Development of Telemedicine-Based Managed Clinical Networks for G ynaecological Cancer in the West of Scotland GD Currie, P Campbell, GF Brunton Beatson Oncology Centre North Glasgow University Hospitals NHS Trust

Background

Beatson Oncology Centre  Largest cancer centre in Scotland providing tertiary cancer care services to 2.7 m population across west of Scotland  radiotherapy & chemotherapy services  site specific cancer teams  clinical trials unit  radiobiology research unit

Issues in Cancer Care

Poor outcomes in cancer care Shortage of oncologists Specialists moving between clinics Requirement for multidisciplinary decision making process Communication between primary, secondary care Tumour site specialisation

Managed Clinical Networks

“Linked groups of health professionals and organisations from primary, secondary and tertiary care working in a coordinated manner unconstrained by existing professional and Health Board boundaries to ensure the equitable provision of high quality clinically effective services throughout Scotland” MEL(1999)10 - prospective audit - deliver requirements of Clinical Standard Board for Scotland with evidence based (SIGN) guidelines - plan for service redesign and improve the patient journey

MCN Core Principles

- Robust data collection system - Discussion time to develop evidence based guidelines - Effective communication links - Strategic planning to influence redesign of service - Facilitate educational and research activities - Demonstrate improvements as a result of an effective network

How Could Technology Help?

Gynaecology Managed Clinical Network chosen to pilot the application of modern information technology and networked information systems to support the oncology MCN’s in the West of Scotland Pilot funded by Scottish Executive’s Scottish Telemedicine Action Forum (Aug 2000 – Aug 2003)

Project Aims and Objectives

 Establish ‘virtual’ clinical meeting rooms using video conferencing.

 Provide a secure clinical information system to describe the patient journey - electronic episode record of care.  Provide a core repository for essential clinical information and medical images, making available all relevant information for MCN decision making process  Assist with establishment of robust data sets & facilitate audit processes  Provide means of informing primary, secondary and tertiary care teams of ongoing cancer care.

Gynaecology MCN Pilot

• 300 patient referrals / year • BOC with 5 DGHs across west of Scotland • Oncologists, gynaecologists, pathologists, surgeons, radiology, nursing, radiography, clinical trials

Project Phasing

1. Videoconferencing Implementation • Establish a v irtual MCN meeting room • Share pathology, radiology images across VC system • Record MCN decisions using existing Access database - limited visibility to VC participants 2. Clinical Information & Image Management System (CIIMS) Implementation

Videoconferencing System

Nov 01 – Feb 02  Sony VC units installed at five MCN sites  Communication using BT ISDN-6 lines Sep 2002  Accord Multi Conferencing Bridge  6 x ISDN-6 (384 kbps) + 6 x IP  Mixed ISDN / IP Network  Full IP within Glasgow sites

MCN VC Meetings

Video Conference Activity

60 50 40 30 20 10 0

Ja nu ary M arc h M ay Ju ly Se pt N ov Ja

Calendar Month

n M ar M ay Audit Staff Technical Clinical Trials Staff Nursing Medical

CIIMS Requirement Specification

 MCN Episode of Care Record  Electronic record of the decision on future care management for each patient as decided by MCN participants (diagnosis, surgery, treatment).

 Support the management & organisation of the conference and record who attended.

 Provide a central repository of collated data and images to help the MCN determine the optimum care pathway.

 Patient Care Summary  Data collection tool and audit system

MCN ExceliCare System

 Wide area networked system with central SQL database  Electronic interfaces built to deliver automatic update of demographics, key labs data, radiological images, pathology images   Reporting and audit tools E-mail communication of summary data  Conference management tools to anonymise patient identity during VC meetings; all network communication over NHSNet / HealthNet Community (secure network)

CIIMS Implementation

 Small number of pilot systems ( 15-20 clients installed across WoS initially)  Data forms agreed and security permissions applied  Manual data entry (registration, conference lists, special forms)  CIIMS screens dynamically pushed to all participants during VC sessions using NetOp software across NHSNet  Summary reports e-mailed to clinical staff after MCN session for patient follow-up  Data captured consistent with MCN (SIGN) guidelines for future audit purposes

CIIMS Electronic Interfaces

Interfaces developed with ‘automated’ transfer of data & images into ExceliCare  Demographics (iSoft, COMPAS, SCI)  Key Laboratory data (Telepath, Revive, SCI)  Pathology images (microscopy, e m scope)  Radiology images (CT, MRI)  Key Radiotherapy treatment data (VARiS) MCN dependent  Key Chemotherapy treatment data (ChemoCare)

CIIMS end of Phase 3

NORTH GLASGOW TRUST

Glasgow North HOMER PAS TELEPATH

CROSSHOUSE HOSPITAL COMPAS PAS REVIVE LABS / RAD CT SCANNER STORE

Excelicare Client PC

Crosshouse Firewall Exceliport Slave Server

Excelicare Client PC Glasgow Royal

VARIS RT Excelicare Data Store Server

Excelicare Client PC Stobhill

CHEMOCARE

N H S N et

INVERCLYDE HOSPITAL

Excelicare Client PC

SCI PAS, LABS, RAD

He alth Ne t C om m.

Inverclyde Firewall Exceliport Master Server North Glasgow Firewall

HealthN et Com m.

FORTH VALLEY TRUST

Excelicare Client PC

SCI PAS, LABS, RAD

Falkirk

Forth Valley Firewall

H e a lth N e t C o m m .

Excelicare Client PC

LANARKSHIRE TRUST

Excelicare Client PC Beatson Oncology Centre

Lanarkshire Firewall

Courtesy of AxSys Technology Ltd

SCI PAS, LABS, RAD PACS STORE

Hairmyres

Excelicare Client PC

Wishaw

ExceliCare MCN – How does it work

 Pre Conference     Secretarial / admin staff prepare case record Patient registered to MCN, supporting data ‘pulled’ Patient entered onto Conference List Selected images chosen by specialists for meeting  During Conference  Application locked in a Conference Mode  Record reviewed & updated during discussion  Summary available for distribution

Technical Challenges

Data Quality  Identifying the correct patient (CHI)  Data matching via interfaces requires high accuracy  Bespoke interfaces due to limitations of connecting systems Image capture  Imaging units visible on LAN / WANs?

 Requirements for adequate bandwidth  DICOM connectivity / compliance

Clinical Challenges

Standardisation  Variation in Pathology testing regimes  Differences in radiology acquisition & reporting  Coding & nomenclature Cultural change  Acceptance of new technology  Process changes

Benefits in Patient Care

 Earlier case discussion with specialist input  Educational opportunities for MDT teams  Reduced professional isolation  Higher quality data set leading to improved audit  Rollout to other MCNs with steps towards a Scottish cancer EPR?

Questions?