Radiotherapy has always demanded precision; it is also a cancer treatment with a high patient throughput. At one of Europe’s largest teaching hospitals, we manage hundreds of patients each day across imaging, planning, pre-treatment, and treatment delivery. That scale brings operational complexity. It also introduces risk if systems are not designed to support staff under pressure. Globally, more than half of all cancer patients will require radiotherapy at some point in their treatment, making consistency and reliability at scale essential to safe and precise care delivery.
When everything works well, the pathway feels seamless. Patients move from referral to treatment with the right checks completed at the right time. When it does not, the issues tend to surface in small, easy-to-miss moments—steps delayed, overlooked, or assumed to have been handled by someone else. In a busy department, those gaps matter.
For many years, radiotherapy departments have focused on digitizing records and moving away from paper. That work is essential. Paper is easily lost, difficult to track, and slow to move between teams. However, digitizing information alone does not remove risk if processes still depend on people remembering what comes next. A digital record can still sit untouched if nothing prompts action.
As early adopters of informatics software, such as MOSAIQ (Elekta ONE OIS) and Smart Workflows (Smart View), which integrates radiation and medical oncology workflows, we quickly learned that electronic documentation alone is insufficient. The biggest shift for our department has been moving toward structured, task-guided workflows that actively support the next step in the care pathway. The goal is not to replace clinical judgement, but to reduce variation and remove avoidable reliance on memory in a high-volume practice.
The operational reality of scale
Operating at scale exposes a simple truth: variability multiplies quickly. In practice, many radiotherapy safety challenges emerge from process and communication gaps across complex care pathways rather than from treatment technology itself. A delayed imaging review, missed referral, or incomplete documentation can ripple across an entire day’s workload. Radiotherapy pathways are necessarily complex to ensure safety, which also increases the cognitive burden on staff, particularly when services are running at capacity.
In many departments, safety still depends on individuals remembering to complete the next step after finishing another task. This is not a failure of people; it reflects the limits of human memory in a pressured clinical environment. When critical actions rely on recall, risk and inefficiency tend to appear in predictable places. Manual handovers introduce friction, referrals require follow-up, and imaging review can be missed when it sits outside a clearly defined process. Approvals may even proceed without complete documentation, shifting responsibility back onto individual vigilance.
Moving these processes onto a computer screen alone does not solve the problem. Without structured systems that actively guide action, electronic systems can reproduce the same gaps that once existed on paper.
From records to task-guided workflows
Instead of expecting staff to remember the next step, tasks are now triggered automatically based on what has already occurred. If something always needs review or sign-off, the system should make that visible and persistent until it is done.
Imaging review is a good example; it’s central to modern radiotherapy, yet it was historically vulnerable because it relied on a manual prompt. With systems such as Elekta ONE OIS, an oncology information system and electronic medical record that integrates radiation and medical oncology workflows, image imports can be configured to trigger a review task automatically. Instead of being something a clinician has to remember, review becomes embedded directly into the clinical process, and the task remains visible until it is addressed, supporting accountability and consistency.
In practice, we use smart task boards to manage Cone Beam CT review across the department. When an image set is imported into Elekta ONE, a task is generated and linked to the machine that acquired it. This ensures responsibility sits with the correct team and allows us to monitor review status at a departmental level while still tailoring views to individual treatment units. Visual alerts help staff quickly identify anything overdue, including images from the previous day.
The impact is greater reliability. With 12 linear accelerators operating across different clinical areas, this approach supports a standard method for image review without adding unnecessary complexity.
The same principles apply to consent, protocol checks, and other critical steps. When workflows enforce sequence and visibility, staff spend less time worrying about what might have been missed and more time focusing on clinical care.
Adoption across a diverse workforce
While structured systems improve consistency, their impact ultimately depends on how well they are adopted in daily practice. Technology alone does not deliver change. Adoption is where most technology initiatives succeed or fail. In a large department, staff have different levels of experience, confidence, and comfort with digital systems. Concerns about speed, reliability, and loss of autonomy are common and legitimate.
From the outset, we approached process redesign as a multidisciplinary effort. Problems were discussed openly, and workflows were broken down into small, manageable changes. Introducing change incrementally allowed us to monitor safety, gather feedback, and adjust as we went.
Communication mattered. Keeping staff informed and actively inviting feedback helped build trust. We learned quickly that a single standardized approach rarely fits every area. Developing robust templates that could be adapted for specialist services made adoption easier and helped teams see their own practice reflected in the system.
A common concern is that electronic processes slow work down. Sometimes an individual task does take slightly more time, but the overall patient journey almost always benefits. Removing paper scanning, filing, chasing, and rework delivers gains that outweigh any additional seconds spent completing a digital form.
Measurable improvements in efficiency
One advantage of structured electronic methods is that their impact can be measured. In our Leksell Gamma Knife stereotactic radiosurgery service for intracranial tumors and lesions, we moved from a paper-heavy approach to a largely electronic workflow, using tools such as Elekta’s Smart View. We anticipated challenges, particularly in a same-day treatment service.
What we found was that removing paper eliminated delays we had simply accepted as unavoidable. Forms no longer travelled between areas. They were not misplaced or incompletely filled. On average, we now save around 30 minutes per patient for same-day treatments compared with previous paper-based methods.
Across the wider department, digital forms routinely save between 30 seconds and one minute per form. Applied across approximately 8,000 patients each year, these incremental efficiencies translate into many hours of clinical and administrative time returned to patient care. Compliance improves, missing documentation becomes rare, and data is immediately available for audit and service evaluation. As these systems become more embedded in daily practice, however, new considerations begin to emerge.
Equity and unintended consequences
Technology change must be implemented carefully. Without attention, it can introduce new inequities for both staff and patients. Uneven training can create variation in practice. Poorly designed workflows can disadvantage patients with lower health literacy or limited access to electronic communication.
System design must account for these realities. Systems should support clarity, flexibility, and multiple perspectives. When done well, technology helps close gaps rather than widen them.
Learning from workflow data
Structured, task-guided systems generate a level of insight that paper methods never could. Delays, omissions, and variations become visible, allowing bottlenecks to be identified and addressed, and small changes to be evaluated using real evidence rather than anecdote. Over time, this lays the foundation for continuous improvement, enabling meaningful links between performance and clinical outcomes, service quality, and patient experience.
As radiotherapy demand continues to grow and services become more complex, safety cannot depend on memory alone. Consistent, measurable processes help reduce variation, support staff, and maintain reliability at scale. From our experience at Leeds, the most effective digital changes are rarely dramatic. They are the quiet, well-designed steps that ensure the right action happens at the right time, every time.
About Peter Enever:
Peter Enever is Head of Radiotherapy at Leeds Cancer Centre within Leeds Teaching Hospitals NHS Trust, where he leads clinical radiotherapy operations and innovation across one of the UK’s largest cancer treatment centers. A therapy radiographer by training, he focuses on improving treatment workflows, patient safety, and the integration of advanced technologies into everyday care. Peter works closely with digital oncology platforms, including Elekta’s radiotherapy software solutions, to support more connected, efficient treatment planning and delivery across the radiotherapy pathway.