RADIOTHERAPY ACTIVITY PLANNING
HORIZON SCANNING REPORT - STREAMLINING TECHNOLOGIES
The remit of this group was to look at how 'streamlining new technologies and improving communications' between radiotherapy centres in Scotland could be used to provide better access to these technologies, with a resulting improvement in the availability of state of the art treatment for patients.1. General communication/collaboration
Before even looking at the use of information technology to communicate between centres, it is necessary to look at better collaboration between centres. Taking as an example the introduction of IMRT. If each Scottish department continues to work independently developing and implementing what is essentially the same process, each will have considerable resource requirements in terms of time, workforce and financial cost. In addition, limited resources of some departments may restrict timely development resulting in inequitable access to modern treatment deliveries across Scotland. There needs to be national sharing of experience and even the workload to ensure faster progress. In addition such partnership development would allow on-going audit between centres thereby assisting in the development of quality control procedures.
How would we achieve this? We could have, for example, a Scottish IMRT Development Group with frequent meetings held during the implementation period, open to all centres to attend and therefore including those that may not be currently going through the process. Examples where this approach could have been useful in the past (and possibly still useful) are prostate brachytherapy and stereotactic radiotherapy. In the future the development of both image guided and image gated radiotherapy could benefit.
An alternative approach would be to identify one centre to develop a specific technique and then use their expertise to install it in another centre, including teaching and training of staff. It recognised that now all centres would be in a position to consider this option and therefore further consideration might be given to he provision of supernumerary staff to assist with new developments and implementing then nationally.
The diversity of equipment may be a problem but given the recent move to buy Varian this should be less of an issue. Freedom of choice for all departments, about the manufacturer they select, must be preserved but debate between centres on the rationale might prove beneficial. In the future, if it is seen that the overheads involved with the development of new technology can be substantially reduced by purchasing from a particular manufacturer, then that could play a significant factor in decision making.
We suggest looking at developing better collaboration now, if we can accept the cultural change. A first move could be to set up a Scottish Development Group with representatives from all centres to explore the possibility and with the remit to cover all new techniques, not just IMRT. The group should draw from all professions working in radiotherapy, but would be mainly composed of physicists because of their role in the development and introduction of new technology. Part of the remit of any such group should be to monitor the development of IT to provide data communication between centres.2. Data transmission between centres
The next level up would be to set up data communication links between the radiotherapy centres. Two components would be necessary:
a) The transfer of images, contours etc. to the remote site and completed plans returned.
Most data communication between different scot.nhs.uk locations takes place on 'Health Net Community' a virtual private network ( VPN) run for the NHS by BT. This is either an upgrade to or another name for NHSNet. HealthNet Community Gateway connects NHS Scotland to the wider NHSNet. At least half of Trusts in Scotland have migrated to HealthNet Community Scotland. It appears that communication does not go out over the wider Internet and therefore there should be no problem with data security. However, this is not entirely consistent with other advice that only data going to a local scot.nhs.uk address is secure.
There would not be a great deal of difficulty in setting up a connection between specific locations within radiotherapy departments as this would be done by configuring their various firewalls. At present, the bandwidth of some of the networks is quite low so large data sets would probably require minutes or tens of minutes to send.
b) A video conferencing arrangement to allow interactive discussions based around planning system displays.
The present situation is that there is a slow migration from the use of ISDN lines to using the data network. Because of the low bandwidth of the network, video conferencing signals can often be of poor quality and could easily have a serious effect, even on static images. Discussions are taking place about upgrades to the networks involved, but no plans are in place yet and that could be one of the most serious difficulties that would need to be overcome. All videoconferencing technology is currently limited to XGA resolution (1024 x 768). It is only in the past year that XGA has become widely available, and higher resolution requires higher bandwidth, so the limitation may exist for some time.
Videoconferencing security is provided by either the use of NHS data networks, or encryption between the teleconferencing hardware. The encryption requires the hardware at either end to be compatible; otherwise the conference will still be possible but will not be encrypted. Most manufacturers' equipment is converging towards universal standards, and it is only older installations where there is still a problem. ISDN communication is not generally encrypted. However, it would not be straightforward to intercept patient information as the data is compressed into packets before it is transmitted.
Current video conferencing installations have dual large display screens, programmed touch-panel control, and high-quality audio pick-up. It is possible to broadcast two streams simultaneously from each site in the conference, for example the view of an audience plus either diagnostic images or a data screen. The requirements for radiotherapy planning would presumably be modest. Small-scale solutions include dual large screen monitors mounted on a mobile unit with cameras. Customised solutions involving a planning workstation would also be possible.
In conclusion, it must be realistic to say that there will be no problems in 10 years time.3. Use of the data network
Assuming that the above is in place, what use could be made of it? On more than one occasion in the past, the suggestion has been made for 'a planning centre for Scotland' where all other centres send their patient data. This has never taken off because technology was not capable of supporting it. Today, the linac complement in Scotland is sufficiently well matched to be able to use common beam data sets and that is a plus. However, the complexity of planning has increased considerably and in the most complex cases requires continuous interaction with medical staff during the process making the practicalities of scheduling such interaction around busy Consultant diaries difficult.
Taking IMRT as an example. All Scottish departments have the technology to treat IMRT since it is standard on all new linacs. If the total number of patients requiring IMRT in Scotland is small, would it be feasible to plan these patients through a centralised and expert resource, but continue to treat at the referring centre? In theory yes, but how would individual centres feel about losing at least some control of the planning process? IMRT planning is an interactive process and not simply 'pushing a button', so video conferencing to observe the planning process at the other end is necessary. Dicom- RT should make the transmission of images/structures/ DMLC files straightforward if the same kit is used. We are probably not far away from being able to do this now, but would we want to? The general feeling is that overall there is not much to be gained, as staff from the referring centre would still need to be involved in the planning process and would still need to set up and perform their own QA.
Other main developments for which we will need to gain expertise in the near future are image guided and image gated radiotherapy, but these are not suitable for this approach as they are used dynamically at the time of treatment. Planning of HDR brachytherapy is another possibility for centralised planning but there are similar problems to IMRT, although the planning is not so complex, even if CT is used.
In conclusion, since planning, and in particular complex treatment planning, is an interactive process there does not appear to be much that can be gained from adopting a centralised planning resource. Further consideration of this will be warranted if a devolved configuration of cancer centres is indicated for Scotland in the future.5. General conclusions
There is undoubtedly potential in using IT to improve and streamline communication although this is difficult to appreciate given the current difficulties in setting up and maintaining a network between radiotherapy centres in Scotland.
Through better collaboration significant gains are to be made by:
sharing expertise through organised development programmes and frequent meetings sharing out major development projects between centres and rolling out to others using the staff from the development site. looking at the possibility of funding supernumerary staff to assist in-house staff with development and provide the roll out to other centres.
These points should be addressed immediately. In addition, the potential and possible future uses of IT technology to improving the treatment and management of patients should be continually assessed.
Horizon Scanning Group of the Radiotherapy Activity Planning Group