The Chief Information Technology Officer in a Radiation Oncology department should be a medical physicist

The Chief Information Technology Officer (CITO) in a Radiation Oncology (RO) department needs to be familiar with not only all aspects of radiation oncology technology but also with the information technology (IT) field, which is ever increasing in complexity. Some would argue that the IT field has become so specialized that only an IT professional should be the CITO, but others might claim that only a medical physicist who understands all the intricacies of radiation oncology should assume this role. It is this latter premise that is the Proposition debated in this month's Point/Counterpoint. The appropriate management of IT in RO is crucial to the safe, effective, and timely delivery of radiation therapy (RT). The medical physicist is in the best position to understand the propagation and transformation of data through imaging, planning, treatment, archiving, and retrieval of prior plans.1 The management and nature of that data have been the subject of many AAPM task group reports2–4 that further prepare the physicist to handle the nuances and clinical implications of these data intensive processes. As physicists trained in every aspect of the RT clinical workflow, we have a profound appreciation of the effects of downtime, upgrades, and installations of imaging devices, treatment planning and linac control systems, and electronic medical records [especially the record and verify (R&V) portions] on our ability to deliver the radiation dose distributions the physicians prescribe. We are called upon to handle problems that prevent, delay, or interrupt treatment delivery. We are uniquely qualified to address the situation with clinically appropriate actions that also satisfy legal obligations to verify the transfer of dose-related parameters.5,6 With RO highly dependent on computer control systems, troubleshooting involves in-depth knowledge of the specialized applications and computers. While a person trained in IT may be familiar with the processes involved in the maintenance of such systems, the management of these systems requires an understanding of the impact of these processes on dosimetric and positioning accuracy. Appropriate timing and execution of these tasks are necessary to allow physicists to ensure that all the clinical data (e.g., treatment planning commissioning data, adaptive imaging data) as well as their interpretation by various systems have been preserved. Historically, the RO medical physicist assumed IT-related responsibilities and has contributed much to healthcare IT.7 Our IT education and skill set grew in the context of the RO clinical workflow. Hence, we have developed policies and procedures that make our IT activities consistent with the overall goal of safe and effective treatments. While the practice of medical physics has become more demanding and we require help from IT professionals, many of our IT colleagues lack the necessary depth of understanding of RO clinical operations.8 We still must provide guidance to them. We are well prepared to make decisions about the required level of IT support and availability, the allocation of IT tasks, and the related QA activities that should accompany these IT processes. RO-related IT resources and activities must be managed by a professional who has the clinical experience to evaluate the impact of those management decisions on the care of patients. Therefore, a medical physicist should be the Chief IT Officer in RO. The title CITO, as with most technical titles, including my own, suffers from ambiguity. A few definitions and assumptions are in order. The Chief Information Officer (CIO), a member of the executive committee, is involved in strategy decisions for enterprise information systems.9 The Chief Medical Information Officer (CMIO), a clinical executive, leads the hospital's electronic medical record (EMR) initiative and manages the clinical IT department.10 By extension, the CITO would operate at the departmental level and have final authority on IT selection and strategy. Dr. Trueblood and Dr. Hogstrom discussed the physicist's role within the field of informatics in 2000 when the prevailing concerns included EMR, PACS, HIS/RIS, and networking.11 The conversation is still relevant today as the list of informatics concerns continues to grow. Kagadis et al.7 identified three key informatics-related issues in radiation therapy which have augmented the role of the medical physicist, namely, R&V QA needs, hospital and radiation oncology EMR integration, and PACS. Furthermore, the Center for Studying Health System Change found oncology's clinical IT adoption rate to be the highest among medical specialties.12 A dedicated CITO position would address these and future informatics concerns in radiation oncology. Enter human resources. I propose the following CITO job description: IT vendor selection authority, budgetary authority to set and manage a departmental IT budget, trend analysis, strategy formulation, and project leadership. The CITO would also serve as radiation therapy and oncology informatics advisor to the CIO and CMIO. For example, if a hospital is replacing an end-of-life PACS, the CITO would sit on the selection committee and argue for the inclusion of DICOM-RT as part of the vendor selection criteria. The hospital IT landscape is constantly changing, and a CITO must be cognizant of clinical informatics trends inside and outside the department. A sampling of informatics projects within the CITO's jurisdiction include radiation oncology information system (ROIS) interface engines (HL7) for code capture, laboratories, formularies, discharge summaries, cancer registries, and transcriptions. Disaster preparedness, data redundancy, and secure off-site access to PACS and ROIS also require CITO leadership and project oversight. Larger departments have costly and formidable IT projects in the form of multisite R&V infrastructure, teledosimetry, and clinical trial integration—all of which necessitate a CITO. The ideal CITO candidate based on the above examples would be a master's level medical informaticist with at least 5 years of experience. My contention against a medical physicist assuming the role is not based on ability but is instead based on the full-time commitment required to fulfill the CITO role. In a similar fashion, physicists do not assume the role of PACS administrator but instead provide strategy and technical expertise to this individual.13 The AAPM report on peer review in clinical radiation oncology physics14 addresses IT as a peer review component but does so by listing software updates for major equipment within the context of patient safety and service continuity. In matters of patient safety, the medical physicist should clearly take a leadership role while the CITO lends assistance. The day-to-day work of ensuring the security, integrity, communication, and redundancy of data does indeed require dedicated IT staff, especially in the era of image guided radiation therapy. A master's level medical informaticist, however, even with 5 years of experience, would not have had sufficient clinical exposure to the subtleties of data transformation within the IT workflow in RO. For example, IT personnel with experience in radiology may be aware of image quality issues, but they most likely do not have experience with RO databases and applications that control the delivery of potentially lethal doses of radiation. RO medical physicists have the training to make clinical judgments about IT. They fully appreciate the implications of IT decisions on the care of patients. While they may not have the full-time commitment to handle daily IT operations and the implementation of new projects, they have the appropriate domain knowledge and sufficient time to manage RO IT processes and communicate with other hospital IT decision makers. Although dedicated nonmedical physicist RO IT professionals may come to appreciate the nuances of RO data operations, this may require many years of experience. During that time, who should make the decisions? Individuals like my learned opponent are rare. For most clinics, their IT support will come from the hospital IT group. RO departments typically do not have dedicated IT support, even though it is increasingly important that they do. Hospitals should at least have their IT departments dedicate specific individuals to RO. In these situations, the only individuals with the clinical judgment to make IT decisions are the medical physicists. Hospital IT should recognize the importance of the medical physicist's IT leadership and RO departments should allocate time for these duties through proper human resource management. The final authority of RO IT decisions must rest with the medical physicist. Appointing medical physicists to be CITOs would give them the voice needed for the IT decision making part of their jobs. In the end, these decisions have an impact on patient care, and the CITO must be willing to accept this clinical responsibility. Key aspects of the RT workflow are highlighted in Dr. Siochi's opening statement and I concur that the medical physicist has a profound technical understanding of these processes. And rightly so, as the medical physicist has been instrumental in every technical RO milestone long before linear accelerator computerized control. The physicist must be granted authority to create and enforce IT policy surrounding mission-critical processes outlined by Dr. Siochi in matters of planning, imaging management, commissioning, and quality assurance. Outside the boundary of the physics operational core, however, lies an ever-expanding set of IT duties as described in my fictitious chief IT officer job description. For example, R&V systems, previously reserved for machine data, have evolved into full-fledged radiation oncology information systems populated with patient data, demographics, scheduling, vitals, Rx dose, laboratories, and notes—all of which are key to physician workflow. The ROIS is one such system which has increased in scope beyond the typical physics workflow and as such could be assigned to the chief IT officer for archival, data mining, security, integration, and curation efforts. Granted, there are intimidating IT challenges within RO physics, and Dr. Siochi is correct to assume that an IT generalist would not be well suited to the specialized nature of RO. My contention is that the CITO must possess specialized informatics training with experience in EMR/RIS, PACS, HL7, and IT project management. The increased adoption of informatics standards (e.g., DICOM-RT) and initiatives such as integrating the healthcare enterprise in RO have removed barriers to entry for informatics professionals into RO. With an increased supply of graduates from healthcare informatics programs, the timing is right to establish the position of Chief IT Officer. As for the selection committee, one well stacked with medical physicists will yield the best candidate.