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HARVARDMEDICAL SCHOOL
Anatomic Pathology Information – The Challenge of Tracking and
Routing at MGH
Thomas M. Gudewicz, MDMassachusetts General Hospital
Harvard Medical School
Information Received, I Understand
HARVARDMEDICAL SCHOOL
Summary• The complexity of pathology information
workflow can be optimized by the application of automated systems, including asset tracking and routing
• Automating a system requires detailed information on workflow to optimize analysis and design considerations
• The collection and analysis of such information is in itself a definable process that assists design
• Iteration is a key component of optimizing analysis and design
HARVARDMEDICAL SCHOOL
Outline
1. Mission, Vision and Driving Forces2. From 1896 to 2010 - The Contrast3. The Challenge4. Tracking and Routing – Defined5. MGH Tracking and Routing –
Today6. Building the Foundation
HARVARDMEDICAL SCHOOL
1. Mission, Vision and Driving Forces2. From 1896 to 2010 – The Contrast3. The Challenge4. Tracking and Routing – Defined5. MGH Tracking and Routing – Today6. Building the Foundation
HARVARDMEDICAL SCHOOL
The Mission and Vision of the MGH Pathology ServiceThe Mission and Vision of the MGH Pathology Service
HARVARDMEDICAL SCHOOL
To deliver the highest quality pathology services
and to move the field of pathology forward
HARVARDMEDICAL SCHOOL
Healthcare - The Driving Forces
Revenue
Customers
RevenueIncrease productivity Cut costsReduce waste
CustomersExternal
• Patients • Health care
providers• Other diagnostic
specialists• Researchers
CustomersExternal
• Patients • Health care
providers• Other diagnostic
specialists• Researchers
Internal• Technical staff• Administrative
staff• Residents and
fellows• Pathologists
RegulatoryRegulatory
GovernmentalInsurance
HARVARDMEDICAL SCHOOL
MGH Pathology Products and Services
• Pathology and clinical laboratory results and reports (clinicians, patients)
• Education and training (technologists, residents, fellows)
• Research materials (tissue, blocks, slides, data)
• Therapeutic modalities (blood and blood products, therapeutic phlebotomy, plasmapheresis, etc.)
HARVARDMEDICAL SCHOOL
MGH Pathology Products and Services
• Pathology and clinical laboratory reports (clinicians, patients)
• Education and training (technologists, residents, fellows)
• Research materials (tissue, blocks, slides, data)
• Therapeutic modalities (blood and blood products, therapeutic phlebotomy, plasmapheresis, etc.)
Information
HARVARDMEDICAL SCHOOL
1. Mission, Vision, and Driving Forces2. From 1896 to 2010, the Contrast3. The Challenge4. Tracking and Routing – Defined5. MGH Tracking and Routing – Today6. Building the Foundation
1896
2010
HARVARDMEDICAL SCHOOL
ResearchLaboratories
Histo- compatibility Laboratory
Immunology Laboratory
Research Finance & Admin
Roles and Functions of the MGH Pathology Service
Clinical Services
InformaticsEducational Programs
Core Clinical Laboratories
Surgical Pathology
Service
Quality and Safety
Cytology Service
Microbiology Laboratory
Divisions:
Services:
Point of Care Testing
Diabetes Laboratory
HealthCare Center
Laboratories
Execute Mission Support Function
AutopsyService
Blood Transfusion
Services
HARVARDMEDICAL SCHOOL
MGH Pathology: Service Workload
Services• Clinical laboratories: >10 million tests • Surgical pathology: ~80,000 specimens• Cytopathology: ~61,000 specimens• Autopsy: ~300• Microbiology: ~400,000 specimens • Blood transfusion service:
• Donor center• ~70,000 total blood component transfusions • ~35,000 RBC units transfused• ~3000 outpatients treated
Employees• ~700 staff• ~ 85 faculty• ~ 80 trainees
Budget• MGH ~$100M• MGPO ~$25M
HARVARDMEDICAL SCHOOL
1. Mission, Vision, and Driving Forces2. From 1896 to 2010 – The Contrast3. The Challenge4. Tracking and Routing – Defined5. MGH Tracking and Routing – Today6. Building the Foundation
HARVARDMEDICAL SCHOOL
Sunquest CoPath / MGH Collaboration
• Software co-development: efficient, flexible work, specimen & information flow.
• Strengthen the informatics infrastructure: use advanced diagnostic & information management (IM) technologies.
• Provide a revenue stream: commercial distribution of the software.
Aug 2009 – 10-yr. joint development agreement with Sunquest Information Systems on the next generation AP/CP based LIS.
HARVARDMEDICAL SCHOOL
Collaboration Project Requirements
1.Retire PowerPath & Implement Sunquest CoPath 5.0 AP-LIS.
2.Analyze, re-design, & optimize workflow top to bottom.
3.Apply automation, advanced diagnostic & IM technologies, digital pathology, molecular tests, operational Business Intelligence (dashboards)
HARVARDMEDICAL SCHOOL
1. Mission, Vision, and Driving Forces
2. From 1896 to 2010 – The Contrast3. The Challenge4. Tracking and Routing – Defined5. MGH Tracking and Routing –
Today6. Building the Foundation
HARVARDMEDICAL SCHOOL
Tracking and Routing
Routing - system to determine where an asset is directed during the life cycle given the status of the system.
Tracking - system to determine at what point an asset is located (and where it has been) in the case life cycle.Systems may be manual or automated.
HARVARDMEDICAL SCHOOL
Assets - DefinedHard Assets: Any
identified physical item assigned to a case• Tissue, blocks, slides.• Paper requisitions,
documents and reports
• x-ray film.
Soft Assets: Non-physical (electronic, virtual) information
• EMR, PACS Images
• CD’s (?)
Unidentified (Hidden) Assets: Any asset created or required for production not assigned a system ID • “Just-in-case” unstained slides• Electronic image not linked to system• Tissue blocks for IPX controls
HARVARDMEDICAL SCHOOL
Assets - Defined
Whether machine readable or not, assets must be
assigned a fixed, unique, traceable ID
S10-02341A2 L-3Doe, John
MBH Pathology
https://Archive132/Shared%20Documents/Proc34A
HARVARDMEDICAL SCHOOL
Tracking – Where is the Asset?
SPOT – Specimen Point of Tracking
A station or location at which an asset is recorded or logged (time in, receipt by, condition, etc.,)
Ideally, define SPOTs at hand-off points
• human-human • human-machine• machine-machine
HARVARDMEDICAL SCHOOL
Routing – Where Do Assets Go?
Route: User defined criteria outlining the SPOTs that an asset must enter & exit for processing
3 Types:1. Standard Process 2. Contextual Process3. Business
Intelligence (BI) Process
HARVARDMEDICAL SCHOOL
Routing – Where Do Assets Go?Standard: Route pre-defined at receipt by limited criteria (e.g., prostate core bx – Route routine process, 3L H&E slide/block).
Contextual: Standard route modified by pre-defined data that drive special considerations (e.g., priority, day of week or time, pathologist, consult case, associated assets, phone requests).
BI: Real-time redirected routes based on up- & down- stream conditions (optimized Work in Progress (WIP), i.e., dashboard driven).
HARVARDMEDICAL SCHOOL
1. Mission, Vision, and Driving Forces
2. From 1896 to 2010 – The Contrast3. The Challenge4. Tracking and Routing – Defined5. MGH Tracking and Routing –
Today6. Building the Foundation
HARVARDMEDICAL SCHOOL
MGH Tracking and Routing - Today
• Barcode technology.• Limited SPOTs (7).• Begins at
accessioning.• Ends in histology
prior to delivery of slides to pathologist.
• After that – all bets are off.
No existing software or automated rules.
Automated Tracking Automatic Routing
HARVARDMEDICAL SCHOOL
MGH Barcoded Asset Tracking System
System:• MGH internally
customized system.• Implemented late
2004 and fine tuned through 2006.
• Linear barcodes.• Scanners (Symbol,
Orbit) single line and omnidirectional; keyboard wedge.
Program Interfaces:
• PowerPath/AMP (Advanced Materials Processing)
• Transcription Service Server (SoftScript)
• MS Access Program• Custom programs
(Visual Basic, etc.)
HARVARDMEDICAL SCHOOL
MGH Barcoded Asset Tracking System
Barcodes printed:• Requisitions• Gross transcription
service• Specimen containers• Cassettes• Slides• Ventana• FocalPoint
System Functions:• 1° use is task
automation • Limited tracking
information (PowerPath Specimen Tab)
• Manual PowerPath tracking function exists
HARVARDMEDICAL SCHOOLBarcode Use - Surgical
Pathology
Gross Lab Histology Lab
At patient point of collection a specimen barcode is (often) generated from the ADT systemPoint of
Collection
Create SpecimenBarcode
ADT System
Manual
Accession Desk1. Requisition2. Transcription 3. Container4. Cassettes
Gross Bench
Create Transcription
Case
Gross Lab
Enter Block Log
Gross Lab
Print New Cassettes
Gross Lab
Delete Extra Cassettes
Gross Lab
Discard or Save Specimen
ADTBarcode
Transcription Barcode
Requisition Barcode
AMP / PPth
MS Access
Soft Script Server
AMP/PPth Barcode
Extra Cassette
Container
Visual Basic / PPth
Share Ware /PPth(BW)
Histology Lab
Block Log Reconciliation
Cutting Station
Create Slide Labels
Check-out BenchSlide/Block
Scan Slide only
AMP / PPth
MS Access
AMP / PPth
Slide
Cassette
Manual
HARVARDMEDICAL SCHOOLBarcode Use - Cytology and
AutopsyCytopathology
Autopsy Pathology
Cutting Station
Create Slide Labels
Check-out BenchSlide/Block
Scan Slide only
AMP / PPth
AMP / PPth
Slide
CassetteManual
Autopsy Accession
Label CassettesAMP /PPth
Non-Gyn Acc’sion
Create1. Requisition &2. Slide Labels
Gyn AccessionCreate
1. Requisition &2. FocalPoint labels
Open Cytotech FocalPoint
Review
Cytotech Signout
Focal Point
CustomScript
AMP / PPth
PPth
Manual Manual
ADT Barcode
Requisition Barcode
HARVARDMEDICAL SCHOOL
Existing System Strengths and Weaknesses
Strengths• Marginal Cost• Asset IDs generated
and distributed electronically
• Limited tracking possible(Who, What, When,
Where)
• Automation of routine tasks
• Good reliability• Reduced errors
Weaknesses• Limited SPOTs• Customized programs
• LIS/equipment interface
• Succession planning difficult (programers)
• Linear barcode• Manual action• Not readable
through objects• Limited data
capacity, ruggedness
• Orientation dependent
HARVARDMEDICAL SCHOOL
1. Mission, Vision, and Driving Forces2. From 1896 to 2010 – The Contrast3. The Challenge4. Tracking and Routing – Defined5. MGH Tracking and Routing – Today6. Building the Foundation
HARVARDMEDICAL SCHOOL
Building the Foundation
The overlay of automation technology on an existing
inefficient, sub-optimized manual tracking system will result in . . .
Implementing an Automated Tracking & Routing System
Processing
Storage
Garbage In
Garbage Out
HARVARDMEDICAL SCHOOL
Building the Foundation
1. Detailed documented knowledge of the workflow from specimen collection to final storage or disposal of assets.
2. Use of analytical tools to identify and remove causes of defects (errors) and minimize variability.
3. Employee ownership and strong management and leadership support.
Success is based on:
Lean Six Sigma
Sounds like:
HARVARDMEDICAL SCHOOL
LEAN principles:• Just in time supply• Right person – right
job• Work flow
continuity; up-stream processes in direct proximity to down-stream processes
LEAN - The Seven Wastes
1. Overproduction2. Waiting3. Transportation4. Processing5. Inventory6. Motion7. Defects
Building the Foundation
HARVARDMEDICAL SCHOOL
Previous MGH LEAN Experience
Results:• Reduced average
routine surgical TAT from 48 hr to 20 hr.
• Reduced average Biopsy TAT from 24 hr to 16 hr.
• Reduced overtime from 3.5 FTE’s in 2005 to 0.97 FTE’s in 2006
• Improved morale.
Mar 2005 – Aug 2006 Histology Redesign
Project
Incorporated Lean concepts of workflow analysis, re-design, standardization, including the barcode system.
HARVARDMEDICAL SCHOOL
Foundation Building – 1st Step
Document workflow from specimen collection to final storage or disposal of assets.
HARVARDMEDICAL SCHOOL
Foundation Building – 1st Step
Present system – strengths, weaknesses, preferences.• PowerPath LIS Analysis
• Exit interviews with users at all steps of production.
• Workflow Analysis• Map workflow of existing production system.
Future system – capabilities, requirements and desires.• Sunquest CoPath 5.0 requirements and
specifications • Generate Gap analysis
• Workflow• Idealized workflow design
HARVARDMEDICAL SCHOOL
Foundation Building – 2nd Step
Use analytical tools to identify and remove causes of defects (errors) and minimize
variability.
HARVARDMEDICAL SCHOOL
Foundation Building – 2nd StepMethods:• Work flow charts• Failure Modes and
Effects Analysis (FMEA)
• Time motion analysis• Workflow simulation• Fishbone (Ishikawa)
diagrams• Histograms• Pareto charts
• Check sheets • Run charts• Spaghetti
diagrams• Value Stream
Map • Project
management tools Charter Change management Resource plans
HARVARDMEDICAL SCHOOL
Analysis Methodology
1. Map work flow analyses by functional areas identifying all decision points and hand-offs.
2. Identify how the system falters or fails (failure modes).
3. Confirm process by direct observations.4. Incorporate time-motion analysis,
Spaghetti diagrams, etc. as necessary.5. Simulate alternative work flows with
available data (iGrafx®).
HARVARDMEDICAL SCHOOL
Workflow Chart – Back Bench
The Devil in the Details
Back Bench Process
Bac
k B
ench
DecalcificationLegal Case,
Save or Medical Device?
Cassette Deletion in PowerPath,
using Boston Workstation
Process Owner: Denise Bland-Piontek
Cytogenetics? Return to client
Dictation sent to SoftScript
Tumor Bank?
Needed for resident?
Special Instructions?
Cassettes printed at accession area
Send to Cytogenetics, Flow
Cytometry, Microbiology, Cytology Cell Block, Stones,
Molecular
MGH Consult?
Extra Tissue Stored
Specimen time stamped, with
stamper
<10 cassettes needed?
Requisitions batched, sent to
transcription
Photo req’d?Take a photo at
photo stationOR, Clinics, Consults, Cytology Specimens
Accessioner walks to Gross, tech cuts specimen sample
Paper log
Small Grossing
Bench
Reserve for Resident (may be significant delay)
Tissue Stored Indefinitely
Specimen received, logged(Accessioning)
Flow, Micro, Cytology, or
Stones?
Gross Only?
More or fewer cassettes needed?
After 8:30AM and Same Day
Rush?
Cassettes printed at cassette printing
station
Requisition Form
Save 6 weeks
Cassettes placed in racks, photo of
rack taken for tracking purposes
Enter case and number of
cassettes into logLegal, Medical or Save?
Bone?
Large or Small?
Client Want?
Extra cassettes placed in bucket for deletion from
case
Tissue older than 2 weeks?
Tissue discarded
Specimen sent to Histology
Work with PowerPath to
adjust number of cassettes
Add ribbon and note with
instructions to cassette
Send to Transcription for Accession
Y
N
Y
No
No
Y
Yes
No
No
No
No Yes
Small
Large
Yes
Yes
NoNo
More
Specimen grossed,
placed into appropriate cassette(s)
No
Yes
Yes
Save
Yes
LegalM.D.
No
Yes
No
Yes
NoYes
Yes
End
No
Specimen sample sent
to Tumor Bank
Specimen logged in
PPTH, labels printed
Upload to pat_dim2
Same Day Rush?
No
Specimen Hand Delivered to
Histology
Requisition hand delivered to Transciption
Yes
Delay
Access
Frozen Section?
N
Frozen Section Process
YFewer
HARVARDMEDICAL SCHOOL
Failure Mode and Effects Analysis (FMEA)
• Product development and operations management tool for analysis of failure modes (FM) in various phases of a product life cycle.
• FMs are errors or defects in a process, design, or item.
• Team approach used to identify failure modes (potential or actual) based on experience and risk analyses.
• Drives designs by prioritizing highest risk failures for early attention.
HARVARDMEDICAL SCHOOL
FMEA Cycle
Detect Failure Mode
Calculate Risk Priority Number
RPN = S x O x D
Recommend Actions
Identify Causes& Assign Occurrence #
(O)
Identify Prevention /
Detection Process & Assign
Detection #(D)
Identify Effects & Assign Severity #
(S)
The higher the RPN,
the more likely a
failure has a negative
effect on the system
Implement Actions & Check Results
HARVARDMEDICAL SCHOOL
FMEA – Small Gross Bench• QA Assistant™ Web-based application• Download to PDF or MS Excel
• Document management• Generates reports
HARVARDMEDICAL SCHOOL
Examine bag and contentsScan bar code on
container / cassetteExamine tissue
Transfer cases from accession area to Small
Gross Room (SGR)
1
RUSH not brought to SGRRoutine case not brought to SGR
No or insufficient fixative / preservative in containerTissue missingTissue lostTissue too smallTissue damagedWrong tissue in containerTissue requires more cassettes than pre-labeled cassettesDescribed lesion not present on received tissueMultiple specimens submitted in single container
Reader not workingBar code unreadable
Accession errorRequisition or container missingMismatched requisition/containerLabels missing or illegible on containers or documentsCassettes missing or insufficientMismatch information on container and/or cassettes and/or requisitionSpecimen is a large gross room case Information mismatch on container and/or requisition Missing or illegible identifying information on container and/or requisitionSpecimen cannot be processedAdd-On material accessioned with new accession numberMissing or illegible clinical information on container and/or requisitionFixative or preservative leaked from containerContainer or documents contaminated with gross blood or bodily fluids
Failure Modes
Small Gross Room Process Step
FMEA – Failure Modes Summation
HARVARDMEDICAL SCHOOL
Initial Project Results
• 27 Functional Areas (FA) mapped for workflow
• Workflow confirmation by observation complete in 1 area and ongoing in 2nd but largest functional area
• 1 FMEA completed
HARVARDMEDICAL SCHOOL
Summary of 27 Functional Areas (FA)
StepsDecision
PointsHand Off's
Total 466 81 233
Ave/FA 17 3 9
HARVARDMEDICAL SCHOOL
Simple Sign-Out: 1 H&E slide
Functional Area StepsDecision
PointsHand Off’s
Accession & Gross 53 18 21
Histology 28 2 13
Embedding 29 6 8
Microtomy/Stain 11 1 4
Signout 15 2 3
Total 136 29 49
Ave 27 6 10
HARVARDMEDICAL SCHOOL
AcknowledgmentsCarlos AlayaWilliam AminDenise Bland-PiontekMaya DaderlingJames HappelChris ObergDavid McClintockMichelle Schwab-Macdonald
HARVARDMEDICAL SCHOOL
Questions?