CanNET WA team, Albany Hospital, Albany and Great Southern Region, WA

Focus is on the top five cancers - breast, lung, colorectal, urology, melanoma. However, patients with other cancers are also discussed.

• General physicians
• General surgery
• Pathology
• Radiology
• Medical Oncology (via videoconference from Perth)
• Radiation Oncology (via videoconference from Perth)
• Rural cancer care coordination
• Oncology clinical nursing
• Breast care nursing
• Regional palliative care coordination
• Social work
• Cancer Council patient support
• General practitioners (GPs)

General physician

Currently the project coordinator for CanNET, but with plans to recruit a multidisciplinary team coordinator

Meetings are held fortnightly on a Wednesday at 7.30am, maximum 1 hour duration, but often less. Established in January 2008

The team aims to discuss every newly diagnosed patient. Additionally, the team also puts forwards patients they are particularly concerned about or they feel would benefit from additional specialist advice from Perth.

To make sure that local cancer patients (in Albany, WA, a regional centre) have access to a locally-based coordinated care process, a multidisciplinary care review by oncology specialists, timely referrals and the right referral pathways.

Bring together key clinicians for regular multidisciplinary case discussions, with involvement and support from additional specialists based in Perth (participating via videoconference).

The meeting agenda is prepared by the meeting coordinator in advance of the meeting using information provided by participating clinicians. Records about all patients discussed are kept in an Excel spreadsheet, and all required patient information, images and other documentation is stored on a shared electronic drive that can only be accessed by members of the team.

The meeting coordinator sets up the meeting room, attends meetings, take notes and prepares management plans that are entered into the Excel spreadsheet, the patient's notes and are sent to the patient's GP.

For particularly complex cases, the specialists based in Perth take the cases to their own Perth-based multidisciplinary team meetings for discussion.

• Patients are receiving timely referrals, a coordinated approach to appropriate treatment and care planning, and fewer gaps in their care.
• The team is being brought together and functioning as a team, covering every part of the patients' treatment journey.
• Educational and benchmarking benefits through the involvement of Perth-based specialists who are working in established multidisciplinary team.

• Challenging to established a shared understanding of the roles and responsibilities of all team members.
• Challenging to encourage local GPs to refer their patients locally (rather than using their established referral pathways to Perth-based specialists).
• Lack of electronic health records.

• Develop Terms Of Reference for the team
• Make use of effective Chairing skills and techniques to facilitate involvement of all team members
• Time and word-of-mouth – referral practices are slowly changing as GPs see and hear about the benefits of the locally-based coordinated care

• Set up a database for managing meeting records
• Employ a multidisciplinary team coordinator
• Educational opportunities for the team

The following can be made available to other teams:

• Team Terms Of Reference
• Meeting agenda
• Patient Management Plan template
• Patient information pamphlet about multidisciplinary teams

In hindsight, the first thing to focus on when bringing together a new team is the team itself. For example, hold a team workshop to enable team members to get to know each other personally before they start working together as a team.

Breast Team, North Coast Cancer Institute, Coffs Harbour, NSW

Breast cancer

Attendees are represented from both public and private services:

• General Surgery
• Breast Surgery
• Medical Oncology
• Radiation Oncology
• Pathology
• Radiology
• Genetic Counselling
• Pharmacy
• Breast Care Nursing
• Social Work
• Physiotherapy
• Dietetics (where required)
• Administration

Genetic counsellor

Multidisciplinary team coordinator (0.2 FTE), with support from the breast care nurses.

Role currently filled by a non-clinical administrator and shared across four multidisciplinary teams in the Institute.

1 hour weekly meetings held 1.00pm Wednesday, first established in 1999.

All breast cancer patients having surgery: all are discussed pre-surgery and post-surgery. Other team members may also request discussion of patients during later treatment stages.

Ten or more patients may be discussed in each meeting.

Involvement of general practitioners (GPs) in multidisciplinary team meetings is desirable but notoriously challenging. This case study demonstrates the benefits of personal relationships to encourage participation, and the problems of sustainability with this approach.

In the early days of the meetings, coordination of the meetings was a core role of the breast care nurse. In order to facilitate involvement of GPs in the meetings, the breast care nurse personally contacted each relevant GP by phone several days in advance to invite them to attend. Attendance was possible in person or by teleconference.

Irrespective of a GP’s involvement in the meeting, every GP is provided with an outcome letter on the same day as the meeting. The Institute uses an electronic medical record database to collate key information, images and results. During each meeting, the meeting coordinator records the key points for discussion and recommended treatment plan directly into the database.

The information can be viewed on screen by meeting participants for final approval and a summary can be generated and faxed promptly to referring general practitioners.

The personal invitation approach was successful in eliciting participation of 1–2 GPs on average, with a record of 6 GPs attending on one occasion.

Key benefits of GP participation in the meetings include:

• GPs can often provide the team with insights into the patient's physical and emotional wellbeing because they know the patients well
• The meeting provides an opportunity for GPs to ask questions of the treatment team
• Participating GPs feel valued and immediately receive relevant information about their patients
• Dissemination of outcome letters to GPs on the same day of the meetings ensures the GPs have relevant, up-to-date information when their patients visit them during the course of their cancer treatment.

Resource limitations:

• With the transfer of meeting responsibility to a multidisciplinary team coordinator, the opportunity for personal contact is no longer available. The team coordinator has only two days per week to fulfil his/her responsibilities for coordination, attendance and administration of four multidisciplinary team meetings. The resources available do not allow for personal contact with every GP.
• In addition, the multidisciplinary team coordinator’s two days are consecutive – one for attending all meetings and one to prepare the day before the meetings. This means that any GPs contacted only have 24 hours notice of the meeting and are therefore less likely to be able to participate.

• Personal networks
  If the breast care nurse notices a patient on the meeting list has been referred by a GP who is known to be interested in attending the meetings, then she attempts to contact the GP prior to the meeting.
• Technology:
  The meeting room is equipped with relatively sophisticated videoconferencing and teleconferencing facilities to enable remote participation in the meetings. These facilities are regularly used to facilitate remote participation by specialists in other hospitals and could be used by GPs.

Options being considered for future strategies include:

• Work with the local division of general practice to establish a semi-automated system to notify GPs of the meeting by email or fax.
• Hold a session for practice nurses to explore options for involving GPs in the meetings

• Referral form templates
• Information sheet for patients about the multidisciplinary team meetings
• Template for meeting outcomes letter to GPs

Lung cancer multidisciplinary team, Sir Charles Gairdner Hospital, Perth

Lung cancer (including mesothelioma, small cell lung cancer, non-small cell lung cancer).

Core Membership:

• Cancer registry
• Cardiac surgery
• Medical Oncology
• Nuclear medicine
• Palliative Care
• Pathology
• Radiology
• Radiation Oncology
• Registrars and residents
• Respiratory medicine
• Respiratory clinical nursing
• Thoracic nursing (occasional)
• Visiting clinicians

Respiratory physician

Lung Cancer Coordinator (Respiratory clinical nurse) - meetings coordinated by senior registrars in absence of Lung Cancer Coordinator.

Weekly meetings of 1.5 hours

All newly diagnosed patients are discussed pre- and post-operatively for determination of a treatment plan and for post-operative staging. Approximately 6-18 patients discussed per meeting.

How to streamline tracking of patients within multidisciplinary meetings.

Development of an online database linking radiology and pathology

The database is housed on the hospital intranet and the supporting software was developed by a web programmer with close supervision from the Lung Cancer Coordinator and Meeting chair.

Diagnostic and staging information is entered in advance of the multidisciplinary meeting by senior registrars or the Lung Cancer Coordinator to ensure that a full patient history is available during the meeting. Use of the database is password protected and the software tracks who has entered information.

The Lung Cancer Coordinator tracks patients from the point of referral to diagnosis and post-surgery and liaises with relevant members of the team to ensure that:

• patients are discussed as soon as possible once results are available
• appropriate information is available to guide discussions
• patients are seen at the clinic as soon as possible after the meeting

Data are projected onto a screen during the meeting together with pathology and radiology results. The lung cancer coordinator enters treatment recommendations and notes during the meeting as a record of what has been agreed. The software also incorporates a resource page with links to prognostic tools and clinical trials information that can be referred to during the meeting if required.

A print out of the treatment plan is included in the patient’s file.

• Every newly diagnosed patient has the benefit of expert multidisciplinary input into their treatment plan
• Multidisciplinary meetings and treatment planning are streamlined
• Specialists have easy access to information and treatment decisions after the meeting if required, eg during patient consultations
• Meetings provide the benefit of education for junior staff and information sharing and communication between team members

• Lack of adequate funds to develop and refine the software
• Specialist nature of information fields within the database meant development was an intensive process requiring close supervision from team members

• Champions to drive the process, identify solutions and act on them - in this case the Chair, Lung Cancer Coordinator and another nurse practitioner within the department
• Availability of a designated coordinator to do the 'leg work' with a flexible approach, thorough knowledge of patient needs, and a good relationship with all members of the team
• Strong guidance for the team from the Chair
• Good relationship between the Chair and Lung Cancer Coordinator
• Education of all members of the team about what information to enter and the importance of timely data entry
• Presence of a flexible nursing team to provide back up for Lung Cancer Coordinator if required
• Commitment by all relevant disciplines to attend meetings and contribute to meeting discussions

• Refinement of the database to further streamline processes
• Development of a GP treatment plan summary that can be faxed or emailed to the patient’s GP immediately after the meeting
• Options to include input from health professionals in rural and regional areas

Likely to be a valuable approach for other teams, especially those managing complex cancers with large numbers of patients.

Importance of patients having one point of contact within the team (in this case the Lung Cancer Coordinator) to help them navigate the system.

Western and Central Melbourne Integrated Cancer Service (WCMICS), VIC, working collaboratively with: St Vincent's Hospital, Melbourne Health, Peter MacCallum Cancer Centre, The Royal Women's Hospital, Western Health and Werribee Mercy Hospital

Separate meetings for breast cancer, colorectal cancer, haematology, upper gastrointestinal cancer, genitourinary cancer and central nervous system cancer. Separate meetings for most of these tumour streams are held in each of five tertiary hospitals within WCMICS.

This case study outlines an audit process undertaken by WCMICS of 21 team meetings held in five hospitals across these six tumour streams.

Attendance varies for each of the 21 meetings. The audit used the core membership recommended in the Victorian Department of Human Services Patient Management Frameworks as a gold standard.

The Chair varies for each of the 21 meetings. In 13 meetings the Chair is the head of the relevant surgical unit. In most of the remaining 8 meetings, the Chair is the registrar or fellow from the relevant surgical unit.

The meeting coordinator varies between hospitals and between tumour streams. Most frequently (in 8 meetings) the surgical registrar is the coordinator, sometimes with assistance from a nurse coordinator or administrative staff. In the other meetings the meeting coordinator role is fulfilled by a range of staff including breast care nurses and surgical fellows.

In general, meeting coordinators are responsible for compiling meeting agendas, obtaining required medical and psychosocial information such as external radiology, and documenting meeting recommendations.

Varies across the 21 meetings: 76% are held weekly, 14% are held fortnightly and 10% are held monthly.

The length of meetings ranges from 30 minutes to one hour.

Varies across the 21 meetings. The range includes:

• all new cases and recurrent cases being discussed
• only complex cases being discussed
• flagging new cases by listing them on the agenda but discussing only complex cases in detail.

Time constraints influence whether or not all new cases are discussed. Some teams have acknowledged that they think they need to discuss more cases than they do currently.

Prior to the audit and ensuing changes, less than one-quarter of the meetings had developed written protocols specifying criteria for inclusion of patients for discussion.

Anecdotally it had been reported that the multidisciplinary team meetings across the Integrated Cancer Service needed to be improved, particularly in relation to documentation. Information about current processes was needed before undertaking any quality improvement activities.

A total of 21 multidisciplinary care meetings were audited across six tumour streams in five tertiary hospitals:

1. An existing meeting audit tool (within the Multidisciplinary meeting toolkit, development by the Cancer Coordination Unit, Victorian Department of Human Services) was adapted for use by the WCMICS project officer.
2. A lead clinician (typically the head of the service) for each of the multidisciplinary team meetings across the six target tumour streams was contacted to request involvement in the audit.
3. The project officer attended and observed one of each of the 21 meetings. In most cases the observer was able to sit unobtrusively in the back of the room during the meeting.
4. A follow-up meeting was held with each of the lead clinicians to discuss the observations and to fill in any gaps in the data.
5. For each tumour stream (across hospitals), data were collated and presented to the relevant Integrated Cancer Service tumour stream group. In most cases the data were compared with data for the combined tumour streams. Where relevant or requested, results for individual meetings were also available.
6. Results were compared with best practice in multidisciplinary team meetings (using a literature review, the multidisciplinary care information developed by the National Breast and Ovarian Cancer Centre, and the Multidisciplinary meeting toolkit development by the Cancer Coordination Unit, Victorian Department of Human Services) in order to develop recommendations for improvement.
7. Projects to improve the multidisciplinary team meetings have commenced.

The audit identified several issues that are common across many or all of the meetings. These include:

• inconsistent or no documentation of meeting discussions
• no written meeting protocols (this is an issue as many meeting roles, such as preparation of agendas, chairing and documenting discussions, are fulfilled by staff on rotations, leaving potential for inconsistent meeting processes when staff change)
• lack of discussion of supportive care issues
• difficulties with ensuring attendance by key disciplines
• variation in how (or whether) the GP is notified of the meeting recommendations.

Changes implemented as a result of the audit have already achieved a number of benefits.

• Improved internal communication
  
  • The recommended treatment plans from the meetings are included in the patients’ medical records, ensuring they are accessible to hospital staff who were absent from the meeting or need to refer to them.
• Improved external communication
  
  • General practitioners and other external providers now also receive information about the recommended treatment plan.
• Improved handover information, such as terms of reference and protocols
  
  • Having documented protocols and/or terms of reference assists staff on new rotations to quickly pick up the role and ensures sustainability of meeting processes and improvements over time.

• Access to lead clinicians to obtain audit information and input into improvement activities, particularly due to limited time and availability of clinicians.
• Challenges in gaining the support of services: IT and Health Information Service (HIS).
• Lack of ownership or designated responsibility for discussing patients’ supportive care needs during the meetings.
• Insufficient time during meetings to discuss all patients, and/or lack of organisational support or payment for attendance of all core team members.
• Perceptions of limitations in ‘hard’ evidence (such as from Randomised Controlled Trials or survival data) for multidisciplinary care being used as an excuse to avoid taking part in improvement activities.

• Identification of clinical champions who will help drive the process and influence their peers.
• Establishment of relationships with a range of team members who can help provide access to the lead clinicians and/or meetings.
• Benchmarking of audit results against other hospitals and/or services.
• Use of incentives to encourage participation in the audit process, which can also be used to support change. For example, provision of funding for equipment to support the meetings such as laptops, projectors, microscope accessories.
• Lobbying of Heads of IT and HIS services to gain their support, encouraging clinicians to lobby, and comparing services available between hospitals.
• Inclusion of supportive care as a meeting agenda item.
• Highlighting at Executive levels the organisational barriers to meeting attendance (such as not paying clinicians to attend) and meeting data benchmarked against data from other services.
• Promotion and provision of access to existing evidence regarding the benefits of multidisciplinary care.

• Re-audit of the six tumour groups in early 2009.
• Audit of meetings held by an additional four tumour groups in 2009: lung cancer, head and neck cancer, gynaecological cancers and skin cancer.

• Audit tool:
  http://www.wcmics.org/documents/Multidisciplinary%20Cancer%20Care/
  MDM%20program%20audit%20tool%20v2.xls
• Audit results: http://www.wcmics.org/documents/MDM_AuditResults.pdf
• Treatment plan documentation templates: http://www.wcmics.org/WCMICS-priorities.htm

• Be patient, persistent and flexible – sometimes small steps can be frustrating but they can lead to big changes.
• Persistence and relationship-building are the keys to this kind of work.

• Breast team: aim for all newly diagnosed patients
• Urology team: at discretion of specialist
• Gastrointestinal team: tends to focus on complex patients

Development of templates and proformas:

1. Referral to meeting form
   
   • 1 page paper-based form completed in advance of meeting by the treating specialist.
   • Data fields depend on information considered important for treatment planning for each tumour stream; typically includes demographic information (sticker), medical and family history, pathology and radiology.
   • MDT Coordinator uses referral form to develop a PowerPoint slide for each patient to be discussed at the meeting.
   • Slides projected onto meeting room wall to enable all participants to view results.
2. Treatment plan proforma
   
   • 1-page summary on reverse of Referral to meeting form developed with input from medical records.
   • Completed by the Medical Oncologist during the meeting.
   • Placed in the patient record after the meeting.
   • Aim is for form to follow patient through their treatment path.
3. Patient information brochure
   
   • Based on brochures developed by other teams.
   • Generic brochure used for all cancer streams.
   • Gives a general overview of the aim of multidisciplinary care, who is involved, what is discussed, who will communicate outcomes and billing information; contact number provided in case of questions.
   • Brochures made available to GPs to describe the function of the teams.

• Focus group feedback indicates that the multidisciplinary approach is viewed positively by patients – patients value the input to their treatment plan from a range of specialists.
• Meetings have improved relationships across the hospital – between specialist and allied health professionals and hospital administration.
• Teams are a driver for improvements in cancer services.
• Model is now being used by other non-cancer services within the hospital.

• No major barriers – all staff supportive and committed to the process.
• Time is a restriction, especially for team members who attend more than one meeting – either within or outside the hospital.
• Private service means that team members are not funded to attend meetings – however this has not been a barrier to attendance to date.
• Issues for improvement include: - standardising criteria to determine which patients are discussed.
  - encouraging completion of referral forms by specialists.
  - finding approaches to increase GP input to meetings.
  - determining the most appropriate method for informing GPs of treatment plans.
  

• Recognise the clinical focus for the meetings; business issues are discussed separately in a quarterly meeting involving the Meeting Chairs, Head of Cancer Services, Director and Assistant Director of Medical Services and MDT Coordinator.
• Engage all members of the team in decisions and process changes, eg canvass views about most convenient meeting times; work with team members to make processes as simple as possible.
• Identify a champion to help drive the process and influence peers, eg Meeting Chair or case manager who has good relationships with other members of the team.
• Develop processes based on the local environment.
• Be flexible – recognise that processes may need to be refined or changed with time.
• Good communication between all members of the team is critical.
• Provide refreshments (breakfast provided for early morning meetings).
• Encourage sharing of information and resources between teams – peer review approach is valuable.

• Explore best options for inviting GP input with representatives from Divisions of General Practice.
• Develop a system of electronic data capture that allows information provided on referral form to be used by specialists who need to submit data to professional colleges (eg for RACS audits).
• Review forms to incorporate more tick boxes for ease of completion.

Head and Neck Cancer Multidisciplinary Team, Royal Brisbane and Women's Hospital, QLD

Head and neck cancer (includes public and private patients)

Core Membership:

• Ear, Nose and Throat Surgical Consultants and registrars
• Plastic and Reconstruction Surgical Consultants and registrars
• Maxillo-facial Surgical Consultants and registrars
• Radiation Oncology Consultants and registrars
• Medical Oncology Consultants and registrars
• Senior Dentist (Brisbane Dental Hospital)
• Consultant in Radiology
• Consultant in Nuclear Medicine

Associate Membership:

• Clinical Nurse, Specialist Clinics, Cancer Care Services
• Cancer Care Coordinators
• Head and Neck Clinical Nurse Consultant
• Multidisciplinary Team Coordinator
• Speech Pathologist
• Dietitian
• Data Manager
• Welfare Officer
• Palliative Care
• Any support staff who may be required to assist meeting implementation
• Other health professionals invited by the presenting doctor or Chair of the meeting

A record of meeting attendance is kept by the MDT coordinator.

A separate fortnightly Pathology meeting is coordinated by an ENT registrar.

Dr Robert Hodge, ENT surgeon and in his absence a proxy.

Multidisciplinary Team Coordinator (Administration Officer)

Weekly clinic and meeting:

• 1-hour patient clinic in which team members conduct clinical examinations typically of 12 new patients with Head and Neck cancers; patients may meet up to 10 team members.
• Clinic is followed by a team meeting (up to 3 hours) to discuss management plans.
• The Chair identifies the clinician who will communicate the meeting recommendations to the patient; this is typically the proposed surgical team or allocated oncologist. Another clinician will dictate notes into the chart and letters to the referring doctor.
• While the meeting is occurring, a clinical photographer takes a photograph of each patient for ID purposes as well as photographing the area of the cancer.
• After a morning tea break, patients (together with their relatives or significant others) return to the clinic room to await the meeting recommendation.

The aim is for all newly diagnosed patients to be seen and considered by the team. 12 new patients are admitted to the clinic each week (dictated by available space in clinic); these include:

• newly diagnosed patients
• patients with a Head and Neck cancer recurrence

Multidisciplinary meeting discussion includes these patients in addition to other relevant patients who may be undergoing treatment but require further discussion (up to 20 discussions per meeting) are mentioned.

Cases are typically presented by the Ear, Nose and Throat. Plastic and Reconstruction Surgery or Maxillo-Facial registrars and Radiation Oncology registrars.

How to combine the multidisciplinary clinic and meeting effectively.

Clinic preparation:

• The MDT Coordinator schedules the patients and collates all referral information in advance of the meeting in consultation with the Clinical Nurse and referring specialists. The Chair is advised of changes to the upcoming clinic on a daily basis.
• An appointment letter is sent to the patient along with an information brochure and a letter from the Senior Dentist requesting that they have a dental examination and oral X-ray prior to attending the clinic.
• On the day of the clinic, all relevant information is available outside each examination room, including the patient’s medical chart, current and previous histopathology, imaging reports, blood results, referral letter and data collection form. A speech pathology screening form and nutrition screening form are given to the patient to complete. The clinic room is set up with equipment required for patient examination.

Patient information brochure:

• A patient information brochure is sent to each patient with their appointment letter so that they are prepared for what will be involved on the day. This ensures that patients understand that they will meet a range of health professionals and that they will be required to wait at the clinic while their examination results are considered and their treatment plan is discussed.

Meeting agenda:

• The MDT Coordinator produces an agenda in advance of meeting. This includes attending patients and discussion patients. The patients for discussion are usually referred from the surgical team. The usual discussion issue is the histopathology arising from the patient’s surgery.
• Other issues for discussion are reports from any further imaging that was recommended from the meeting and any treatment concerns. At the meeting the discussion patients’ next phase of treatment and details, such as the allocated Radiation or Medical Oncologist, are confirmed. To ensure patients are not missed, the Clinical Nurse monitors the daily operation lists, which are faxed each morning from the RBWH Operating Theatres, noting any Head and Neck patients. The Clinical Nurse liaises with the surgical team to identify and schedule the patients for discussion.

Meeting documentation:

• Treatment recommendations are captured by an identified member of the team (eg oncology consultants and their Registrars) using the Win Scribe Digital Dictation System; the Chair allocates responsibility for undertaking dictation after the meeting.
• Dictated recommendations are sent to the referring clinician and other relevant clinicians as appropriate.

Data management system:

• The Data Manager records information during the meeting and maintains the Head and Neck Database.
• A simple Cardex system is used by the Clinical Nurse to record outcomes during the meeting as a back-up approach.
• The MDT Coordinator also enters the meeting recommendations onto an Excel spreadsheet.

• Good opportunity for input from all relevant specialties into the treatment plan.
• All relevant treatment team members have the opportunity to meet and examine the patient on the day of the treatment plan being made.
• Patients receive a treatment decision on the day.
• Patients meet the individuals who will be managing their care.
• Pre-admission work can be undertaken on the day.
• Allows a partnership approach between public and private settings.

• Space limits the number of patients who can be seen on one day.
• Large number of specialists and mix of public and private patients means that there is competition for who will be seen.
• Lengthy waits at clinic can be distressing for patients.
• Smooth running of meeting dependent on Chair and effective MDT Coordinator
• Well-established team means that some processes are embedded and change can be a slow process.
• Specialists are VMOs so it can be difficult to contact them before the meeting.
• Time precludes discussion of supportive care issues for every case.

• Specialists are supportive of the meetings and attend regularly, providing alternatives if they are unable to attend.
• Excellent Chair facilitates meeting with large number of attendees and clearly allocates follow-up tasks.
• Good communication and rapport with external ENT, Plastic and Reconstruction and Maxillo-Facial surgeons.

• Incorporate tele-/videoconferencing to encourage discussion of additional patients from distant sites.
• Electronic data management process.
• Development of more detailed criteria to prioritise clinic admission decisions.
• Reformatting the structure of the Head and Neck clinic to enable more patients to attend.
• Incorporation of administrative MDT Coordinator role requires further work.

• Patient information brochure
• Terms of reference

Barwon South Western Regional Integrated Cancer Service (BSWRICS), VIC: breast, colorectal, urology, lymphoma and lung teams based at Barwon Health.

Separate meetings for breast cancer, colorectal cancer, urology cancer, lymphoma and lung cancer.

Surgery, Medical oncology (consultants, registrars and residents), Radiation oncology (consultants, registrars and residents), Pathology, Radiology, Specialist nursing, Clinical trials coordination, General practice liaison (breast, colorectal, urology, and recruiting for lung and lymphoma), Physiotherapy (breast), Students (medical, nursing and pathology), Meeting coordinator and administrator, Patients own general practitioner when possible.

Medical oncologist (urology, lymphoma, lung); Radiation oncologist (breast); Surgeon (colorectal)

Multidisciplinary Care Coordinator. Additional administration support in relation to generating weekly MDT communication, creating agendas, group online radiology images, coordinate pathology requests from external sites, data entry pre and post meeting, and allocating clinicians login.

Differs for each stream:

• breast: weekly Friday 0815-0915
• colorectal: first and third Thursday of the month 0730-0830
• urology: Tuesday every second week 0830-0930
• lymphoma: Friday every second week 1130-1230
• lung: two weeks in every three Fridays 0915-1015

Participating clinicians select patients who would benefit most from a multidisciplinary discussion.

The number of patients discussed differs for each stream, ranging from 4 patients in the urology meeting to up to 7 patients in the colorectal meetings.

How to streamline tracking of patients and documentation of discussions in multidisciplinary meetings. How to improve communication with teams and to provide facilities for interactive, remote participation in the meetings.

Development of an online database and communication system

BiteIt developed the database software (CANMAP) for the Albury-Wodonga Border Cancer Collaboration Project. The database has been further developed to meet BSWRICS requirements.

Key functions and roles of the online database and communication system are described below:

Before multidisciplinary meetings:

• Participating clinicians can log in and add patients to the agenda of a particular meeting.
• Agendas are automatically collated and disseminated to participants via email or e-fax,
• Referring GPs are e-faxed a personalised invitation to attend the meeting. The invitation includes the details of their patient to be discussed.

Administrators check to ensure all images and other required documentation are available for the meetings. Radiology images are now available online via PACS systems or on CD's from providers outside the Geelong region.

Radiologists and pathologists are provided with the opportunity to review images/results prior to the meeting. Radiologists can log in to review images (where the imaging provider offers this service), or they are provided with portable hard drives containing images relevant to each meeting. The hard drives can also be used during the meeting to reduce time spent waiting for images to upload to the website.

During multidisciplinary meetings:

• Documentation and discussions from previous multidisciplinary team meetings (when a patient has been discussed previously) can be made available.

After multidisciplinary meetings:

• Meeting minutes are added to the database; so that for each patient there is a summary of the information presented, key discussion points, and the recommendations for consideration.
• Relevant clinicians can log in and access information and the discussion summary about their patient.

Facilitation of remote participation via streamlined videoconferencing

Videoconferencing participation has recently been taken to new levels in order to enable a haematologist (based in Warrnambool) to participate remotely in the lymphoma multidisciplinary team meetings (held in Geelong Hospital).

Previously BSWRICS has used videoconferencing for education forums to link together staff caring for cancer patients to receive updates and new information about cancer care and treatments.

This knowledge was built on to pilot videoconferencing of regional clinicians into Geelong meetings.

The facilitation of remote access to the meeting required sourcing a room in Warrnambool for the specialist clinician and his team to use to videoconference into the meeting. In Geelong the videoconferencing facilities are available in the conference room the multidisciplinary meetings are held in. Fortunately the region is connected through the South West Alliance of Rural Health (SWARH) network, enabling videoconferencing to other SWARH sites at no cost.

Prior to the first videoconferencing meeting, a practice link up was undertaken to check that participants in Warrnambool could see the pathology slides and radiology images presented in Geelong. The ability to see the pathology and radiology images at the far site depends on the bandwidth of the videoconferencing link.

Participants based in Geelong were informed about the etiquette of video conferencing before the first videoconferencing meeting was held.

The videoconferencing has improved the relationship between the clinicians in the geographically separate sites; it has facilitated streamlined care for patients with a haematological cancer in the region and has provided learning opportunities for the meeting attendees.

Following the piloting of videoconferencing in one meeting, there are plans to implement it into the other meetings.

Options for setting up videoconferencing facilities in the regional clinicians’ rooms are also being investigated, so they can link into the meetings without having to travel to the hospital (as currently happens).

Online database and communication system

• Multidisciplinary meetings and treatment planning are streamlined.
• Clinicians have ready access to patient data, discussion summaries and recommendations for consideration after the meetings if required.
• Ability to send out information regarding conferences and related educational opportunities to multidisciplinary team members.
• Easy to operate system that can be customised to suit the organisations needs. CANMAP can be used for care coordination and project management as well as multidisciplinary care.
• System allows for 1–2 staff members to facilitate multiple meetings.
• Secure system accessible by login only, the system is held on a secure remote server. The system is regularly backed up to prevent loss of data.

Streamlined videoconferencing

• Provide access to multidisciplinary care discussions for rural patients.
• Streamlined care for regional patients requiring referral to Andrew Love Cancer Centre.
• Enable clinicians to participate remotely from their own consulting rooms - will much less disruption to patient consultations (by removing any need to travel to a videoconferencing facility).
• Improve relationships and referring pathways between clinicians.
• Education opportunities for team members.

Online database and communication system

• Implementing a new database can be met with barriers, as it requires change. A change management process needs to be incorporated in the implementation of the system.
• Getting the correct details to use in the communication side of the system can be time consuming. The contact information section also requires constant maintenance to keep it current.

Streamlined videoconferencing

• Learning curve with respect to technology – challenges associated with recently developed technology and with staff learning to use the technology. Having a staff member with IT experience can reduce this barrier, however multiple staff members need to know how to operate the equipment.
• Meeting attendees at both sites of videoconferencing need to be aware of the etiquette required to enable effective communication via videoconference. This can create a real barrier if meeting attendees fail to follow the etiquette, making it difficult to hear and/or communicate.
• In the interest of time it is important that the videoconferencing link is used for multidisciplinary meeting purposes only. Encourage attendees to use other methods of communication for one-on-one communication.

Online database and communication system

• Having a passionate champion for the multidisciplinary meetings – often younger clinicians who have worked in effective multidisciplinary teams in other services – to bring other clinicians on board.
• Facilitating ownership of the meetings by the meeting participants.
• Providing potential future meeting participants with opportunities to see the benefits valued by other multidisciplinary teams, such as access to records, data, streamlining of information into one point.
• Appointment of a dedicated BSWRICS team, in conjunction with the database system, has assisted in the implementation and sustainability of the multidisciplinary meetings.

Streamlined videoconferencing

• BSWRICS Cancer Care Coordinator based in Warrnambool has been available to assist locally to facilitate the haematologist’s participation. For example, assisting with and trialling the set-up of videoconferencing facilities in the consulting rooms, ensuring access to meeting paperwork, providing meeting refreshments.
• Staff members with IT experience and able to operate all equipment.
• Training in skills in effective communication via videoconference.
• A significant community donation has enabled an upgrade of the multidisciplinary team meeting room and the technological capacities of the room in Geelong.

Online database and communication system

• Summary screen with key information about the patient, to be viewed during the team discussion.
• Formulate a brief report of the discussion summary and recommendations for consideration, to be printed onto labels and stuck into the public/private patient notes.
• Facility to e-fax individualised follow-up letter to the patient’s GP after the meeting, containing a patient summary and the recommendations for consideration.
• A log to track audit who is accessing the system and what they are doing while logged in.

Streamlined videoconferencing

• Facilitate remote meeting participation of other interested specialists via streamlined videoconferencing from their consulting rooms.
• Enable specialists in Geelong Hospital to participate remotely in the multi-tumour multidisciplinary meetings held in the smaller centres, including Warrnambool and Hamilton, as required. Requirements include upgrading technological facilities available in the smaller centres.

• A package with sample documents and templates can be made available, such as template letters to participating clinicians, meeting agenda templates, meeting outcome proformas. For further information or a personalised information pack please contact website@BSWRICS.com
• Information about the specific database design and approach can be made available by contacting CANMAP@biteit.com.au or visiting http://www.biteit.com.au/CANMAP.asp

• Having a dedicated person as a single point of contact for organising meetings is essential for sustainability of the meetings.
• IT systems range in degrees of sophistication. Whatever the degree of sophistication, electronic data collation and data access is a key to establishing successful multidisciplinary team meetings.
• Persistence pays off!