RE-ENGINEERED%20WORKFLOW%20IN%20THE%20AP%20LABORATORY:%20Costs%20and%20Benefits

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RE-ENGINEERED WORKFLOW IN THE AP
LABORATORYCosts and Benefits

• Erin Grimm, MD
• Rodney Schmidt, MD, Ph.D
• University of Washington Medical Center
• Seattle, WA

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Disclosures

• The UW-developed software (PowerTrax and
  ePathImage) is licensed through the University of
  Washington.
• The speakers have no relationship with IMPAC
  Medical Systems, owners of PowerPath, or any of
  the other mentioned companies.

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Objectives

• Review current workflow in Anatomic Pathology and
  the need for change
• The UW Anatomic Pathology Automation Project
• A detailed look at each step
• Starting the automation process
• Building a business case
• Questions for the future

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The scope of the problem

• Histology laboratory workflow has not changed in
  decades
• Yet
• Volumes increase
• Laboratories expand

1959
http//history.library.ucsf.edu/imagelib/med_sci_b
uilding_histology_lab_1959.gif
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Problem 1

• Inefficiencies exist that cause waste
• Waste increases expense
• Labor costs
• Poor resource utilization

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Problem 2

• Errors Happen
• Patient ID errors occur in AP
• 4.3 / 1000 surgical specimens1
• 1.9 / 1000 amended reports
• 19.2 of amended reports were due to patient ID
  errors2

1. Makary MA et al. Surgical specimen identification
   errors. Surgery 2007 Apr141(4)450-5
2. Nakhleh RE, et al. Amended reports Q-probes
   study of 1,667,547 accessioned cases ... Arch
   Pathol Lab Med. 1998 Apr122(4)303-9.

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Achievable Error Rates
Error rates Error Prevention Methods Real world Examples
1/100 Clear 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
To go from 1/1,000?1/10,000 requires automation
Resar RK. Making noncatastrophic health care
processes more reliable... Health Serv Res.
2006 411677-1689.
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A Dilemma
What if 1 of tests were errors and 6 of the
errors led to inappropriate care?
40,000 surgical cases / yr
1 are erroneous
400 erroneous surgical cases / yr
6 inappropriate care
24 care problems / yr (gt 2 cases/month)
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Objectives

• Review current workflow in Anatomic Pathology and
  the need for change
• The UW Anatomic Pathology Automation Project
• A detailed look at each step
• Starting the automation process
• Building a business case
• Questions for the future

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UWMC Pathology

• A complex academic environment with
• gt36,000 surgical pathology cases/year

• 178 Faculty Members
• 40 faculty with clinical duties
• 29 Residents and Clinical Fellows
• 35 Graduate Students
• 32 million in NIH grants (2006)

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UW Goal for Automation

• 1) Decrease mislabeling opportunities

Stickers with labels applied (Histology)
Resident/PA requests additional blocks (Gross
Room)
Resident/PA dictates gross description (Gross
Room)
Case accessioned
Signout
Cassettes preprinted and placed with specimen
(Gross Room)
Slides pre- labeled by hand (Histology)
Pathologist calls up case to enters
diagnosis (Offices)
Opportunity for transcription error
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UW Goal for Automation

• 2) Streamline Workflow
• Save Labor (FTEs)
• Automate manual processes
• Ex. Histology order completion, specimen
  discard, image uploads
• Make location/progress of all assets (specimens,
  blocks, slides, and paperwork) visible and
  trackable in the AP-LIS
• Eliminate preprinting/prelabeling
• Initial phase
• Start with projects having
• ? Yield
• ? Developer hrs

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Staged UW Automation

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

Clinical Database (75 hrs)
Slide tracking (1500 hrs)
Whole line automation
2005
2007
2008
2006
Document scanning with imaging suite (150 hrs)
Cassette barcoding (500 hrs?)
New Clinical Database (400 hrs)
Approximate developer hours noted for each project
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Technical info

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

PowerPath Client
PC Thin Client
UW Database
PowerPath Database
SQL Server
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Staged UW Automation

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

Clinical Database (75 hrs)
Slide tracking (1500 hrs)
Whole line automation
2005
2007
2008
2006
Document scanning with imaging suite (150 hrs)
Cassette barcoding (500 hrs?)
New Clinical Database (400 hrs)
Approximate developer hours noted for each project
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Document Scanning

• Goal
• Develop an electronic document management system
• All case-related paperwork is viewable from the
  case specific repository in our AP-LIS
• Workflow
• Paperwork is barcoded when accessioned
• Scanner reads paperwork barcode
• Document is scanned, accepted by office staff,
  and automatically uploaded to the image tab of
  the AP-LIS

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Scanning benefits

• Benefits
• 3.8 hours/day saved for 26 pathologists and
  residents
• Staff satisfaction
• 10.0/10
• Saved 0.25 min/case
• Current usage
• 10,614/month

1. Schmidt RA, et al. Integ. of scanned doc
   mangmt... Am J Clin Pathol. 2006
   Nov126(5)678-83
2. Routbort M, Grimm E, Schmidt R. Optimized
   Document Management. APIII 2006 Conference

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Staged UW Automation

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

Clinical Database (75 hrs)
Slide barcoding (1500 hrs)
Whole line automation
2005
2007
2008
2006
Document scanning with imaging suite (150 hrs)
Cassette barcoding (500 hrs?)
New Clinical Database (400 hrs)
Approximate developer hours noted for each project
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Slide Tracking

• Goal
• Provide real-time status and location of slides
• Benefits include
• Providing real-time case progression information
• Easier location of slides for conference/sendouts
  
• Facilitates workflow analysis via time-stamps
• Drives AP-LIS functionality
• Automates histology order completion and other
  processes

Name
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Slide Tracking Workflow
Histology
Pathology Offices
Sendouts
Faculty signout
File Room
Pull for conference
Resident review
Histology work order completes with scanning
Deliver
Ship
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Slide Tracking Benefits

• FTE Savings

Histology 0.5 FTE Reduced time hunting for mis-delivered slides
Histology 0.5 FTE Auto completion of outstanding orders when slide is scanned
Office staff .5-1 FTE Reduced time for conference preparation
Office staff .25 FTE Increased efficiency regarding send outs
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Staged UW Automation

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

Clinical Database (75 hrs)
Slide tracking (1500 hrs)
Whole line automation
2005
2007
2008
2006
Document scanning with imaging suite (150 hrs)
Cassette barcoding (500 hrs?)
New Clinical Database (400 hrs)
Approximate developer hours noted for each project
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Gross Photography

• Gross photography
• Photo is automatically imported into
  case-specific AP-LIS image tab
• Results
• Improved Quality Focus 50.1 ? 77.8
• Quantity Increased 310 photo/mo ? 503/mo
• Labor Savings
• Resident/PA gt 1 min/case by
• Office Staff 1 FTE (bulk image
  upload)
• IT help requests 1.7/mo ? 0.5/mo
• Cost Savings
• Eliminated cost of darkroom materials
• Eliminated kodachrome storage

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Specimen Discard

• Workflow
• Device scans specimen barcode
• Handheld device queries AP-LIS
• If case signout occurred lt2wks prior
• If case signout occurred gt2wks prior

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Staged UW Automation

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

Clinical Database (75 hrs)
Slide tracking (1500 hrs)
Whole line automation
2005
2007
2008
2006
Document scanning with imaging suite (150 hrs)
Cassette barcoding (500 hrs?)
New Clinical Database (400 hrs)
Approximate developer hours noted for each project
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Cassette barcoding

• Goals
• Streamline workflow
• Cassette barcode drives gross room and histology
  workflow
• Eliminate cassette preprinting
• Eliminates work for accessioners
• Eliminates an error-prone step
• Enable resident/PA to obtain cassettes without
  interruptions

Photo Courtesy of General Data
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Objectives

• Review current workflow in Anatomic Pathology and
  the need for change
• The UW Anatomic Pathology Automation Project
• A detailed look at each step
• Starting the automation process
• The business case
• The issues
• Questions for the future

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The Business Case

• Efficiency
• More volume with same personnel
• 2.50 - 3.00/case (slides, specimens)
• Patient safety
• Optimize patient care
• Prevent rare, catastrophic errors
• Compliance
• Custodial responsibility for patient materials
  (paperwork, slides, blocks, etc).

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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

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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.
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Key Considerations

• This is disruptive technology!
• Use automation to change habits
  (prelabeling/preprinting)
• Dont automate bad workflow
• Each user must benefit
• Select carefully
• Hardware compatibility
• Software compatibility
• Appropriate technology/solution

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Questions

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

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

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

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Questions

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

• Traditional Specimens, blocks, slides
• New derivatives Cells, DNA, tissue banks,
  ancillary labs, biorepositories
• Pre-lab tracking From OR, offices
• Reduce ID (pre-analytic) errors

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Questions

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

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

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Conclusions

• Bar-coding automation
• More than just tracking disruptive technology!
  Workflow changes.
• Allows processing of increased workloads with
  static FTE levels
• Improves patient safety
• Quantifiable gains can be made by upgrading the
  most inefficient/error prone processes in your
  laboratory

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Thank you
UW development team
UW Program Operations Manager Dan Luff

• Erin Grimm, MD
• grimme_at_u.washington.edu
• Rodney Schmidt, MD, Ph.D
• schmidtr_at_u.washington.edu

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Questions for the Future

• What materials will be tracked?
• When does tracking start?
• Traditional materials specimen/blocks/slides
• More specimen derivatives arise ancillary lab
  tests, tissue banking, biorepositories
• ?? Will there be introduction of prelab tracking
  to reduce preanalytical errors

No current product is comprehensive