fiber Optics Network Network Switch Switch Client Sites SunGuard SunGuard SAN SAN Storage Storage System System NYP NYP P3PC P3PC Gateway Gateway x 2 Cornell + Columbia Campuses Hansen Chen 23
Centralized Tx Plan Topology Centralized Tx Plan Office Server Vault Physician & Physics Offices Hospital Hansen Chen 24
One Workstation for 10 People Hansen Chen 25
Bring Technology to People Not People to Technology Hansen Chen 26
Contouring Hansen Chen 27
Tx Plan Hansen Chen 28
Plan Review Hansen Chen 29
Multi-User Environment CT-Sim Image Fusion Contour Plan Define Isocenter Import Diagnostic Images Target Delineation Dose Shaping ROI Define Beams Import Planning CT Images Run DIR Beams Registration Contour Modification Dose Objective Hansen Chen 30
Workflow Streamline a Straight Line Hansen Chen 31
PACS-RT System Candelis ImageGrid Redundant Server Auto Replication PACS-RT DICOM & Data DICOM RT/WFM Data Data TCP/IP Network (4D) CT Simulator Tx Plan Systems Contouring W/S RTT IGRT W/S PET/CT/MR HDR Brachy TPS Plan Review W/S Oncologist W/S Enterprise PACS PSI Brachy TPS Physics W/S Reporting W/S Hansen Chen 32
Workflow Management PACS-RT Web Based Workflow Manager System Functions Dicom/RT Store/Receive Dicom/RT Query/Retrieve Unattended TPS Backup TPS Patient Restore R&V, HIS Patient Archive Off-Line / Off-Site Backup Patient Workflow Patient Simulation Fusion & Contouring Treatment Plan Tx Plan Review Physics Check/QA IGRT / VGRT Image/Report Review Weekly & EOT Chk User Configurable Workflow Required Staff Views Physician Dosimetrist Physicist Therapist Hansen Chen 33
Oncology PACS Storage Hansen Chen 34
Centralized PACS-RT Server OIS Server PACS-RT Server Patient Data Patient Schedule CT Simulation Oncologist W/S Tx Plan RTT W/S Input: CT-Sim Worklist Output: Patient CT Images RT Plan & RTSS Acknowledge Completed Input: CT-Sim Worklist Patient CT Images RT Plan & RTSS Input: CT-Sim Worklist Patient CT Images RT Plan & RTSS Input: CT-Sim Worklist Patient CT Images RT Plan & RTSS Output: All RT Objects Output: All RT Objects Output: All RT Objects Hansen Chen 35
Integration with PACS-RT Use of Back-bone PACS-RT Server Supporting DICOM Query & DICOM Work List PACS-RT Oncologist Review Physicist Monitoring Contour Evaluation DVH Analysis IMRT/IGRT QA Evaluation Hansen Chen 36
Data Tsunami Active Data Patients Under Care Static Data Patient Follow-Ups Data Types Data Types Medical Records, DICOM Images, DICOM RT Objects Hansen Chen 37
EOS Safety in Storage Online Data Redundancy Clustered Servers and SAN Patients Under Treatment Near-Line Data Redundancy Oncology PACS 6 Months to a Year Off-Line Data Redundancy Enterprise Archive in Different Geometric Locations Beyond a Year Hansen Chen 38
EOS Safety in Communication Adapting from FDA 510K Guidelines High Level System Description Architecture Design Chart Hazard Analysis & Risk Management System Requirement Specification (SRS) System Design Specification (SDS) Hazard Trace Matrix & Traceability Analysis Operation Environment Verification and Validation Unresolved Anomalies Hansen Chen 39
High Level Systems Description Approved Tx Plan Daily Tx Delivery Hansen Chen 40
Architecture Design Chart Approved Tx Plan Daily Tx Delivery R&V System Hansen Chen 41
Hazard Analysis & Risk Management Approved Tx Plan R&V System Daily Tx Delivery Hansen Chen 42
SRS & SDS to Mitigate the Risks Extensive Bit-to to-bit Data Check by Human is Too Much Work Designing a Computer Software Tool to Mitigate the Risks A Computer-Aided Tx Data Auditing Software to Improve the Efficiency A Software which can Automatically Monitor Tx Data being Delivered Hansen Chen 43
SRS & SDS to Mitigate the Risks Module A: New Plan Checks Approved Tx Plan R&V System New Software for Tx Data Checking Hansen Chen 44
SRS & SDS to Mitigate the Risks Module B: Daily Tx Log Checks Approved Tx Plan Daily Tx Delivery New Software for Tx Data Checking Hansen Chen 45
Hazard Traceability Analysis Approved Tx Plan R&V System Daily Tx Delivery Hansen Chen 46
Electronic Oncology System Monitoring Whose Responsibility? Hansen Chen 47
Whose Fault? RAID 5 Array Failing Hansen Chen 48
Whose Fault? Restarting a Database Service Hansen Chen 49
Balance with True Colors Server Operating System Network Database Application Desktop Research Development Reporting Troubleshooting Configuration Installation User Rights Clinical Data Hansen Chen 50
Policy & Procedures When Server is Down Should off-line treatment be carried out? Off-line data roll back integrity checks Overwrite Staff role and their rights for overwriting Quality auditing for overwritten data User Rights For each staff group, plus senior staff Who can define user rights Generic user account? Hansen Chen 51
Policy & Procedures Paperless Chart / Electronic Medical Record Patient medical record accessibility by other medical staff Paper signing off vs. electronic signature Login & Logout Login & logout enforcement User activity logging System Continuity Configuration change policy System update policy Hansen Chen 52
Summary Electronic Oncology System (EOS) is playing an essential role in today s s Radiation Oncology service EOS Management Considerations EOS Management Considerations IT Infrastructure Data Safety in Storage Data Safety in Communication Systems Monitoring Policy & Procedures Hansen Chen 53
Conclusion The emerging radiation therapy technology has became more and more complicated with increased clinical procedures and equipments Electronic Oncology System provides one solution to such complicated environment Well designed EOS management from its infrastructure to the implementation is important Safety measures for EOS is by no means critical to the Radiation Oncology practice Hansen Chen 54
Thank You