RIO DE JANEIRO NOV 2016
FUNDACION ARTURO LOPEZ PEREZ
Briefly
• What is FALP
• The New RT challenge
• Modelization of the project
• Productivity issues and quantum leap
• Relation to medical outcomes
• The importance of a global cancer management system
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Time lapse 1954-2016
• FALP is a NGO, NPO founded 62 years ago
• Acting as a stand alone “cancer only social security” system in Chile
• Covering for 20 Eu/month/family cancer specialities: surgery, chemotherapy, RT
• 500.000 suscribers of Falp cancer insurance
• Due to local factors, RT was historically
poorly reimbursed in Chile thus inhibiting
new investments in the field
Un modelo integrado y solidario de salud
MEDICINA ONCOLOGICA PERSONALIZADA: RADIOTERAPIA AVANZADA –CIRUGIA COMPLEJA -ONCOGENOMICA
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• Create an RT activity with high added value
• Of recognized quality and patient centered
• Offer a wide range of therapeutic tools
• Competitive solutions in terms of tecnology, quality control and pricing
• Quantum leap: show how more advanced is less complicated and efficient gap bridging
• Create a comprehensive cancer center on the existing bases started 60 years ago
The vision: new state of the art RT
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Modelization: Time lapse 2013-2015
• Preparation of the de radiation shielding project before the arquitectural plans (Q2-2013)
• High complexity due to the fact that it had to be build below an existing building
• Need of a highly collaborative setup in the area design
• Choice of equipment
• Choice of wide range of QA tools
• Modelizacion of Mosaiq paperless management system
• HL7 external systems interfaces
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First project 08-2013
Flaws in RT management in general
• Buy machines but not foresee:
– radiotherapy solutions and workflow implications
• the importance of organizational factors
– Team building
• Training issues
– Learning to work together
– Quick and easy response to IGRT and SBRT treatments team work
– Solve any possible communication problems through careful department planning
• Generalized and centralized data access in order to tackle: medical, technical and administrative records plus all the department resource mangement
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Time consuming workflows
los tiempos indicados en la tabla son por paciente y por caso simple
Aplicar factor de complejidad para cualquiera de las tecnicas POR PACIENTE Simple : los tiempos indicados en la tabla
mediano : x 2 los tiempos indicados en la tabla complejo: x 3 los tiempos indicados en la tabla
HITOS PRINCIPALES STAFF 3D Varian 3D ELEKTA TOMOTHERAPY VMAT CYBERKNIFE
key staff Support staff key staff Support staff key staff Support staff key staff Support staff key staff Support staff key staff Support staff
1. Evaluacion clinica Comité Multidisciplinar MD residentes 9 horas semanales en promedio por medico
decision terapeutica e etapificacion recepcion 0.5h de cordinacion para recepcion
2. 1ra Consulta y prescripcion RT Seleccion del protocolo de tratamiento MD residentes 1 hora en promedio por medico
Prescripcion: volumenes y fraccionamiento
3. appointment management escaneo de documentacion pacientes, confeccion de agendas, tarjetas de seguridad recepcion TENS 20 minutos por paciente por recepcion o TENS
x2 si cordinaciones con QT, internas externas, convenios con requisitos
4. CT, PET SCAN e inmobilization optimizar aditamentos, adquisicion de escaneos 1 TM MD, M. Phys. 30 minutos por paciente por TM y TENS
1 TENS
5. determinacion de volumenes volumenes Target MD 1h 1h 2h 2h 3h
Organos a riesgo TM MD 1h SN 1h SN 2h SN 2h SN 3h SN
preparacion estudio global si fusion TM M. Phys. SN SN SN SN SN
6. Planificacion de tratamiento construccion y calculo del plan de tratamiento TM M. Phys. 1h SN 1h SN NA 1h NA 1h 4h 4h
7. Fabricacion de protecciones en Cerrobend TENS TM 0.5h NA NA NA NA
8.exportacion a RV documentacion de parameteros de tto TM M. Phys. 1h 0.5h 1h 0.5h NA 0.2h 1h 0.5h 1h 1h
preparcaion estudios de firma IP, CBCT, TOMOSCAN, tracking
9. Patient QA M. Phys. NA NA 1H 1H 1H
10. Tratamiento firma Ok inicio de tratamiento TM, MD M. Phys. 0.25h, 0,25h SN 0.25h, 0,25h SN 0.25h, 0,25h SN 0.25h, 0,25h SN 0.25h, 0,25h SN
tratamientos diarios 2 TM M. Phys. 2 x 0.25h SN 2 x 0.25h SN 2 x 0.5h SN 2 x 0.25h SN 2 x 1h SN
fraccionamientos por tecnica 5 a 6 semanas 5 a 6 semanas 3 semanas 3 a 4 semanas 1 semana
11. evaluacion paciente durante el tto consulta semanal MD, residente Reception 0.1h 0.25h 0.1h 0.25h 0.1h 0.25h 0.1h 0.25h 0.5h *una semana tto
Recepcion: informes, peticiones y licencias varias
12. revision semanal expediente y citas clinico administrativa TM TENS 0.5h 0.1h 0.5h 0.1h 0.1h 0.1h 0.5h 0.1h 0.5h NA
Imagenes MD TM 0.1h 0.1h 0.1h 0.1h NA NA NA NA NA NA
13. Fin de tratamiento reporte, epicrisis e archivo papel MD reception 0.5h 0.5h 0.5h 0.5h 0.5h 0.5h 0.5h 0.5h 0.5h 0.5h
14. facturacion facturacion y reporting reception M. Phys. 1h SN 1h SN 1h SN 1h SN 1h SN
Final project 08-2014 Improved WORKFLOW through gaining 90m2 of open space for collaborative spaces
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Workflow optimizing
2D 1970
3D 1980
IMRT 1999
IGRT 2006
VMAT IORT
Tomotherapy Cyberknife 2010
Proton / IMPT Carbon ion
RT ADAPTAVE….
FALP OCTOBER 2015
How to make up for the lost decades?
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RT in 50 years
what is
the (level 1) evidence?
the budgetary impact?
the cost?
the value for money?
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Methods of economical analisis in healthcare Cost minimizing
Allegedly all the benefits of competing treatments in terms of survival and y quality of life are the same.
only the cost of a new treatment vs. Standard treatment is considered.
The treatment of choice is the cheapest ! Value expressed in : U$
Cost effectivity
The cost of an intervention is related to its impact on clínically relevant end point ("effectiveness”)… like: global survival
Incremental Cost-effectivity Ratio (ICER) is the incremental cost, divided by the incremental benefit of a new intervención relatively to the STANDARD one.
Value expressed in : U$ per year of saved life or U$ per QALYs
US $ 50.000 / year of saved life
extra cost extra effect new treatment
cost per life year gained (LYG)
= incremental cost-effectiveness ratio cost per quality-adjusted life year (QALY)
= incremental cost-utility ratio
= ICER
cost effect
standard treatment
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more effective less costly
st
less effective
more costly more effective
more costly
less effective less costly
ICER
30-40.000€
per (quality adjusted) life year
Ploquin and Dunscombe, R&O 2008 historical evolution of the cost of radiation therapy over 20 years
corrected for inflation and exchange rates
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more complex treatments more time
more resources
capital investments
sophisticated equipment buildings
QA
human resources
treatment
maintenance
QA
El costo de la aplicacion de las nuevas tecnologias
materiales costo
salarial
Ploquin and Dunscombe, Radiother Oncol 2008 Tramientos mas complejos:
• mas tiempo de preparacion
• mas recursos humanos y materiales
Lievens Y, IJROBP 2003 20
Multidisciplinary cordination
Perrier et al. R&O 2013
IGRT, prostate
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more complex treatments
contain costs without impact on quality?
1. limit cost of resources
2. optimize use of resources
3. decrease total treatment time
4. (time per fraction X number of fractions)
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Unique range of solutions in South America
• Cyberknife
• Tomotherapy
• Elekta VMAT
• LIAC (IORT)
• Mosaiq Paperless
Lievens Y. The Breast 2010
hypofractionation, breast resource costs
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“It’s always too early until, unfortunately, it’s suddenly too late!”
(Buxton)
ext en t c lin ic al u se
time development Phase I-II
use in RCT unethical?
belief / widespread use
premarket emerging diffusing established obsolete
co st c alc ula tio n fina nc ing
fina nc ing
>
> eff ec tiv en es s c os t eff ec tiv en es s
uncertainty
Bonastre et al. Bull cancer 2006
Impact of training and previous experience
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25 SUB-PROJECTS IN ORDER TO GO LIVE in 2015
1 Tomotherapy HD
WORK FLOWS
ARQUITECTURA ERGONOMETRICA INTERFACES CON SICI
2015: PET-CT big bore RADIOTERAPIA
1 Acelerador VMAT
IORT /HDR
- CENTRO PAPER LESS MOSAIQ 30 LICENCIAS
- CONECTIVIDAD 100% SICI Y RCC
3 XIO 2 MONACO 8 FOCAL
Neuro-Radiocirugía
1 CYBERKNIFE
M6
The booster: Elekta Consulting services
• 100% paperless since day 1 means all your processes and interfaces with other services are 100%
operational and optimized
• Centralized document fast scanning
• Workflow modeling
• Workflow automation with IQ Script
• ESI :
– ADT (in and out)
– SIU (agendas in and out)
– DOC export (comite requests) – DOC Import (comite results)
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THE MANAGEMENT SYSTEM IS KEY
MOSAIQ paperless in 2015 MOSAIQ big data in 2016
ESI+ IQ SCRIPT
MICRO-
MANAGEMENT
MANAGING THE CHANGE= NEW STREAMLINED ORGANIZATION 1. NEW MD AGENDA ALLOWING TO CONTROL
1. PATIENTS WORKFLOW
2. QUALITY OF PET CT IMAGING 3. QUALITY OF CONTOURING
4. QUALITY OF TREATMENT PLANS REVIEWS AND SIGNATURE 5. PATIENT TREATMENT QA
6. MACHINE QA
7. OPTIMIZATION OF RESOURCE USAGE (TECHNICIANS, RADIOGRAPHERS ETC..}
8. WAIT LIST REMOVAL
9. ALL RT TASKS UNDER CONTROL
10. ALL TASKS MANAGED THROUGH MOSAIQ QCL
2. NEW JOB DESCRIPTIONS FOR ALL THE PERSONNEL INVOLVED IN RT
3. DOCUMENT ALL SOP (STANDARD OPERATION PROCEDURES) OF NEW TECHNIQUES EMPLOYED, FROM END TO END
1. CONSULTATION 2. SCAN
3. CONTOURING 4. PRESCRIPCION
5. TREATMENT PLAN REVIEW 6. PATIENT SETUP AND IGRT
7. END OF TREATMENT EVALUATION 8 FOLLOW UP SCHEMES
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The booster: Elekta Consulting services
• Build a procedure code nomenclature
• Configure MOSAIQ with the procedure code nomenclature
• Develop charge capture quality control reporting
• Implement charge capture process and
controls for quote process and billing process
• Validate account and charge exchange process
with CISI (FALP billing system)
Out of scope
Treatment cost
DIRECT INDIRECT
Personnel Material
Equipment
RT patient related activities RT support act.
Intake
consultation Medical
review …
APBI - brachytherapy SBRT – lung –
5 fractions …
Overhead
Other Equipment
Maint. & QA
Material Time driven
Activity
consumption Per fraction
Non-RT, care activities
Non- care activities RT patient
related RT
support
Mark-up % on treatment cost
80% fraction 20% patient
56.6%
Hulstaert et al, Rapport 198 KCE 2013
The booster: Elekta Consulting services, reducing
overheads and operations costs through automated interfaces
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Time consuming workflows
los tiempos indicados en la tabla son por paciente y por caso simple
Aplicar factor de complejidad para cualquiera de las tecnicas POR PACIENTE Simple : los tiempos indicados en la tabla
mediano : x 2 los tiempos indicados en la tabla complejo: x 3 los tiempos indicados en la tabla
HITOS PRINCIPALES STAFF 3D Varian 3D ELEKTA TOMOTHERAPY VMAT CYBERKNIFE
key staff Support staff key staff Support staff key staff Support staff key staff Support staff key staff Support staff key staff Support staff
1. Evaluacion clinica Comité Multidisciplinar MD residentes 9 horas semanales en promedio por medico
decision terapeutica e etapificacion recepcion 0.5h de cordinacion para recepcion
2. 1ra Consulta y prescripcion RT Seleccion del protocolo de tratamiento MD residentes 1 hora en promedio por medico
Prescripcion: volumenes y fraccionamiento
3. appointment management escaneo de documentacion pacientes, confeccion de agendas, tarjetas de seguridad recepcion TENS 20 minutos por paciente por recepcion o TENS
x2 si cordinaciones con QT, internas externas, convenios con requisitos
4. CT, PET SCAN e inmobilization optimizar aditamentos, adquisicion de escaneos 1 TM MD, M. Phys. 30 minutos por paciente por TM y TENS
1 TENS
5. determinacion de volumenes volumenes Target MD 1h 1h 2h 2h 3h
Organos a riesgo TM MD 1h SN 1h SN 2h SN 2h SN 3h SN
preparacion estudio global si fusion TM M. Phys. SN SN SN SN SN
6. Planificacion de tratamiento construccion y calculo del plan de tratamiento TM M. Phys. 1h SN 1h SN NA 1h NA 1h 4h 4h
7. Fabricacion de protecciones en Cerrobend TENS TM 0.5h NA NA NA NA
8.exportacion a RV documentacion de parameteros de tto TM M. Phys. 1h 0.5h 1h 0.5h NA 0.2h 1h 0.5h 1h 1h
preparcaion estudios de firma IP, CBCT, TOMOSCAN, tracking
9. Patient QA M. Phys. NA NA 1H 1H 1H
10. Tratamiento firma Ok inicio de tratamiento TM, MD M. Phys. 0.25h, 0,25h SN 0.25h, 0,25h SN 0.25h, 0,25h SN 0.25h, 0,25h SN 0.25h, 0,25h SN
tratamientos diarios 2 TM M. Phys. 2 x 0.25h SN 2 x 0.25h SN 2 x 0.5h SN 2 x 0.25h SN 2 x 1h SN
fraccionamientos por tecnica 5 a 6 semanas 5 a 6 semanas 3 semanas 3 a 4 semanas 1 semana
11. evaluacion paciente durante el tto consulta semanal MD, residente Reception 0.1h 0.25h 0.1h 0.25h 0.1h 0.25h 0.1h 0.25h 0.5h *una semana tto
Recepcion: informes, peticiones y licencias varias
12. revision semanal expediente y citas clinico administrativa TM TENS 0.5h 0.1h 0.5h 0.1h 0.1h 0.1h 0.5h 0.1h 0.5h NA
Imagenes MD TM 0.1h 0.1h 0.1h 0.1h NA NA NA NA NA NA
13. Fin de tratamiento reporte, epicrisis e archivo papel MD reception 0.5h 0.5h 0.5h 0.5h 0.5h 0.5h 0.5h 0.5h 0.5h 0.5h
14. facturacion facturacion y reporting reception M. Phys. 1h SN 1h SN 1h SN 1h SN 1h SN
