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.

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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.

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“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

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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.

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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

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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

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Elekta’s purpose is to invent and develop effective solutions for the treatment of cancer and brain disorders. Our goal

is to help our customers deliver the best care for every patient. Our oncology and neurosurgery tools and treatment

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Fortis Memorial Research Institute snapshot

Treatment systems:

Elekta Axesse™ – May 2013

Elekta Synergy® – September 2013

OIS: MOSAIQ® 2.5

Treatment planning: Monaco®, XiO®

Patient volume: Approx. 60 patients per day

Staff:

Consultants – 2

Attending consultant – 1

Clinical associate – 1

Senior residents – 3 MD’s in radiation oncology

Medical physicists – 5

Radiation therapists – 8

Administrative support – 1

Nurses – 3