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A computerized data collection system for a cancer centre
Clinical Oncology (1994) 6:237-241 © 1994 The Royal College of Radiologists
Clinical Oncology
Original Article A Computerized Data Collection System for a Cancer Centre A. M. Elespe, S. Dische, M. I. Saunders and M. Pepperell Mount Vernon Centre for Cancer Treatment, Mount Vernon Hospital, Northwood, Middlesex, UK
Abstract. A data system has been designed for a cancer centre and, with the close collaboration of staff, has been brought into use. Data are continuously gathered by doctors, nurses, radiographers and cancer registration staff for the contracting process, cancer registration, audit, research and development.
Keywords: Audit; Chemotherapy; information; Database; Radiotherapy
or more in registration, the existing system was clearly inadequate.
METHOD
Contracting
INTRODUCTION
Recent years have witnessed an explosion in the development of information technology applied to medicine and much attention has been given to hospital information systems [1]. The National Health Service (NHS) reforms, in particular the managerial and contracting systems which have been adopted, have also introduced a need for accurate data about work load to be readily available [2]. Data for the purpose of cancer registration have been gathered in the UK for over 50 years and centres for cancer treatment register all the patients who attend. At Mount Vernon, as in other institutions, this registration is performed by specially trained cancer registry staff. The case notes only become available to registry staff at between 3 and 6 months after the first attendance because of their constant use during the period of active treatment. The cancer registry staff are trained to extract the data required but it is not possible for this to be validated by the doctors, radiographers and nurses responsible for treatment. There are, therefore, inevitable inaccuracies in registry data obtained in this way [3]. With the need for absolute precision now required for contracting, and the lag of 6 months
Correspondence and offprint requests to: Professor Stanley Dische, Marie Curie Research Wing for Ontology, Mount Vernon Centre for Cancer Treatment, Mount Vernon Hospital, Northwood, Middlesex HA6 2RN, UK.
The data required by the cancer registry for onward transmission to the All Thames Registry at Sutton include the personal details of the patient, their address and postcode, the general practitioner's name and address and the patient's NHS number. Features of the initial management by surgery, radiotherapy, chemotherapy, hormonal therapy and by any other form of treatment, are added. Follow-up data are collected annually for 5 years and then every 5 years. The new requirements include much of the data contained in the cancer registration system; however, it was necessary to know whether the patient was attending under the NHS or privately and whether they were doing so on an inpatient, outpatient or day case basis. Most importantly, in the past only the initial courses of treatment were recorded, but now details of all treatment at any time in the patient's attendance at the cancer centre are provided and with high precision. In 1986 software was developed so that the cancer registry data could be gathered on the research computer system. This enabled tapes to be prepared at regular intervals and sent to the Thames Cancer Registry for direct addition to their database. It was decided that the new centre operation system should be grafted upon that previously used for cancer registration. With the new system the data are gathered from the first moment the patient is seen by a member of the cancer centre staff; and this is commonly at a peripheral clinic held in one of the 11 district hospitals attended. To facilitate this 'B' and 'C' forms were devised to register new patients and those formerly treated who are required to attend the centre (Figs 1 and 2). A 'G' form has been designed to allow addition of data concerned with treatment using radioactive sources. The data on the initial forms ('B', 'C' and 'G') are included by the registry staff. Further data are added to the patient's record as shown in the flow diagram (Fig. 3).
238
A. M, Elespe et al.
Mount Vernon Centre for Cancer Treatment (Affix Patient Label Here) M.V. No ..................... D.O.B..........
B Form
The outlined boxed section should be filled in for EVERY NEW patient coming to the cancer centre OR when any of the details in the box have CHANGED
Name ................................................ Hospital at which Oncology clinic held
Address ............................................ Mount Vernon Wexham Park Hillingdon Northwick Park Lister
Postcode ...........................................
[] [] [] [] []
Luton and Dunstable Barnet St AIbans Hertford County Watford
[] [] [] [] []
Hemel Hempstead [] Edgware [] QE II [] If other hospital specify:
GP name ........................................... Tel.no ....................... [ ]
Referred by (name) ......................................... consultant [ ] Tick if no telephone Private yes [ ] Requiring yes [ ] Intent: patient
no [ ]
hospital transport
Diagnosis:
Primary site
Consultant .......................................
Histology ........................................... Radiotherapy treatment external beam
yes [ ] no [ ]
[] [] []
EJM [ ] EG [ ] DF [ ]
For treatment to
Inpatient [] Outpatient [ ] Day case []
Primary [] Regional nodes [ ] Metastasis []
Simulation Shell/mask construction
Linear [ ]
yes [ ] yes [ ]
PH
[] [] []
Has MV notes
......................................
yes
[]
......................................
no
[]
SXR [ ]
no [ ] no [ ]
ARM [ ] RGJ [ ] GR [ ]
Site of mets.
To be treated as:
Number of fractions .......... in ........... days on:]'he treatment will require:-
SD MS RA
no [ ]
GP [ ] radical palliative
Electrons [ ]
CT planning OR [ ] Non-CT planning [ ]
Energy Electron ........... MeV Inc/opposing ports [ ] OR plan []
Radiotherapy treatment - other therapy (Pleasewrite in all details)
1-131 [ ]
Admission Marie Curie [ ] Ward 10 [ ] Ward 11 [ ] details
Bishopswood [ ] Other [ ]
Other instructions/transport requirements
Date of admission ........... for ....... days
Local X-rays sent [ ]
Path. results required
[]
Local notes sent
[]
X-rays required
[]
MCRW patient
[]
CT-scans required
[]
MRI-scans required
[]
Doctor's signature:
Date
For radiographer's use
Date of MV CT • scan
..........................................................
..........................
Tickiffirm
LA1 [ ]
LA2 [ ]
LA3 [ ]
LA4 [ ]
LA5 [ ]
SXR [ ]
appointment
[]
Tickif firm
Time .................. [ ]
Tickiffirm
Simulator: Date .................................. Time .................. First treatment: Date
[ ]
appointment
appointment
Fig. 1. T h e 'B' form. This form, which has a single carbon copy for retention in the notes, is completed whenever a patient is to attend for a course of radiotherapy. To save needless repetition for each patient the items within the box are filled in w h e n the patient attends for the first course and t h e n a m e n d e d only if there are changes in the details. T h e shaded boxes are currently computerized. T h e 'B' form follows the path shown in Fig. 3.
A Computerized Data Collection System for a Cancer Centre
239
This outlined boxed section should be filled in for EVERY NEW patient coming to the Cancer Centre or
Mount Vernon Centre for Cancer Treatment
when any of the details in the box have CHANGED
To be treated as:
(Affix Patient Label Here) M.V. No ..................... D.O.B..........
Has MV
yes [ ]
notes?
no [ ]
Inpatient [ ]
Outpatient [ ]
C Form
Day case [ ]
Admission date ............................ for ........ days
Requiring hospital transport
yes no
[] []
Name ................................................ Address ............................................
Postcode ...........................................
Hospital of referral
Mount Vernon Wexham Park Hillingdon Northwick Park Lister
[] [] [] [] []
Luton and Dunstable garnet St AIbans Hertford County Watford
GP name ........................................... Referred Cons. [ ] T i c k if no Tel.no . . . . . . . . . . . . . . . . . . . . . . . l ~ J by ........................................ telephone
[] [] [] [] []
Hemel Hempstead [] Edgware [] QEII [] If other hospital specify: ........................................
GP [ ]
Intent: radical [] palliative [ ]
Consultant
Diagnosis: Primary site .......................................
SD MS
[] []
EJM [ ] EG [ ]
ARM [ ] RGJ [ ]
Histology ...........................................
RA
[]
DE
GR [ ]
MOUNT VERNON HOSPITAL CHEMOTHERAPY ORDER FORM yes
PP
affix patient label here
[]
10
[]
no [ ]
[]
REFERENCE no. Amended order [ ]
11 [ ]
Confirmed by (PHARMACIST)
MC [] Chemo suite
[] []
Ordered by .......................................... date ....................
Consultant M ............ Ward
[]
PH DC
......................................
Other: ......................... Drug 1
Drug 2
Drug 3
Drug 4
Route
IV IM SC oth:
IV IM SC oth:
IV IM SC oth:
IV IM SC oth:
Delivery system
Syringe
Syringe
Syringe
Syringe
Drug Dose
Bag
Bag
Bag
Bag
Special req. vol. Time req. (24 hr) Date req.
O. ho,d
Take OFF initials
O. ho,d
O. ho,.
Special requirements
FOR P H A R M A C Y USE O N L Y
DILUENT VOLUME PRODUCT CODE No.
SEND ENTIRE FORM TO PHARMACY Fig. 2 The 'C' form. This is used whenever a patient comes to the cancer treatment centre for a course of intravenously administered cytotoxic agents. As with the 'B' form the whole of it is completed only at the first attendance at the centre. Unlike the 'B' form, the 'C' form is repeated for each treatment cycle during a course. Two extra copies are automatically made to be sent to the pharmacy, one for onward transmission to the chemotherapy dispensary. The shaded boxes are currently computerized.
240
A.M. Elespe et al.
Booking radiographer
with drugs required
Arranges simulator, appointments,
Daily treatment CANCER REGISTRATION
CHEMO DISPENSARY UNIT
I
/
Fig. 3 Diagram showingthe general data flow. Each morning the cancer registration staff create a patient computer record for all 'B' and 'C' forms which have arrived. Once the record is created those concerned with the patient's care can review and update the record at any time. The details of the treatment finallygivenare, in the case of chemotherapy, recorded at the time of each intravenous injection and, with radiotherapy, when the course is completed. In place of the manually prepared radiotherapy summaries these are now printed out for inclusion in the patient's notes. At this time the chemotherapy treatments are not similarly handled, but this is a readily achievable future development. From the data bank, daily treatment lists are prepared for the radiotherapy treatment machines.
H A R D W A R E AND SOFTWARE
RESULTS
The first computerization of data from the cancer registry was achieved in 1986 using a UNIX, PDP 11/ 73 computer, operated by the Marie Curie Research Wing of the cancer centre. Programs were written using the 'C' language and the data were held in in-hospital written ASCII data files. In 1988, the whole research system was changed to run on a D E C MicroVAX II, VMS operating system (version 4) and the structure was changed to one running on a relational data base, Oracle (version 5). The programs were replaced with ones written in SQLForms, part of the Oracle programming language. In 1991, both the operating system and the database were upgraded to versions 5.4 and 6, respectively, and the MicroVAX II was replaced by a MicroVAX 3400 cluster. Programs have now been written in 'C' and SQL, to allow the extra data to be added on to the existing database to create the new system. Each user within the cancer centre has access to a digital video terminal, usually a 320 or 420, in order to run the programs. These terminals are linked to terminal servers, which in turn are connected to the cluster via an Ethernet fibre-optic network. The servers allow communication between the terminal and Ethernet. In the case of the pharmacy department and the chemotherapy suite, where there were no existing terminal servers, a diskless personal computer (PC) was installed. A n Ethernet card is included with each PC and this serves a similar function to a terminal server, thus allowing the PC to communicate with the network. The system will accommodate all 11 database users from the four main work areas, plus printers, at any one time. The new information system is used to supply data, not only for contracting purposes, but also for research and to predict work-load statistics. Since radiotherapy and chemotherapy cannot be booked without registration, every patient for treatment is necessarily included in the system prospectively.
The system was first introduced to the centre in July 1991 with the objective of full engagement by 1 April 1992, which was achieved. Those who were most expert in each of the disciplines concerned were requested to record the data, so securing a high level of accuracy. In order to gain their co-operation and support it was necessary for them to be relieved of some burdens and gain some benefit from the operation of the system. With radiotherapy, it was possible to relieve the radiographers of the daily task of creating the appointment lists for each therapy machine and also of preparing manually the patient's treatment summary. The use of the computer led to a standardization of the presentation of the data and the summary, which in itself made for improvement in precision. Until the introduction of the new system, the pharmacist responsible for the cancer treatment centre held a hand-written card index on which every drug prescription was transcribed. The introduction of the new system allowed for the computerized record to replace this. The chemotherapy sisters were provided with a computerized diary record of all the bookings for treatment to replace their hand-written diaries in return for the task of updating the record with the doses and drugs finally given. In this way the system compensated, at least in part, for the extra burden of work imposed by committing the data to the database. A positive attitude on the part of all the staff involved in applying the data system has been a welcome and essential feature; this co-operation was enhanced by consultation at all stages in development and the incorporation of useful suggestions made by the potential users to facilitate the smooth introduction of the system. The finance department of the Mount V e r n o n Hospital NHS Trust now receives all the required data concerning treatment given in a particular month by the 15th day of the following month. Data
A Computerized Data Collection System for a Cancer Centre
are all related to the health district in order to facilitate the contracting function. The data bank is now used to set targets for contracts before the onset of the financial year.
D I S C U S S I O N AND C O N C L U S I O N The system has allowed hospital management to negotiate with purchasers a change in the contracting currency from finished consultant episodes to the number of radiotherapy fractions (individual treatments) and chemotherapy administrations. All the running costs of the cancer centre are, therefore, apportioned to the new currency, which is felt to be a more appropriate measure of cancer patient activity. Purchasers were impressed to see a full patient minimum data set available on the new system which couples, therefore, with the requirements of the NHS contracting system. This is an interesting example of purchasers agreeing to deviate from contracting by finished consultant episodes. The reliability of the data held in the cancer registry is at the highest level and is continuously being updated. Research and development is an important aspect of the centre's work and the new system is facilitating this important activity. The data bank is available for audit purposes and all types of survey are now readily possible. In the future the system can easily be extended to provide detailed costing of the care given to an individual patient with cancer. This can impact upon overall plans of man-
241
agement and enable a greater sophistication of the contracting process. The Royal College of Radiologists has encouraged the development of information systems and has promoted the Clinical Oncology Information Network (COIN) [4-6]. The development of information systems need to be securely based upon a practical experience such as that recorded in this report.
Acknowledgements. We
wish to thank Kevin Crocombe for his contribution to the programming of the system, and other members of the Marie Curie Research Wing staff for their help and advice, Mr Stephen Ramsden, Chief Executive of the Trust, for his encouragement and support and all staff of the Cancer Treatment Centre for their co-operation. Mrs Eileen Davies kindly prepared the manuscript.
References 1. Bunch C. Developing a hospital information strategy: A clinician's view. Br Med J 1992;304:1033-6. 2. NHS Information Management Group. Information management and technology strategy overview. Birmingham: NHS IMG, 1992. 3. Gulliford MC, Bell J, Bourne, HM, et al. The reliability of cancer registry records. Br J Cancer 1993;67:819-21. 4. Squire CJ. COIN revised proposal. London: Royal College of Radiologists, 1993. 5. James N, Carrington-Johnson C, McKenzie C. Developing and implementing a user-driven department database system. Implications for the Royal College of Radiologists' COIN proposal. Clin Oncol 1994;6:31--4. 6. Karp SJ, Squire CJ. Clinical oncology information network (COIN). Clin Oncol 1994;6:5-6. Received for publication October 1993 Accepted following revision March 1994
Clinical Oncology
Original Article A Computerized Data Collection System for a Cancer Centre A. M. Elespe, S. Dische, M. I. Saunders and M. Pepperell Mount Vernon Centre for Cancer Treatment, Mount Vernon Hospital, Northwood, Middlesex, UK
Abstract. A data system has been designed for a cancer centre and, with the close collaboration of staff, has been brought into use. Data are continuously gathered by doctors, nurses, radiographers and cancer registration staff for the contracting process, cancer registration, audit, research and development.
Keywords: Audit; Chemotherapy; information; Database; Radiotherapy
or more in registration, the existing system was clearly inadequate.
METHOD
Contracting
INTRODUCTION
Recent years have witnessed an explosion in the development of information technology applied to medicine and much attention has been given to hospital information systems [1]. The National Health Service (NHS) reforms, in particular the managerial and contracting systems which have been adopted, have also introduced a need for accurate data about work load to be readily available [2]. Data for the purpose of cancer registration have been gathered in the UK for over 50 years and centres for cancer treatment register all the patients who attend. At Mount Vernon, as in other institutions, this registration is performed by specially trained cancer registry staff. The case notes only become available to registry staff at between 3 and 6 months after the first attendance because of their constant use during the period of active treatment. The cancer registry staff are trained to extract the data required but it is not possible for this to be validated by the doctors, radiographers and nurses responsible for treatment. There are, therefore, inevitable inaccuracies in registry data obtained in this way [3]. With the need for absolute precision now required for contracting, and the lag of 6 months
Correspondence and offprint requests to: Professor Stanley Dische, Marie Curie Research Wing for Ontology, Mount Vernon Centre for Cancer Treatment, Mount Vernon Hospital, Northwood, Middlesex HA6 2RN, UK.
The data required by the cancer registry for onward transmission to the All Thames Registry at Sutton include the personal details of the patient, their address and postcode, the general practitioner's name and address and the patient's NHS number. Features of the initial management by surgery, radiotherapy, chemotherapy, hormonal therapy and by any other form of treatment, are added. Follow-up data are collected annually for 5 years and then every 5 years. The new requirements include much of the data contained in the cancer registration system; however, it was necessary to know whether the patient was attending under the NHS or privately and whether they were doing so on an inpatient, outpatient or day case basis. Most importantly, in the past only the initial courses of treatment were recorded, but now details of all treatment at any time in the patient's attendance at the cancer centre are provided and with high precision. In 1986 software was developed so that the cancer registry data could be gathered on the research computer system. This enabled tapes to be prepared at regular intervals and sent to the Thames Cancer Registry for direct addition to their database. It was decided that the new centre operation system should be grafted upon that previously used for cancer registration. With the new system the data are gathered from the first moment the patient is seen by a member of the cancer centre staff; and this is commonly at a peripheral clinic held in one of the 11 district hospitals attended. To facilitate this 'B' and 'C' forms were devised to register new patients and those formerly treated who are required to attend the centre (Figs 1 and 2). A 'G' form has been designed to allow addition of data concerned with treatment using radioactive sources. The data on the initial forms ('B', 'C' and 'G') are included by the registry staff. Further data are added to the patient's record as shown in the flow diagram (Fig. 3).
238
A. M, Elespe et al.
Mount Vernon Centre for Cancer Treatment (Affix Patient Label Here) M.V. No ..................... D.O.B..........
B Form
The outlined boxed section should be filled in for EVERY NEW patient coming to the cancer centre OR when any of the details in the box have CHANGED
Name ................................................ Hospital at which Oncology clinic held
Address ............................................ Mount Vernon Wexham Park Hillingdon Northwick Park Lister
Postcode ...........................................
[] [] [] [] []
Luton and Dunstable Barnet St AIbans Hertford County Watford
[] [] [] [] []
Hemel Hempstead [] Edgware [] QE II [] If other hospital specify:
GP name ........................................... Tel.no ....................... [ ]
Referred by (name) ......................................... consultant [ ] Tick if no telephone Private yes [ ] Requiring yes [ ] Intent: patient
no [ ]
hospital transport
Diagnosis:
Primary site
Consultant .......................................
Histology ........................................... Radiotherapy treatment external beam
yes [ ] no [ ]
[] [] []
EJM [ ] EG [ ] DF [ ]
For treatment to
Inpatient [] Outpatient [ ] Day case []
Primary [] Regional nodes [ ] Metastasis []
Simulation Shell/mask construction
Linear [ ]
yes [ ] yes [ ]
PH
[] [] []
Has MV notes
......................................
yes
[]
......................................
no
[]
SXR [ ]
no [ ] no [ ]
ARM [ ] RGJ [ ] GR [ ]
Site of mets.
To be treated as:
Number of fractions .......... in ........... days on:]'he treatment will require:-
SD MS RA
no [ ]
GP [ ] radical palliative
Electrons [ ]
CT planning OR [ ] Non-CT planning [ ]
Energy Electron ........... MeV Inc/opposing ports [ ] OR plan []
Radiotherapy treatment - other therapy (Pleasewrite in all details)
1-131 [ ]
Admission Marie Curie [ ] Ward 10 [ ] Ward 11 [ ] details
Bishopswood [ ] Other [ ]
Other instructions/transport requirements
Date of admission ........... for ....... days
Local X-rays sent [ ]
Path. results required
[]
Local notes sent
[]
X-rays required
[]
MCRW patient
[]
CT-scans required
[]
MRI-scans required
[]
Doctor's signature:
Date
For radiographer's use
Date of MV CT • scan
..........................................................
..........................
Tickiffirm
LA1 [ ]
LA2 [ ]
LA3 [ ]
LA4 [ ]
LA5 [ ]
SXR [ ]
appointment
[]
Tickif firm
Time .................. [ ]
Tickiffirm
Simulator: Date .................................. Time .................. First treatment: Date
[ ]
appointment
appointment
Fig. 1. T h e 'B' form. This form, which has a single carbon copy for retention in the notes, is completed whenever a patient is to attend for a course of radiotherapy. To save needless repetition for each patient the items within the box are filled in w h e n the patient attends for the first course and t h e n a m e n d e d only if there are changes in the details. T h e shaded boxes are currently computerized. T h e 'B' form follows the path shown in Fig. 3.
A Computerized Data Collection System for a Cancer Centre
239
This outlined boxed section should be filled in for EVERY NEW patient coming to the Cancer Centre or
Mount Vernon Centre for Cancer Treatment
when any of the details in the box have CHANGED
To be treated as:
(Affix Patient Label Here) M.V. No ..................... D.O.B..........
Has MV
yes [ ]
notes?
no [ ]
Inpatient [ ]
Outpatient [ ]
C Form
Day case [ ]
Admission date ............................ for ........ days
Requiring hospital transport
yes no
[] []
Name ................................................ Address ............................................
Postcode ...........................................
Hospital of referral
Mount Vernon Wexham Park Hillingdon Northwick Park Lister
[] [] [] [] []
Luton and Dunstable garnet St AIbans Hertford County Watford
GP name ........................................... Referred Cons. [ ] T i c k if no Tel.no . . . . . . . . . . . . . . . . . . . . . . . l ~ J by ........................................ telephone
[] [] [] [] []
Hemel Hempstead [] Edgware [] QEII [] If other hospital specify: ........................................
GP [ ]
Intent: radical [] palliative [ ]
Consultant
Diagnosis: Primary site .......................................
SD MS
[] []
EJM [ ] EG [ ]
ARM [ ] RGJ [ ]
Histology ...........................................
RA
[]
DE
GR [ ]
MOUNT VERNON HOSPITAL CHEMOTHERAPY ORDER FORM yes
PP
affix patient label here
[]
10
[]
no [ ]
[]
REFERENCE no. Amended order [ ]
11 [ ]
Confirmed by (PHARMACIST)
MC [] Chemo suite
[] []
Ordered by .......................................... date ....................
Consultant M ............ Ward
[]
PH DC
......................................
Other: ......................... Drug 1
Drug 2
Drug 3
Drug 4
Route
IV IM SC oth:
IV IM SC oth:
IV IM SC oth:
IV IM SC oth:
Delivery system
Syringe
Syringe
Syringe
Syringe
Drug Dose
Bag
Bag
Bag
Bag
Special req. vol. Time req. (24 hr) Date req.
O. ho,d
Take OFF initials
O. ho,d
O. ho,.
Special requirements
FOR P H A R M A C Y USE O N L Y
DILUENT VOLUME PRODUCT CODE No.
SEND ENTIRE FORM TO PHARMACY Fig. 2 The 'C' form. This is used whenever a patient comes to the cancer treatment centre for a course of intravenously administered cytotoxic agents. As with the 'B' form the whole of it is completed only at the first attendance at the centre. Unlike the 'B' form, the 'C' form is repeated for each treatment cycle during a course. Two extra copies are automatically made to be sent to the pharmacy, one for onward transmission to the chemotherapy dispensary. The shaded boxes are currently computerized.
240
A.M. Elespe et al.
Booking radiographer
with drugs required
Arranges simulator, appointments,
Daily treatment CANCER REGISTRATION
CHEMO DISPENSARY UNIT
I
/
Fig. 3 Diagram showingthe general data flow. Each morning the cancer registration staff create a patient computer record for all 'B' and 'C' forms which have arrived. Once the record is created those concerned with the patient's care can review and update the record at any time. The details of the treatment finallygivenare, in the case of chemotherapy, recorded at the time of each intravenous injection and, with radiotherapy, when the course is completed. In place of the manually prepared radiotherapy summaries these are now printed out for inclusion in the patient's notes. At this time the chemotherapy treatments are not similarly handled, but this is a readily achievable future development. From the data bank, daily treatment lists are prepared for the radiotherapy treatment machines.
H A R D W A R E AND SOFTWARE
RESULTS
The first computerization of data from the cancer registry was achieved in 1986 using a UNIX, PDP 11/ 73 computer, operated by the Marie Curie Research Wing of the cancer centre. Programs were written using the 'C' language and the data were held in in-hospital written ASCII data files. In 1988, the whole research system was changed to run on a D E C MicroVAX II, VMS operating system (version 4) and the structure was changed to one running on a relational data base, Oracle (version 5). The programs were replaced with ones written in SQLForms, part of the Oracle programming language. In 1991, both the operating system and the database were upgraded to versions 5.4 and 6, respectively, and the MicroVAX II was replaced by a MicroVAX 3400 cluster. Programs have now been written in 'C' and SQL, to allow the extra data to be added on to the existing database to create the new system. Each user within the cancer centre has access to a digital video terminal, usually a 320 or 420, in order to run the programs. These terminals are linked to terminal servers, which in turn are connected to the cluster via an Ethernet fibre-optic network. The servers allow communication between the terminal and Ethernet. In the case of the pharmacy department and the chemotherapy suite, where there were no existing terminal servers, a diskless personal computer (PC) was installed. A n Ethernet card is included with each PC and this serves a similar function to a terminal server, thus allowing the PC to communicate with the network. The system will accommodate all 11 database users from the four main work areas, plus printers, at any one time. The new information system is used to supply data, not only for contracting purposes, but also for research and to predict work-load statistics. Since radiotherapy and chemotherapy cannot be booked without registration, every patient for treatment is necessarily included in the system prospectively.
The system was first introduced to the centre in July 1991 with the objective of full engagement by 1 April 1992, which was achieved. Those who were most expert in each of the disciplines concerned were requested to record the data, so securing a high level of accuracy. In order to gain their co-operation and support it was necessary for them to be relieved of some burdens and gain some benefit from the operation of the system. With radiotherapy, it was possible to relieve the radiographers of the daily task of creating the appointment lists for each therapy machine and also of preparing manually the patient's treatment summary. The use of the computer led to a standardization of the presentation of the data and the summary, which in itself made for improvement in precision. Until the introduction of the new system, the pharmacist responsible for the cancer treatment centre held a hand-written card index on which every drug prescription was transcribed. The introduction of the new system allowed for the computerized record to replace this. The chemotherapy sisters were provided with a computerized diary record of all the bookings for treatment to replace their hand-written diaries in return for the task of updating the record with the doses and drugs finally given. In this way the system compensated, at least in part, for the extra burden of work imposed by committing the data to the database. A positive attitude on the part of all the staff involved in applying the data system has been a welcome and essential feature; this co-operation was enhanced by consultation at all stages in development and the incorporation of useful suggestions made by the potential users to facilitate the smooth introduction of the system. The finance department of the Mount V e r n o n Hospital NHS Trust now receives all the required data concerning treatment given in a particular month by the 15th day of the following month. Data
A Computerized Data Collection System for a Cancer Centre
are all related to the health district in order to facilitate the contracting function. The data bank is now used to set targets for contracts before the onset of the financial year.
D I S C U S S I O N AND C O N C L U S I O N The system has allowed hospital management to negotiate with purchasers a change in the contracting currency from finished consultant episodes to the number of radiotherapy fractions (individual treatments) and chemotherapy administrations. All the running costs of the cancer centre are, therefore, apportioned to the new currency, which is felt to be a more appropriate measure of cancer patient activity. Purchasers were impressed to see a full patient minimum data set available on the new system which couples, therefore, with the requirements of the NHS contracting system. This is an interesting example of purchasers agreeing to deviate from contracting by finished consultant episodes. The reliability of the data held in the cancer registry is at the highest level and is continuously being updated. Research and development is an important aspect of the centre's work and the new system is facilitating this important activity. The data bank is available for audit purposes and all types of survey are now readily possible. In the future the system can easily be extended to provide detailed costing of the care given to an individual patient with cancer. This can impact upon overall plans of man-
241
agement and enable a greater sophistication of the contracting process. The Royal College of Radiologists has encouraged the development of information systems and has promoted the Clinical Oncology Information Network (COIN) [4-6]. The development of information systems need to be securely based upon a practical experience such as that recorded in this report.
Acknowledgements. We
wish to thank Kevin Crocombe for his contribution to the programming of the system, and other members of the Marie Curie Research Wing staff for their help and advice, Mr Stephen Ramsden, Chief Executive of the Trust, for his encouragement and support and all staff of the Cancer Treatment Centre for their co-operation. Mrs Eileen Davies kindly prepared the manuscript.
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