RE-ENGINEERED WORKFLOW IN THE AP LABORATORY: Costs and Benefits

RE-ENGINEERED WORKFLOW IN THE AP LABORATORY:Costs and Benefits

Erin Grimm, MDRodney Schmidt, MD, Ph.D

University of Washington Medical CenterSeattle, WA

DisclosuresDisclosures

The UW-developed software The UW-developed software (PowerTrax and ePathImage) is (PowerTrax and ePathImage) is

licensed through the University of licensed through the University of Washington.Washington.

The speakers have no relationship The speakers have no relationship with IMPAC Medical Systems, with IMPAC Medical Systems,

owners of PowerPath, or any of the owners of PowerPath, or any of the other mentioned companies.other mentioned companies.

ObjectivesObjectives

1.1. Review current workflow in Anatomic Review current workflow in Anatomic Pathology and the need for changePathology and the need for change

2.2. The UW Anatomic Pathology Automation The UW Anatomic Pathology Automation Project Project

• A detailed look at each stepA detailed look at each step

3.3. Starting the automation processStarting the automation process• Building a business caseBuilding a business case

4.4. Questions for the futureQuestions for the future

The scope of the problemThe scope of the problem

Histology laboratory Histology laboratory workflow has not workflow has not changed in decadeschanged in decades

YetYet• Volumes increaseVolumes increase• Laboratories expandLaboratories expand

http://history.library.ucsf.edu/imagelib/med_sci_building_histology_lab_1959.gif

1959

Problem #1Problem #1

Inefficiencies exist that cause wasteInefficiencies exist that cause waste

Waste increases expenseWaste increases expense• Labor costsLabor costs• Poor resource utilizationPoor resource utilization

Problem #2Problem #2

Errors HappenErrors Happen

• Patient ID errors occur in APPatient ID errors occur in AP• 4.3 / 1000 surgical specimens4.3 / 1000 surgical specimens11

• 1.9 / 1000 amended reports1.9 / 1000 amended reports• 19.2% of amended reports were due to patient ID 19.2% of amended reports were due to patient ID

errorserrors22

1. Makary MA et al. Surgical specimen identification errors…. Surgery 2007 Apr;141(4):450-5 2. Nakhleh RE, et al. Amended reports … Q-probes study of 1,667,547 accessioned cases ...

Arch Pathol Lab Med. 1998 Apr;122(4):303-9.

Error ratesError Prevention

MethodsReal world Examples

1/100Clear process

Reliance on education/vigilance

Errors filling out lab requisition

Failure to give results to patients

Suboptimal specimen

1/1,000

Clear process

Systems for error identification and mitigation

Mislabeled specimens

1/10,000

1/100,000

Advanced design + Automation

Error ID/ mitigation

Specimen loss

Computer interface errors

Achievable Error RatesAchievable Error Rates

Resar RK. Making noncatastrophic health care processes more reliable... Health Serv Res. 2006; 41:1677-1689.

To go from

To go from

1/1,0001/1,0001/10,000

1/10,000

requires automation

requires automation

A DilemmaA Dilemma

40,000 surgical cases / yr 40,000 surgical cases / yr

24 care problems / yr24 care problems / yr (> 2 cases/month)(> 2 cases/month)

400 erroneous surgical cases / yr 400 erroneous surgical cases / yr

1% are erroneous1% are erroneous

6% inappropriate care 6% inappropriate care

What if 1% of tests were errors and What if 1% of tests were errors and 6% of the errors led to inappropriate care?6% of the errors led to inappropriate care?





3.3. Starting the automation processStarting the automation process• Building a business caseBuilding a business case


UWMC PathologyUWMC Pathology

• 178 Faculty Members 178 Faculty Members • 40 faculty with clinical 40 faculty with clinical

dutiesduties

• 29 Residents and 29 Residents and Clinical Fellows Clinical Fellows

• 35 Graduate 35 Graduate Students Students

• $32 million in NIH $32 million in NIH grants (2006)grants (2006)

A complex academic environment with:A complex academic environment with:• >36,000 surgical pathology cases/year>36,000 surgical pathology cases/year

1) Decrease mislabeling opportunities1) Decrease mislabeling opportunities

UW Goal for AutomationUW Goal for Automation

= Opportunity for transcription error

Signout

Case accessione

d

Cassettes preprinted and

placed with specimen

(Gross Room)

Slides pre- labeled by

hand

(Histology)

Pathologist calls up case to

enters diagnosis

(Offices)

Stickers with

labels applied

(Histology)

Resident/PA requests

additional blocks

(Gross Room)

Resident/PA dictates gross

description

(Gross Room)

UW Goal for AutomationUW Goal for Automation

2) Streamline Workflow2) Streamline Workflow Save Labor (FTEs)Save Labor (FTEs)

• Automate manual processesAutomate manual processes• Ex. Histology order completion, specimen discard, Ex. Histology order completion, specimen discard,

image uploadsimage uploads• Make location/progress of all assets (specimens, Make location/progress of all assets (specimens,

blocks, slides, and paperwork) visible and trackable blocks, slides, and paperwork) visible and trackable in the AP-LIS in the AP-LIS

• Eliminate preprinting/prelabelingEliminate preprinting/prelabeling

Initial phaseInitial phaseStart with projects having Start with projects having

• ↑ ↑ Yield Yield • ↓ ↓ Developer hrsDeveloper hrs

Staged UW AutomationStaged UW Automation

Approximate developer hours noted for each project

2005

2007

2008

2006

Gross room• Photography (80 hrs)• Specimen container disposal (50 hrs)

Document scanning with imaging suite

(150 hrs)

Slide tracking

(1500 hrs)

Cassette barcoding(500 hrs?)

Whole line automation

Clinical Database (75 hrs)

New Clinical Database(400 hrs)

Technical infoTechnical info

Custom software Custom software was written as was written as a Windows a Windows application application using using Microsoft Microsoft Visual Studio Visual Studio C#.Net and C#.Net and SQL ServerSQL Server

UW Database

SQL Server

PowerPathDatabase

PC Thin Client

PowerPath Client

UW Clients



2005

2007

2008

2006



(150 hrs)

Slide tracking

(1500 hrs)





Document ScanningDocument Scanning

GoalGoal• Develop an electronic document management Develop an electronic document management

system system

• All case-related paperwork is viewable from the All case-related paperwork is viewable from the case specific repository in our AP-LIScase specific repository in our AP-LIS

WorkflowWorkflow• Paperwork is barcoded when accessionedPaperwork is barcoded when accessioned

• Scanner reads paperwork barcodeScanner reads paperwork barcode

• Document is scanned, accepted by office staff, Document is scanned, accepted by office staff, and automatically uploaded to the image tab of and automatically uploaded to the image tab of the AP-LISthe AP-LIS

Scanning benefitsScanning benefits

Benefits:Benefits:• 3.8 hours/day saved 3.8 hours/day saved

for 26 pathologists for 26 pathologists and residents and residents

• Staff satisfaction:Staff satisfaction:• 10.0/1010.0/10• Saved 0.25 min/caseSaved 0.25 min/case

• Current usage:Current usage:• 10,614/month

1. Schmidt RA, et al. Integ. of scanned doc mangmt... Am J Clin Pathol. 2006 Nov;126(5):678-83

2.2. Routbort M, Grimm E, Schmidt R. Optimized Document Management…. APIII 2006 ConferenceRoutbort M, Grimm E, Schmidt R. Optimized Document Management…. APIII 2006 Conference



2005

2007

2008

2006



(150 hrs)

Slide barcoding(1500 hrs)





Goal:Goal:1.1. Provide real-time status Provide real-time status

and location of slidesand location of slidesBenefits include:Benefits include:• Providing real-time case Providing real-time case

progression informationprogression information• Easier location of slides for Easier location of slides for

conference/sendoutsconference/sendouts• Facilitates workflow analysis via Facilitates workflow analysis via

time-stampstime-stamps

2.2. Drives AP-LIS functionalityDrives AP-LIS functionality• Automates histology order Automates histology order

completion and other completion and other processesprocesses

Slide TrackingSlide Tracking

Name

Slide Tracking WorkflowSlide Tracking Workflow

Histology work order

completes with scanning

Ship

Resident review

Deliver

Faculty signout

File Room

Pull for conferenc

e

Sendouts

Histology

Pathology Offices

Slide Tracking BenefitsSlide Tracking Benefits

FTE SavingsFTE Savings

HistologyHistology +0.5 +0.5 FTEFTE

Reduced time hunting for Reduced time hunting for mis-delivered slidesmis-delivered slides

+0.5 +0.5 FTEFTE

Auto completion of outstanding Auto completion of outstanding orders when slide is scannedorders when slide is scanned

Office Office staffstaff

+.5-1 +.5-1 FTE FTE

Reduced time for conference Reduced time for conference preparationpreparation

+.25 +.25 FTE FTE

Increased efficiency regarding Increased efficiency regarding send outssend outs



2005

2007

2008

2006



(150 hrs)

Slide tracking

(1500 hrs)





Gross PhotographyGross Photography

Gross photographyGross photography• Photo is automatically imported into case-Photo is automatically imported into case-

specific AP-LIS image tabspecific AP-LIS image tab

ResultsResults• Improved Quality Focus 50.1% Improved Quality Focus 50.1% 77.8% 77.8%• Quantity Increased 310 photo/mo Quantity Increased 310 photo/mo 503/mo 503/mo• Labor SavingsLabor Savings

• Resident/PA > 1 min/case by Resident/PA > 1 min/case by

• Office Staff 1 FTE (bulk image upload) Office Staff 1 FTE (bulk image upload)

• IT help requests 1.7/mo IT help requests 1.7/mo 0.5/mo 0.5/mo

• Cost Savings Cost Savings • Eliminated cost of darkroom materials Eliminated cost of darkroom materials

• Eliminated kodachrome storageEliminated kodachrome storage

Specimen DiscardSpecimen Discard

WorkflowWorkflow

• Device scans Device scans specimen barcode specimen barcode

• Handheld device Handheld device queries AP-LIS queries AP-LIS

• If case signout If case signout occurred <2wks occurred <2wks priorprior

• If case signout If case signout occurred >2wks occurred >2wks priorprior




2005

2007

2008

2006


(150 hrs)

Slide tracking

(1500 hrs)





Cassette barcodingCassette barcoding

Goals:Goals:• Streamline workflowStreamline workflow

• Cassette barcode drives Cassette barcode drives gross room and histology gross room and histology workflowworkflow

• Eliminate cassette Eliminate cassette preprintingpreprinting

• Eliminates work for Eliminates work for accessionersaccessioners

• Eliminates an error-prone Eliminates an error-prone stepstep

• Enable resident/PA to Enable resident/PA to obtain cassettes without obtain cassettes without interruptionsinterruptions Photo Courtesy of

General Data





3.3. Starting the automation processStarting the automation process• The business caseThe business case• The issuesThe issues


The Business CaseThe Business Case

1.1. EfficiencyEfficiency• More volume with same personnelMore volume with same personnel• $2.50 - $3.00/case (slides, specimens)$2.50 - $3.00/case (slides, specimens)

2.2. Patient safety Patient safety • Optimize patient careOptimize patient care• Prevent rare, catastrophic errorsPrevent rare, catastrophic errors

3.3. ComplianceCompliance• Custodial responsibility for patient materials Custodial responsibility for patient materials

(paperwork, slides, blocks, etc).(paperwork, slides, blocks, etc).

Buy vs. Build Decision

• “Buy” is now possible• Some LIS vendors (IMPAC, CoPath, et al)• Others (RA Lamb, Dako, Ventana, UW)• Others in development

• Most are expensive (S/W and H/W)

• No current product is comprehensive

Hardware

• Label printers – inexpensive

• Bar-code readers – inexpensive

• Cassette printers – expensive (most)

• Slide printers – expensive

For distributed JIT workflow, we need “personal” cassette printers and slide printers that are as inexpensive, reliable, and ubiquitous as label printers.

Key ConsiderationsKey Considerations

1)1) This is disruptive technology!This is disruptive technology!• Use automation to change habits Use automation to change habits

(prelabeling/preprinting)(prelabeling/preprinting)• Don’t automate bad workflowDon’t automate bad workflow• Each user must benefitEach user must benefit

2)2) Select carefullySelect carefully• Hardware compatibilityHardware compatibility• Software compatibilitySoftware compatibility• Appropriate technology/solutionAppropriate technology/solution

QuestionsQuestions

Where are the boundaries for the AP-Where are the boundaries for the AP-LIS? LIS? Who providesWho provides bar-coding bar-coding solutions?solutions?

Major automation providers are not AP-LIS Major automation providers are not AP-LIS vendors (Dako, Ventana, RA Lamb, UW)vendors (Dako, Ventana, RA Lamb, UW)

Implicit challenge to LIS vendor “lock-in”Implicit challenge to LIS vendor “lock-in”•Reporting/billing in one appReporting/billing in one app•Lab/material handling in different appLab/material handling in different app

QuestionsQuestions

Where are the boundaries for the AP-Where are the boundaries for the AP-LIS? LIS? What will be trackedWhat will be tracked??

Traditional: Specimens, blocks, slidesTraditional: Specimens, blocks, slides

New derivatives: Cells, DNA, tissue banks, New derivatives: Cells, DNA, tissue banks, ancillary labs, biorepositoriesancillary labs, biorepositories

Pre-lab tracking: From OR, officesPre-lab tracking: From OR, offices•Reduce ID (pre-analytic) errors

QuestionsQuestions

How much of the financial benefits will How much of the financial benefits will labs be able to retain?labs be able to retain?

• Hardware?

• Implementation?

• Software?• Purchase/support pricing model• Per-item metering

ConclusionsConclusions

Bar-coding automation Bar-coding automation

• More than just tracking – disruptive More than just tracking – disruptive technology! Workflow changes.technology! Workflow changes.

• Allows processing of increased workloads Allows processing of increased workloads with static FTE levelswith static FTE levels

• Improves patient safetyImproves patient safety

• Quantifiable gains can be made by Quantifiable gains can be made by upgrading the most inefficient/error prone upgrading the most inefficient/error prone processes in your laboratory processes in your laboratory

Thank you

UW development teamUW development team

Erin Grimm, MDErin Grimm, [email protected]

Rodney Schmidt, MD, Ph.DRodney Schmidt, MD, [email protected]

UW Program UW Program Operations ManagerOperations Manager

Dan LuffDan Luff

Questions for the FutureQuestions for the Future

2.2. What materials will be tracked?What materials will be tracked?

When does tracking start?When does tracking start?• Traditional materials: specimen/blocks/slidesTraditional materials: specimen/blocks/slides• More specimen derivatives arise: ancillary lab More specimen derivatives arise: ancillary lab

tests, tissue banking, biorepositoriestests, tissue banking, biorepositories• ?? Will there be introduction of prelab ?? Will there be introduction of prelab

tracking to reduce preanalytical errorstracking to reduce preanalytical errors

No current product is No current product is comprehensivecomprehensive

RE-ENGINEERED WORKFLOW IN THE AP LABORATORY: Costs and Benefits

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