Virtual Multidisciplinary Review of a Complex Case Using a Digital Clinical Decision Support Tool to Improve Workflow Efficiency
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Journal of Multidisciplinary Healthcare Dovepress
open access to scientific and medical research
Open Access Full Text Article
ORIGINAL RESEARCH
Virtual Multidisciplinary Review of a Complex
Case Using a Digital Clinical Decision Support
Tool to Improve Workflow Efficiency
Khee Chee Soo 1 Objective: Integration of distinct clinical perspectives in multi-disciplinary tumor board
Issam Al Jajeh 2 meetings is critical to determine optimal patient care. Digital tools can support the data
Raymond Quah 3 consolidation needed for meeting preparation and data sharing during complex case reviews.
Hoe Kuen Brandon Seah 4 In this paper, we assessed the value of a clinical decision support tool on workflow efficiency
and conducting a complex case review of a dermatofibrosarcoma protuberans (DFSP) tumor.
Sharon Soon 4
Methods: Case presentation was performed by each unique clinical specialty that had
Espen Walker 4
relevant information about the patient; an oncologist, a pathologist, and a radiologist.
1
General Surgery Department, Farrer Virtual discussion was completed online with case presentation and documentation with
Park Hospital, Singapore; 2Department of
Pathology, Farrer Park Hospital, NAVIFY Tumor Board. Workflow efficiency assessment was done through interviews and
Singapore; 3Department of Diagnostic observation of the # of steps across different team members involved in preparing and
Radiology, Farrer Park Hospital, conducting cancer multidisciplinary team (MDT) meetings before and after the implementa
Singapore; 4Roche Diagnostics Asia
Pacific, Ltd, Singapore tion of the NAVIFY Tumor Board solution.
Results: Case review consisted of surgical and therapeutic intervention history, distinct
histological and sequencing patterns representative of DFSP, with radiological review to
determine areas for surgical intervention. Consolidation of clinical input led to
a recommendation of a formal external hemipelvectomy with potential chemotherapy.
Workflow assessment demonstrated a 46% total reduction in the # of steps for meeting
preparation (from 69 to 37), with specific changes based on role: data manager (33 to 15),
pathologist (26 to 13), radiologist (no change), and logistics (5 to 4). There was a 31% total
reduction in the # of steps for conducting the meeting (from 51 to 35).
Conclusion: Utilizing a digital clinical decision support tool helped to consolidate patient
data and improved case presentation through workflow efficiency. This allowed for improved
interdisciplinary discussion on a complex DFSP case and supported the determination of
a clinical decision.
Keywords: multidisciplinary team meetings, clinical decision support, digital tool, workflow
efficiency, virtual MDT
Introduction
Making the right clinical decision for cancer treatment is critical for optimal patient
outcomes. With the complexity of factors involved in each patient’s case, it is
Correspondence: Espen Walker necessary to be able to review the massive amount of information available in
Roche Diagnostics Asia Pacific, Ltd, 8
Kallang Avenue #10-01/09 Aperia Tower a targeted manner relevant to the patient. Cancer multidisciplinary team (MDT)
1, 339509, Singapore meetings bring together experts in each specialty to contribute to the clinical
Tel +65 8428 0386
Email espen.walker@roche.com decision making.1,2 With a blend of pathology, radiology, and surgical expertise
Journal of Multidisciplinary Healthcare 2021:14 1149–1158 1149
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Soo et al Dovepress
available, the key clinicians can provide their input to decision support tool. Despite the remote settings
drive the best decision for the patient and are now con imposed due to the covid-19 pandemic, the clinicians
sidered best practice in clinical care.2,3 were able to discuss the case, reach a decision with
Distinct clinical settings across public and private care confidence and suggest treatment.
settings require different levels of involvement from the
primary care provider. In an academic medical center,
Materials and Methods
there are often residents or junior physicians to assist in
the preparation of case material. Some institutions employ
Patient Case Review Process in MDT
Case review at the Farrer Park Hospital MDT incorporated
nurse navigators that are responsible for collating and
various specialties and comprehensive review of relevant
bringing together case information for physician review,
information. It started with the oncologist (surgical, radia
bringing increased efficiency and better service integration
tion or medical), presenting the patient clinical summary
to patient management.4,5 In private and non-academic
and previous treatments. The radiologist then shared the
settings, the primary care provider must bring together
imaging results and potential changes in tumor size or
all the case information, in addition to any relevant pub
shape over time in response to previous treatments. This
lications or trials that may relate to the case to prepare
included each lesion of interest, and assessment whether it
a presentation for the MDT meeting. MDT meetings are
has responded to previous treatments. Details assessed
limited by the capacity of the information to be collated
include the extent of the tumor and tumor spread, whether
and presented well.6 There is a need for tools that can
by direct invasion of adjacent structures, lymphatic spread,
allow easy case preparation and seamless presentation of
metastatic deposits and perineural extension. The patholo
cases to ensure appropriate diagnostic and therapeutic
gist then reviewed the histological and molecular findings
options are discussed and implemented for each patient.
to describe the recurrent tumor’s histological type and
Recent advances in technology have enabled quicker
grade to relate findings to the first resection and interven
access to patient information and potential treatment
ing recurrences. The gross photographs of various resec
options. Navigating the massive amount of data available
tion specimens were presented to demonstrate the extent of
can be challenging. Selection of the patients to include in
disease and to address the differential diagnosis. Finally,
an MDT must be prioritized to those that have a complex
the team discussed relevant publications and potential
history and need for a variety of expertise.7 It is necessary
treatment options, aligned on and documented the deci
to bring the relevant information quickly to the clinician to
sions and next steps (Figure 1).
make the best decision for the patient. Virtual MDT meet
ings have been emerging as essential to deliver optimal
healthcare for complex cases in a remote setting,8 with Digital MDT Process
examples of clinicians stating that virtual MDTs provide The digital MDT is similar to the standard case review with
the same standard of care as face-to-face MDTs.9 some exceptions. To comply with social distancing regula
Digital MDT tools, such as NAVIFY Tumor Board can tions due to covid-19 pandemic in Singapore and minimize
support operational details and improve efficiency in MDT face-to-face interactions, physicians dialed in to a video call
preparation.5,10,11 With the recent need for virtual connec using Zoom Enterprise software (San Jose, California,
tivity following the covid-19 pandemic, digital engage USA) to discuss the case. As each presenter must share
ment has become necessary to bring clinicians together their unique perspective of the case through different tools
online. Transition of the traditional MDT into a “Smart- available, various systems were utilized to share each data
MDT” has allowed continuity of care for oncology point to the MDT group. For case presentation, NAVIFY
patients,12 with clinicians easily adapting to the virtual Tumor Board (Roche Diagnostics Information Systems,
setting.11 Belmont, California, USA) presentation mode was used to
In this publication, we describe the implementation display patient case history information, histopathology
of NAVIFY Tumor Board into the Farrer Park Hospital images, and immunohistochemistry results via screen shar
MDT meeting and the clinical application on ing. The NAVIFY Tumor Board solution is a cloud-based
a complex case reviewed during a virtual MDT meet workflow product that can help facilitate MDT meetings by
ing. We also demonstrate improvements to the work displaying relevant clinical data per patient. It supports the
flow of the MDT meetings using this digital clinical preparation, presentation and documentation of MDT
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Figure 1 Flowchart of Multidisciplinary (MDT) meeting at Farrer Park Hospital.
meeting by displaying a holistic patient dashboard for logistics of the meeting included the data manager, medi
oncology teams to make clinical decisions.5,10,11 The radi cal affairs/quality department manager, clinical assistant,
ologist then took over screen sharing to display MRI images and pathology lab assistant. Clinicians interviewed were
available on his computer. Each attending physician was the pathologist, radiologist, and surgical oncologist.
able to provide input on the various aspects of the case, By reviewing the MDT workflow, identification of the
utilizing various hospital data management systems viewed process steps involved in the preparation and conduction
sequentially. Documentation of the clinical decision made of the MDT meeting was done. Each action completed by
was done in NAVIFY Tumor Board for the patient case. the various team members (such as scheduling a meeting
or preparing a slide to present) was designated as a distinct
Workflow Assessment of Digital Clinical step in the process.
Decision Support Tool Observations of the MDT meetings at FPH hospital
Assessment on the MDT meeting workflow was done were completed to review any changes to the workflow
before and after implementation of NAVIFY Tumor before and after implementation of NAVIFY Tumor
Board to determine how this digital tool could improve Board. Various aspects of the meeting were reviewed,
efficiency. Interviews were completed with members of including qualitative assessment of the effectiveness of
the MDT meeting including those setting up the meeting the digital clinical decision support tool to support work
as well as clinicians conducting the meeting to gather load distribution and patient file compilation.
feedback on how a digital clinical decision support tool Documentation of the number of process steps required
may improve workflow efficiency. Informants were to prepare and conduct the MDT meeting was done to
selected based on their involvement in preparation of con quantify the effectiveness of the digital clinical decision
duct of the MDT meeting. Individuals supporting the support tool.
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Results attendees from the radiologist’s computer using the hospi
tal’s image viewing system. As this was a virtual meeting,
Oncologist Case Overview
all attendees could easily view the image on their compu
The oncologist shared the patient background and history
ter. It demonstrated a heterogeneously enhancing mass
of treatments with the dashboard view in NAVIFY Tumor
arising from the right acetabulum, extending into the
Board that included the relevant information for the virtual
right hip joint (Figure 2B). Compared to the earlier MRI
discussion. A 48-year-old female with a history of multi
of 4 January 2020 (Figure 2A), this mass demonstrated
ple surgeries starting in 2009 for a right groin tumor was
interval increase in size. The mass was close to the right
discussed. At the first surgery, the groin tumor was identi
external and internal iliac arteries and veins, as well as
fied as a dermatofibrosarcoma protuberans (DFSP). At this
closely abutted the urinary bladder. While there may be
time, the margins were determined to be negative (3mm).
a need to partially resect the urinary bladder, this may be
In 2014, recurrence was noted locally, and the second
repaired, without significant loss of function. As such, the
surgery was done. The surgical margins were involved,
possibility of limb preservation hinges on being able to
and at the third surgery, negative margins were finally
achieve clear surgical margins while being able to preserve
obtained.
the right external iliac arteries and veins.
In 2016, on CT surveillance a soft tissue mass was
noted just above the previous surgical site. After resection,
the tumor was reported as a high-grade sarcoma. Radical
Pathologist Case Review
Utilizing presentation mode in NAVIFY Tumor Board, the
adjuvant radiation therapy was given post operatively. In
pathologist was able to display the histological images
2017, another soft tissue mass was noted adjacent to the
along with customized text to emphasize areas of interest
psoas muscle, above the site of the pelvic resection.
during the virtual online meeting. The gross anatomical
Further resection (5th) was done. Clear surgical margins
findings include a recurrent dominant pelvic mass, spa
were obtained but follow-up CT scan showed further pel
tially nearest to the primary groin tumor, that consisted of
vic recurrence. This was treated with pazopanib, temozo
fish-flesh-like nodules set in a fibromyxoid lipomatous
lomide then bevacizumab respectively. However, tumor
tumor-like mass (Figure 3). The peritoneal lesions com
was noted to be progressing on radiological surveillance.
prised small nodules and plaques with rather similar
Next Generation Sequencing (NGS) testing done with
composition.
Foundation One CDx (Foundation Medicine, Cambridge,
The tumor portrayed several architectural profiles mir
Massachusetts, USA) and the report results were viewed
roring its variegated gross appearance. The pelvic mass
within the NAVIFY case specific dashboard under biomar
fish-flesh-like nodules comprised spindle cell sarcoma
ker status. The report showed a COL1A1-PDGFB gene
with a lipomatous background and low-grade, atypical
fusion supporting a diagnosis of DFSP. Imatinib was
lipomatous patterns (Figure 3A). The colonic peritoneal
started and over the year, the dose had to be escalated as
nodules comprised variegated tumor with circumscribed
there was radiological evidence of tumor progression. Her
nodule and infiltrating areas of spindle cell sarcoma and
sixth surgery was in 2019 (ten years after initial diagno
sclerosing lipomatous tumor (Figure 3B). Such morphol
sis). This time the psoas muscle was resected on bloc with
ogy in a retroperitoneal sarcoma would be fitting of well-
the right colon. Latest CT scan however had shown pelvic
differentiated liposarcoma, sclerosing lipoma-like, with
recurrence with tumor involving the pelvic acetabulum
areas of de-differentiated liposarcoma with high-grade
and bladder.
spindle cell sarcoma and low-grade dermatofibrosarcoma
(DFSP)-like patterns with pericellular fat infiltration
Radiologist Case Review (Figure 3C).13 The primary tumor had a morphology of
Assessment of key organs and vascularisation surrounding slender spindle cells with cart-wheel arrangement and was
the surgical site is critical for surgical planning. the basis for rendering a diagnosis of DFSP.
Preservation of specific structures is vital to retaining This appears to be a rare case of DFSP of skin and soft
function, whether for pre-operative surgical planning, or tissues with multiple local recurrences and resections.
in pre-radiation treatment planning. Medical imaging Spatial extension into adjoining intra-abdominal soft tis
allows for non-invasive viewing of these structures. The sues and peritoneum; with morphological transformation
MRI image of 1 June 2020 was presented to the MDT in intermediate grade spindle cell sarcoma. The most
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Figure 2 (A) MRI images taken 04 Jan 2020 showing mass near right acetabulum. (B) MRI images take 01 Jun 2020 showing a heterogeneously enhancing mass arising from
the right acetabulum, extending into the right hip joint.
fitting tumor type of intra-abdominal recurrence is DFSP, patient; however, she did not wish further surgery so
based on pericellular fat infiltration, agreeable immunohis instead elected for palliative chemotherapy.
tochemistry and typical COL1A1-PDGFB gene fusion.
Workflow Assessment Results
MDT Meeting Outcomes Utilisation of a digital clinical decision support tool in
The MDT meeting members discussed the care after the a virtual MDT can allow for improved cross functional
respective presentations. As the tumor had shown resis discussion and efficient case review to allow optimal clin
tance to imatinib after 1 year of treatment, it was con ical decisions to be made. Assessment of the MDT meeting
cluded that the tumor would now be quite resistant to workflow at Farrer Park identified potential areas that could
further chemotherapy. With no other targeted therapy be improved with the preparation and conduction of the
recommended, it was decided further surgery was the MDT meeting at Farrer Park Hospital, as well as steps
treatment of choice. However, there was a recognition that had potential for optimization with a clinical decision
that adequate surgical margins might be difficult to obtain, support digital tool. Prior to the implementation of NAVIFY
especially as the tumor had extended to the region adjacent Tumor Board, preparation for the meeting included manual
to the lower pole of the right kidney and intra-peritoneally data collection and preparation activities, such as patient file
into the pelvis including into the wall of the urinary collection and pathology image collation. Conducting the
bladder. MDT meetings, there was difficulty in standardising tumor
While it may be possible to do an internal hemipel board files across different laboratory systems and it
vectomy, sparing the lower limb, a formal external hemi required coordination across many different departments.
pelvectomy would be the soundest option from the Implementation of NAVIFY Tumor Board was done for
oncological perspective. These decisions were documented the MDT meeting at Farrer Park Hospital for both in person
in the patient’s case in NAVIFY Tumor Board. The find and virtual meetings. During the transition to using NAVIFY
ings and recommendations were discussed with the Tumor Board, there was an increase in the work required to
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For meeting preparation, the total # of process steps
went from 69 before, 72 during the transition, to 37 after
implementation (Figure 4A). Specific roles in the MDT
meeting had different changes in the # of process steps for
preparation. Data manager went from 33 steps before to 15
steps after implementation, pathologist went from 26 steps
before to 13 steps after, radiologist remained the same
with 5 steps both before and after, while logistics went
from 5 steps before to 4 steps after (Figure 4B).
For conducting the meeting, the # steps went from 51
before, 52 during the transition, to 35 after implementa
tion. There was a temporary increase in the # of steps
during the transition due to change management that was
resolved. Overall, there was a 46% reduction in prepara
tion, and 31% reduction in conducting the MDT meeting
(Figure 4A).
Discussion
Continuity of cancer care is critical and cannot be inter
rupted based on restrictions in social interaction. Virtual
MDTs have emerged as a solution to allow multidisciplin
ary discussion and collaborative decision-making in the
age of covid-19.9 In this study, we describe an improved
efficiency in the MDT meeting at Farrer Park Hospital
with the implementation of the NAVIFY Tumor Board
solution. Specific roles, such as data manager and pathol
ogist saw an improvement in the preparation process as
compared to other roles. Utilizing this digital clinical
decision support tool, the oncologist, pathologist, and radi
ologist were able to share and discuss their findings
regarding a complex DFSP case and propose a surgical
intervention.
At daily encounters with cancer patients, new diag
noses are made, responses to treatment are noted and
recurrences are detected. MDT meetings provide physi
cians an opportunity to present such patients for discussion
with their peers.14 Inputs and insights from other clinicians
Figure 3 (A) Recurrent pelvic mass with fish-flesh nodules in myxoid lipomatous
provide great benefit for patients. However, there is a need
background. (B) Pelvic mass spindle cell sarcoma. (C) Low-grade sarcoma with to improve MDT meetings in order to keep up with the
pericellular fat infiltration growth pattern typical of DFSP.
increasing complexity of healthcare information15–17 and
maintain efficiency with patient care management.18
prepare and conduct the meeting, including learning how to When patients are discussed at MDT meetings, their
use the system and manual input of data. After the transition clinical decisions are protected from the vagaries of indi
period however, workload was re-distributed across indivi vidual professional preferences. Appropriate clinical trials
duals and preparation was streamlined. Having a single plat are suggested that can allow otherwise hopeless patients
form allowed for a common data repository and the opportunity to receive the latest medical advances.
documentation of next steps for patients. MDT meetings also help to cross-educate physicians19
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Figure 4 (A) Workflow assessment on the total # of steps assessed before and after implementation of the NAVIFY TB tool. During preparation, the # of steps went from
69 to 37 (46% reduction). For conducting the meeting, the # steps went from 51 to 35 (31% reduction). (B) Preparation step changes before and after implementation of
NAVIFY TB. Data manager (33 to 15 steps), pathologist (26 to 13 steps), radiologist (no change), logistics (5 to 4).
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and trainees20 involved and are the cornerstone of sound preparation were not affected by a digital preparation tool.
cancer medicine. The improvement in pathologist preparation we observed
Complexity of cancer biology and therapies has gone may be due to the pathologist in our study using the
beyond the capacity for an individual to keep up to date NAVIFY Tumor Board presentation mode to discuss the
with all the information and options available. Clinical DFSP case, as opposed to a different image display tool as
decision support tools, such as NAVIFY Tumor Board, the radiologist did. Both the radiologist and pathologist
aim to support clinicians to review the comprehensive used independent viewing tools in the Krupinski study.
diagnostic data, patient history, and additional information While we were able to separate out the specific roles
needed for a clinical decision.11 NAVIFY has the capacity that benefitted from a digital clinical decision support tool
to manage meeting logistics as well as improve data col for meeting preparation, we did not stratify the role type
lection and review. With the potential to view relevant when collecting the # of steps for meeting conduct. Further
publications, clinical trials, and treatment guidelines that studies would be needed to determine which users would
match the patient’s profile, this can help streamline overall benefit from a digital clinical decision support tool in the
patient review. Documenting decisions made and next conduct of an MDT.
steps with a clinical decision support tool like NAVIFY For the case of DFSP reviewed, it was critical to have
can improve accessibility to patient information for future the various experts available to provide their input. The
monitoring. oncologist reviewed the patient history, including the ther
As the diagnostic data available to review patients apy and surgeries done with what options were available.
increase, tools to organize and support clinicians to deter The pathologist provided histological assessment and com
mine what is clinically relevant are needed.6 Workflow parison to previous case history. The radiologist described
assessments of the various processes that take place in the extent of the tumor, and potential regions of resection
the preparation and conduct of an MDT meeting can needed. All together, these experts suggested a viable sur
help make them more efficient. With the increased use of gical option for this patient using a digital clinical decision
virtual MDTs,8 there has been an increase in MDT func support tool to enable better cross-functional collabora
tionality that allows for improved patient care. tion. Despite the thorough historical review, pathologist
At Farrer Park Hospital, the use of NAVIFY Tumor testing, and radiological examination pointing to a formal
Board tool has allowed for an improvement in the work external hemipelvectomy as the best option, the patient
flow efficiency by reducing the # of steps needed in the decided another surgery was not her preference.
preparation and conduct of MDT meeting. However, as the Palliative chemotherapy was the patient’s decision despite
tool was being implemented, there was an increase in the # clinical recommendation. This demonstrates the various
of steps due to challenges in adopting a new technology influencing factors that go into clinical decision, with the
into the standard clinical workflow. As seen from the pre patient being the final decision maker.
and post data, this increase in # of steps was only tempor The consideration of including the patient in MDT
ary, largely attributed to the challenges of a change man meetings must take into account various factors. These
agement process in adopting a new technology in the include the healthcare provider’s view and what they are
MDT meeting workflow. These challenges were quickly willing to discuss in front of the patient,7 as well as how
resolved, resulting in a final reduction in steps needed to much the patient may contribute or hinder the conversa
prepare and conduct the MDT meeting. tion. A potential benefit to including the patient would be
Tracking the steps of the distinct roles involved in to allow them to ask questions or share their treatment
meeting preparation gave insights into who may benefit preferences.21 Knowing that surgical intervention was not
most from a digital clinical decision support tool. In our preferred by the DFSP patient may have influenced the
assessment, the data manager and pathologist saw their treatment suggest outcomes from the clinicians at the
steps cut in half with the use of a digital tool, while the MDT meeting.
radiologist and logistics function did not see any change. This study continues to build the collection of evidence
These results are in line with studies that show digital tools demonstrating the value of digital clinical decision support
can improve overall preparation, but may be different tools in MDTs and virtual engagement. The case study
across multiple users.5 However, in a pilot study for described is an example of how complex case can benefit
NAVIFY Tumor Board;10 both pathologist and radiologist from various clinical expertise to understand the patient
1156 https://doi.org/10.2147/JMDH.S307470 Journal of Multidisciplinary Healthcare 2021:14
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background and clinical findings. As virtual MDTs Author Contributions
become more and more common9 and healthcare delivery All authors have contributed to this manuscript according to
is happening from different locations,22 a deeper under the IMCJE authorship guidelines and have been involved in
standing of the benefits and limitations of the digital tools the primary five criteria for authorship: (1) Made a significant
and processes involved is needed. contribution to the work reported, whether that is in the
conception, study design, execution, acquisition of data, ana
Conclusion lysis and interpretation, or in all these areas. (2) Have drafted
As digitization becomes ingrained in the healthcare pro or written, or substantially revised or critically reviewed the
cesses, we need to determine what tools can bring value to article. (3) Have agreed on the journal to which the article
impact clinical care as well as the process to adopt these will be submitted. (4) Reviewed and agreed on all versions of
tools. In identifying and adopting the right clinical deci the article before submission, during revision, the final ver
sion support tools, we should always maintain the empha sion accepted for publication, and any significant changes
sis on the patient pathways and decisions that can improve introduced at the proofing stage. (5) Agree to take responsi
patient outcomes. With a complex DFSP case as described bility and be accountable for the contents of the article.
here, it was valuable to bring together insights from the
oncologist, pathologist, and radiologist to provide optimal
Funding
care planning virtually, especially with the social distan
This work was supported financially by Roche
cing regulations from the covid-19 pandemic. As such,
Diagnostics, Ltd.
clinical decision support digital tools, like NAVIFY
Tumor Board, were beneficial in allowing for continuity
of cancer care management at Farrer Park Hospital. Disclosure
Khee Chee Soo has received honorarium and held consultant
Abbreviations and advisory roles for Roche. Hoe Kuen Brandon Seah,
MDT, multidisciplinary tumor board; DFSP, dermatofibro Sharon Soon, and Espen Walker are employees of Roche
sarcoma protuberans; FPH, Farrer Park Hospital; MRI, Diagnostics and have stock and ownership interests in
magnetic resonance imaging; NGS, next generation Roche. The authors report no other conflicts of interest in
sequencing. this work.
Ethical Approval and Consent to References
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