Feature | December 03, 2006

Crossing Conventional Boundaries to Manage Patient Data

Next-generation systems will expand breadth, depth of software capabilities, workflow efficiencies.

Joel Goldwein, Ph.D., vice president, Medical Affairs, IMPAC Medical Systems, Mountain View, CA

Joel Goldwein, Ph.D., vice president, Medical Affairs, IMPAC Medical Systems, Mountain View, CA

Among the array of clinicians that Outpatient Care Technology covers and reaches, oncologists arguably are the most computer-savvy – at least with their profession.
Why? They routinely use information systems to precisely target tumors and diseased tissue, shape radiation beams and deliver the optimal dose of radiation therapy.
But that’s not all. A growing number of radiation therapists also are plugging electronic health record capabilities into their IT systems at a seemingly faster clip than their counterparts in other clinical settings.
While they may be farther along than other clinicians, however, it stands to reason they’re also looking ahead to what else they can do with their oncology information management systems (OIMS) – what additional bells and whistles they can tap into next that will help them do their jobs better and improve patient care delivery.
Outpatient Care Technology Editor Rick Dana Barlow posed a series of questions to key executives of the leading OIMS technology manufacturers connected to the industry zeitgeist to tap into their intelligence on what they foresee as the next generation of products.
What do you foresee as the next big development in OIMS applications to expand functionality or improve performance? Why? How do you envision the next-generation OIMS functioning differently? What additional capabilities and features will be available to enhance patient care, particularly in the outpatient setting? If you could design and program the most futuristic OIMS applications known to man, what useful features would it include?
Response from: Jacob Philip director, Radiation Oncology Business Unit, and Joel Goldwein, Ph.D., vice president, Medical Affairs, IMPAC Medical Systems, Mountain View, CA
The success of advanced therapeutic techniques depends heavily upon the use of advanced imaging techniques. Imaging plays a major role in the identification and segmentation of the treatment volume, in the determination of the appropriate plan of management, and in the daily setup for treatment. Additionally, imaging technology can be used for periodic quality assurance and the assessment of treatment efficacy.
To sufficiently address today’s technology, oncology-specific information systems must support image management as a seamlessly integrated part of the electronic medical record. Additionally, the OIMS must be able to reconcile the growing divergence between treatment options, clinical management solutions and the tools available for treatment management.
With the expanding frontier of options clinicians face in this situation, there will be a need for a unifying force that advances convergence and emphasizes a common user experience. Traditional and legacy processes and products will need to evolve into solutions that present information in a meaningful manner that accommodates the increasing data diversity. In other words, today’s technology has created the need for a whole new class of products that cross conventional product boundaries that provide insight not as yet available.
Cancer therapy comprises multiple disciplines – surgery, radiation, and chemotherapy – all of which share a common goal of providing the best treatment outcome for the cancer patient, but all of which require different IT capabilities for the electronic patient record. Therefore, the OIMS must not only provide depth but also must offer breadth in its oncology-specific functionality in order to further the medical benefits of technological advances, and to even provide features that extend beyond the cancer center to improve all aspects of oncology diagnosis, research, treatment, follow-up, etc.
As clinicians begin to realize the scale of both the quantity and richness of information that today’s technology provides, they will gravitate toward information solutions that ensure access and promote analysis and decision-making based on today’s enriched data sets. A product that provides a decision-maker with insight or clinical outcomes advantages will encourage the practice of evidence-based medicine and possibly will even offer the decision-maker an advantage in outcomes over his colleagues.
Extending beyond the cancer center, continued development of industry standard interoperability will allow disparate systems to seamlessly exchange information, and enhance the patient care processes. The OIMS will not only be core to patient management, but will also be capable of processing clinical protocols, coordinating care, managing interdisciplinary communication and integrating data from numerous external sources. Enhanced imaging and storage capabilities will facilitate multimodal care and the use of targeted therapies. Linkages to external data sets will facilitate access to clinical trials, and assist the delivery of research data to research organizations. Real-time interfaces to cancer registry systems will enhance knowledge concerning cancer populations leading to further strides in the surveillance process.
Cancer therapy is provided in many different settings – free standing, private practice and hospital based; large, disparate organizations and small, single modality facilities. The OIMS must be flexible enough to co-exist amongst other HIT systems in a multispecialty organization, comprehensive enough to support free standing organizations, and robust enough to operate over a wide-area network. The next-generation OIMS would be most useful if it’s designed from the outset with such flexibility of functionality.
Moreover, integration with virtually any planning or delivery platform is another significant requirement. Many traditional imaging and surgical navigational products will continue to cross over into radiation oncology, and will further expand the diversity of choices available to clinicians, as outcomes persistently play a greater role in regulating the proliferation of technology. But the cycle times and the speedy rate of market penetration for many of these new products will mandate multivendor connectivity.
Developers of the next-generation OIMS should provide products that demonstrate a high degree of technology convergence. As both existing and new processes are refined, and as the new product cycle times continue to shorten, products that promote real efficiency and productivity gains will have a definite advantage.
Patient care – especially in the outpatient setting – will require better integration with and support of all enterprise information needs. Full fidelity portability of electronic records across physical boundaries, independent of IS vendor, will aid in process flow automation. And the development and adoption of standards-based communication protocols will weigh heavily in future enhancements to patient care.
The state-of-the-art of electronic medical systems for oncology goes beyond the ability to simply store and retrieve patient clinical information. The path forward involves increasingly powerful process-flow automation tools that facilitate the delivery and management of increasingly precise treatments, with the electronic patient record as the information and automation hub in the overall process.
The oncology-specific patient record also will take on an increasingly integral role as the control center for clinical trial management and for overall outcomes analysis. There is a wide range of outcomes for cancer patients spanning potentially many years. The oncology-specific electronic patient record must provide not only the ‘point of care’ capability during the patient’s treatment, but also the ability to ‘follow’ the patient over a potentially long period of time, abide by the emerging and evolving standards for data collection, and aggregate information for a large patient population in a format that can be used for detailed analysis.
Such a solution would capture and retain all clinical information, automatically perform rules-based analyses on that information taking into account historical data from both the patient’s record and the population sample and provide a real-time distillation of information of those elements most likely to affect patient care.
This system would trigger alerts and periodically notify the status of clinical management, would advise when changes to the intended course of care are encountered and suggest improvements based on information from both historical and expert knowledgebase resources.
Finally, this system would provide a clinical dashboard that would expertly summarize the current condition and graphically and succinctly display information elevating the role of the clinician from that of an information aggregator and manager to that of an analyst and decision-maker.
Response from: Richard Stark, vice president, Worldwide Marketing, Varian Medical Systems’ Oncology Systems Business, Palo Alto, CA
For optimal radiation therapy, clinicians seek to maximize the radiation dose delivered to a tumor while protecting the surrounding healthy tissues. In the quest for ever more precise and ever more accurate treatments, a host of new modalities and technologies has emerged. These developments have two things in common: 1) treatment plans that require a mountain of information about each patient’s anatomy and physiology, and 2) an explosion of digital data and images that are crucial for carrying out sophisticated, targeted treatments.
The challenge of managing all this data is changing the industry. The oncology information system (OIS) of the future will ensure that all clinical data and images are captured, stored and made accessible when and where they are needed for delivering advanced treatments like IMRT, IGRT and IGRS. That means, among other things:
• handling different diagnostic image modalities — CT, PET, MR, ultrasound — and making it possible not just to see these images but to manipulate them,
• generating new images each day right at the treatment machine,
• preserving coordinate systems and annotations throughout the course of treatment, and
• rendering all this information clinically useful.
New technologies require new processes that can strain a department’s clinical workflow. The OIS of the future must make it easier and faster for users to plan and deliver advanced forms of treatment without slowing the flow of patients. That means building in workflow to manage standard strategies as well as the transfer of tasks from one staff member to another, using templates and automation to streamline processes, and making interfaces intuitive and easy to learn.
Future iterations of Varian’s OIS will be ever-more workflow-driven, with modules, screens and views that are optimized for each broad category of professionals, but then finely customizable by individual users. At Varian, we continually work with our customers to determine what an optimal workspace would be for each group, and then give users the power to adapt the workspace for their own unique processes.
With IGRT, the radiation therapy profession has moved another step in the direction of DART Dynamic Adaptive Radiotherapy — an emerging approach for more personalized cancer care that involves using up-to-date image data to adapt a patient’s treatment based on constantly-evolving information about changes in tumor shape, size, position and even function. This means using technology to deliver the right dose to the right place at the right time, every time, even when the targeted tumor moves, shrinks, changes shape or develops hypoxic areas.
At Varian, we see several different approaches to dynamic adaptation, including offline, online, and real-time DART, and we have designed our OIS to enable all three. Offline DART, or the use of images to modify a treatment plan between treatment sessions, can be used to deal with gradual changes in anatomy or physiology, such as tumor shrinkage over a course of treatment. Online DART deals with daily variations in patient anatomy just before each treatment, such as displacement of the prostate due to the contents of the bladder or bowel. And real-time DART deals with mobile targets that move during treatment, such as lung tumors moving due to respiration.
Making all of these different kinds of DART treatments clinically practical will require excellent connectivity between robust information management and image processing, rapid treatment planning and advanced treatment delivery systems within a networked clinical environment. It requires us to generate, access, interconnect, interpret and act on new patient information in real time. The OIS of the future must fully support this kind of dynamic adaptive treatment process.

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