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Australia’s Prince of Wales Hospital eases into its second paperless year with Elekta oncology information system

The common recollection among past users of a non-electronic radiotherapy workflow is how much paper-chasing they did. Tethered to the world of paper patient charts and reports, radiotherapy department staff were constantly walking to get paper materials, filing them, bringing them places and searching for them. Add to that the tedium of filling out paper forms, transferring electronic information to forms and trying to read handwriting on forms.

With its upgrade to MOSAIQ 2.41 in 2012, the radiation oncology department at Sydney, Australia’s Prince of Wales Hospital began a methodical transition away from its 47-year-old paper-based environment. In November 2015, Prince of Wales Hospital completed its first full year with a comprehensive, completely electronic workflow with MOSAIQ® Oncology Information System.

Prince of Wales team

“We began thinking about going paperless when we started running low on paper treatment sheets and wondered whether there was a better option for the treatment sheet, instead of just printing a new batch of the existing form,” says Chin Hwa Chan, Senior Radiation Therapist. “The issue was that it was very time-consuming to fill in this form because we needed to manually transfer all the information from simulation and the treatment planning computer to the treatment sheet. Depending on the treatment’s complexity, it could take anywhere from 30 minutes to two hours to complete this process.”

Chan adds that the paper-based radiotherapy service brought the usual, additional problems:

  • Storage space: The department had to keep patient folders in the department for seven years and Prince of Wales was running out of space to store them.
  • Wandering records: The folders containing patient records were borrowed by different departments and radiotherapy department sections. Folders were temporarily misplaced or unlocatable.
  • Human error/legibility: Transferring information from computers to paper forms increased the potential for mistakes. Also, the frequent illegibility of handwritten notes on patient records meant that staff needed to clarify instructions with the writer.
  • Accessibility: Obtaining a patient folder always involved a walk of varying distances to the record storage room.
  • Separate images: Because they were larger than the patient record folder, film jackets could not be stored with these folders.

migration from paper charts to paperless with MOSAIQCompactor filing systems housing patient treatment folders took up a great deal of space in Prince of Wales’ radiotherapy department. The conversion to an electronic workflow eliminated the need to store paper patient files, enabling Prince of Wales to convert this room into office space.

MOSAIQ steps in

“MOSAIQ offered several solutions that would accommodate our desire to go paperless,” he says. “It would support electronic visualization of 2D images and PDF export of treatment plans into MOSAIQ. It also provided IQ Scripts, for automating workflow steps and thinning out the treatment folder. Finally, it would give us a great deal of flexibility in creating customized assessments.”

Functionality in MOSAIQ – the ability to import 2D electronic portal images (EPI) directly from the treatment machines – enabled the center to take its first step toward a paperless workflow. Before the upgrade, the EPIs used for treatment verification had to be converted to hard films, which could only be viewed on a light box, physically carried to where they were needed, and stored separately from the patient’s treatment folder.

“Now, the radiation oncologists can access all patient images within the department from any nearby MOSAIQ terminal,” Chan notes.

Prince of Wales staff then began systematically converting paper treatment sheet components into information fields in MOSAIQ. The first components included the case description and patient setup instructions, followed by demographics, patient measurements, radiation oncology requests and so on, until all treatment sheet fields were in MOSAIQ. In addition, the implementation of treatment plan PDF export to MOSAIQ, and the acquisition of more computer monitors, allowed staff to review practically everything electronically at multiple locations.

IQ Scripts automates workflow

The use of IQ Scripts in MOSAIQ permitted staff to inject more automation and customization into the radiotherapy workflow. IQ Scripts uses simple scripting via preferences that link together tasks in a chain. They automatically trigger the presentation of one or more new Quality Checklists (QCL) or an assessment when a previous QCL or assessment is completed.

“We used IQ Scripts to design a booking form within MOSAIQ, so the radiation oncologists could do bookings in their office. Then a front desk staff member receives this booking form as a QCL,” he explains. “We also use IQ Scripts for automatic QCL generation after each task is completed. For example, when the treatment plan is completed and is checked by a radiation therapist, when this person completes the QCL, the next QCL will be generated and sent to the physicist, then on to the treatment staff.”

Before IQ Scripts, this workflow was a manual process involving physical log books.

“With IQ Scripts, the workflow is more streamlined and we save time,” Chan says. “All the information is in MOSAIQ. With just a few clicks, we can see everything we need.”

And it is not simply the volume of information now accessible in MOSAIQ, it is the OIS’s ubiquity in the radiotherapy department. It has accumulated 86 MOSAIQ workstations distributed throughout radiation oncology – from the treatment area and radiation oncologist and physicist offices to the clinics, consultation rooms, simulation and nurses’ station.

“MOSAIQ is everywhere now – we can check anything from virtually any desk. Just two steps from where you are, you can find a computer and log in,” says Stéphanie Corde, PhD, Deputy Director of Radiation Oncology Medical Physics. “Before MOSAIQ, it took 10 minutes to find the chart to just check one little thing. We walk a lot less now.”


MOSAIQ also facilitated the creation of many custom assessments for radiation therapy. The tabbed/checkbox format of an assessment consolidates several individual, but related tasks.

“We have assessments for daily machine QA, treatment planning steps and simulation checklist – a total of about 40 assessments and the list is growing,” Chan says. “Assessments reduce visual clutter and eliminate excess QCL’s.”

Looking back

Prince of Wales radiotherapy staff have entered the records of 21,000 patients into MOSAIQ; eventually the records of all patients dating back to 1967 – a total of about 80,000 patients – will be accessible on the system. Now, a few months into their second paperless year, the difficulties of a non-electronic workflow are a fading memory, according to Chan.

MOSAIQ workstation

“All of the issues we encountered daily before we went live with MOSAIQ have been resolved,” he says. “We’re saving time and have eliminated human error by not transferring data manually between planning and treatment, and the workflow is significantly streamlined because we have ready access to data at any MOSAIQ terminal. The staff are happier and more efficient, and patient waiting time has been reduced. The time we save translates directly into more patient interaction. MOSAIQ even helps us with that, because if patients have any questions about their treatment or appointments, we can just bring up their electronic record instead of locating their treatment folder and searching through it.”

Prince of Wales is now at the point of refining its paperless workflow, running Crystal reports, creating more assessments and utilizing the full capacity of MOSAIQ. With an upgrade to MOSAIQ 2.6, for example, the department has been able to customize the home page of each MOSAIQ user.

“With their own unique home page, radiation oncologists, for instance, can instantly see what they need to do that day or what they have in the clinic – what plans they need to approve and what images they need to sign off on,” Chan observes.

“And now, for any paper forms that come into the department from outside – like referral sheets or paper test forms – we can use a function called E-Scan to scan these documents into MOSAIQ. There are still some things we need to do, but we have effectively completed our paperless transformation.

“Of course, this major transformation of our department would not have been possible without the buy-in and participation of all radiation therapy department staff and administration,” he continues. “Their enthusiastic use of MOSAIQ and the feedback they provided during the migration to paperless was invaluable.”