When the department of radiation oncology at the University of Iowa’s Holden Comprehensive Cancer Center, Iowa City, moved to its new quarters in May 2005, it went electronic. Only one paper form remains in use. Making this new system possible are integrated sets of software applications from Siemens called COHERENCE™ and LANTIS®, which were created specifically for the planning, management, and documentation of radiation therapy.

The LANTIS Oncology Management System, a suite of programs running on the open syngo® platform in Windows®, is designed to coordinate, manage, and document every step in the delivery of radiation treatment, from the initial consultation through final billing. It allows a staff to complete, in minutes, many procedures that used to take hours, as well as to deliver high-quality care. Patient records are maintained in electronic charts designed specifically for oncology and are in full compliance with government regulations. All data are backed up daily and protected by a firewall.

LANTIS has several modules, which may be implemented individually or simultaneously. At the core is Commander, a verification and recording system. Image RT integrates diagnostic and treatment images from various modalities with the patient’s chart, while RTP Link imports treatment plans to the chart. Side-by-side comparisons of reference and treatment images are possible. Supervisor manages the schedules for sites, staff, and patients, and Iowa plans for automatic capture of charge data for billing in the future. Using Digital Photos and Facts, users ensure that the correct patient gets a given treatment with the prescribed arrangement of the radiation fields. Extended Barcodes is available to track the movement of charts and images, but is not used at Iowa at this time since all charts and images are electronic. Transcriber manages documents. Clinical Assessments tracks patients through treatment and aids in the practice of evidence-based medicine. Gateway interfaces with the hospital information system, allowing importation of demographic and laboratory data, and automates administrative communications. The Charge Export module is planned to send procedure codes to the hospital information system for billing. Reporter allows the creation of customized documents for particular needs, such as tracking trends.

The results of the conversion to an electronic department are highly satisfying, but the transition was not easy. Preparation and staff training required 6 months, and even after the move to the new facility, the old one remained open for about 6 weeks so that patients already in treatment could finish without the replanning of their treatment or conversion of their paper records.

Laurie Smith

According to Laurie Smith, administrator of the department, the first step in the conversion was deciding exactly how the new facility should function. A team was assembled consisting of a member from every constituency: schedulers, nurses, physicists, therapists, physicians, and administrators. “We went through the paper patient charts page by page, asking, first, ‘Do we need this information?’ and, second, ‘If we do, where will it live in LANTIS?'” Smith reports. “We also determined how, if a document needed a signature, we would get it. We had to determine how to guarantee access for everyone who needed particular information while guarding against release to those who should not view it. We worked on this process until everyone was comfortable with the thinking.”

With Siemens’ help, the team then did a full workflow analysis covering every step in a treatment, from the moment the patient picks up the telephone to schedule the first appointment until the treatment is completed. The team first defined the workflow as it was and then redefined it to make it much smoother.

The results of these intensive studies were presented to the entire departmental staff for critique at an all-day retreat. Several suggestions were made that were incorporated into what became a 10-page workflow document that had the responsibilities of each specialty color coded: red for nursing, blue for residents, green for physicians. Not only was this document a basis for training, but it demonstrated to the staff that no one works in isolation and that if someone fails to complete assigned tasks on schedule, the next person cannot do his or her job.

The next step was hands-on training for 1 to 2 hours per week in mock clinics conducted in the completed new facility, which was not yet in use. Siemens provided a practice database, and graduate students played the roles of patients. A member of each specialty was present for each training session while a mock patient was moved physically and electronically through a treatment, with the staff entering data as they would for an actual patient. By the time the new facility opened, everyone was comfortable using LANTIS.

The COHERENCE™ software application (left) is designed to support and enable treatment planning, while the LANTIS® program (right) is the workflow manager.

Paper is tenacious, and the department has not managed to abolish it entirely. At the end of an appointment, the physician completes a document for the billing staff that also says when the patient needs to return for the next appointment. The front desk schedules the appointment from the sheet. “That’s only one piece of paper for each clinic visit,” Smith notes.

For anyone considering a similar conversion, Smith has advice. “First, you have to have a leadership team that includes someone from each constituency,” she says. “Second, everybody has to be committed to the project and willing to change the way they do things. It is very hard to let go of paper. At the same time, you need to be willing to hear what the problems are, or might be, and be open about responding to them. Third, you need real practice so your staff can see how patients and data move through the system.”

John M. Buatti, MD, professor and head of the department of radiation oncology at the University of Iowa Carver Medical School, advises that conversion to a fully electronic department be done in a single, comprehensive step. He has not seen many departments succeed with a staged approach, he says, “because that implies that you have fallback. If you have that option, invariably, when you are stressed in a clinical situation, you will find it easier to use your familiar system rather than the new one.”

Department members will be presenting a description of the conversion process at the winter Radiological Society of North America meeting. “LANTIS has saved us more than paper,” Smith reports. “It has saved us staff time. Everything is at everybody’s fingertips wherever they are. Nobody has to spend time tracking down and fetching records. That has been our biggest savings. Electronic management is not just an easier way to work. It is better patient care.”

Paperless Workflow Streamlines Therapy
Darlene Chesnut

Darlene Chesnut, Chief Therapist in the Department of Radiation Oncology at the University of Iowa Holden Cancer Center, summarized the effect of installing LANTIS by saying “it streamlines everything.” It also dramatically cuts the amount of time spent on activities not directly related to delivering care.

“In the past, when physicians wanted a chart, they grabbed it from your control area,” Chestnut explains. ” Because of this there were times that the therapist would have to hunt for a chart while the patient waited for their treatment. Now, the physicians can be looking at chart information at their desks, allowing the therapist to deliver treatment in a timely fashion. They can also pull up portal images and let us know right away whether the treatment field is positioned correctly or if adjustments need to be implemented. Physicians also have the capability to review all schedules at their desks.

Chestnut traces the path of a patient from the time of referral, which is how most patients reach the department, to the completion of treatment, illustrating how LANTIS controls the workflow. “There is an interface with our hospital system, allowing our receptionist to download the demographic information into LANTIS,” she says. “Our schedulers set up the consultation, and after the patient is seen, the physician decides whether the patient will receive radiation therapy. If so, the physician completes an image request form in LANTIS along with a quality checklist (QCL) form and sends it to the scheduler, who schedules the proper examination for the patient.”

Chestnut continues, “Nursing will then complete in LANTIS an image screening form for the proper imaging procedure. This information includes metal screening for MRI and laboratory values for injection of contrast in CT. Simulation then occurs, and the imaging therapist sends the images to the treatment planning team along with a QCL identifying that planning needs to begin. Several QCLs are required from dosimetrists, physicists, radiation oncology residents, and radiation oncologists to navigate the planning process through completion. A final QCL is then sent by the physicist to the proper treatment machine notifying the therapist that the plan is completed and ready for a chart check and treatment verification.”

On treatment verification day, the therapist properly positions the patient, performs necessary shifts for treatment isocenter, and then aquires images of treatment portals. These portal images are then sent to the proper radiation oncologist for review before treatment delivery the following day. QCLs are sent by therapist to physics for final chart check. The patient then has treatment according to the plan, and on the last day of treatment, a QCL is sent for discharge summary. The patient receives discharge instructions from the nurse.

“In essence we have incorporated the QCL feature in Lantis to pass workflow in an orderly sequence,” Chestnut notes. “It is imperative that everyone completes the QCL by the alloted time frame and sends it to next person in the treatment chain for this process to be successful. In the beginning, we communicated with each other via text paging to make sure the responsible person received their QCL, but now we are comfortable with the QCL system and allow it to process our workflow. Again, everyone has to be meticulous and prompt about completing and forwarding QCLs, because if this does not occur the patient’s information is just sitting there.”

Installing LANTIS required considerable training (see main story), but the work clearly was rewarding.

—J. G. Bronson

Judith Gunn Bronson, MS, is a contributing writer for Decisions in Axis Imaging News.