Bar-coding in AP: OmniTrax as a Full Middleware Solution

Rodney Schmidt, MD, PhD Professor of Pathology, Director of Medical Informatics (Pathology) University of Washington, Seattle

Today’s Story

Lessons from OmniTrax – Lean processes and workflow – Deeper understanding of barcoding • Different levels of barcoding with different benefits – Measures of benefits • Quality and efficiency • Workflow dependent!

– Current capabilities Trade-offs using a middleware solution Need for a bar-code standard

Disclosure

• Bar-coding software developed at UW (OmniTrax and OmniImage) has been licensed by UW to Pathway Pathology Consultants for PowerPath end-users.

• Dr. Schmidt and his team have a revenue-sharing agreement with UW.

• Dr. Schmidt has a consulting agreement with Thermo Fisher for educational talks.

• No other financial relationships with hardware or software manufacturers.

Why barcode?

• Expensive – $23k/gross station – $10k/cutting station – Software • Workspaces change – Wiring, networking • Time investment – Software fast – Workspaces slow – Financing slow • Processes change – Material handling – QA • Jobs change – Workflow – Change management • Pathologists affected!

Who needs the hassle?!

Why barcode?

• Error reduction and patient safety – Errors labeling things – 1/300 (manual) to < 1/10,000,000 (datamatrix) • Reduced medical-legal liability • Custodial responsibility & inventory control • Self-interested reasons – Helps you do your job faster – Reduced time wasted on error resolution – Indirect efficiencies because of better knowledge about where things are

What is Bar-coding?

• Labeling – Putting barcodes on things – Technically easy, cheap (some methods) • Tracking – Location updates; inventory control – Added work; needs software; modest cost • Driving – Using barcodes to expedite workflow – Disruptive technology; expensive; LIS interoperability

Bringing Bar-coding to AP

• Track slides (2005) – Eliminate the “lost slide” problem – Ease conference prep • Specimen labels (2006) – Tissue discards and tracking – Drive gross photography • Block creation and labeling (2008) – Automated JIT production of barcoded blocks – Gross room QA process and tracking • Slide creation and labeling (2008) – Automated JIT creation of barcoded slides – Facilitate workflow and QA • Eliminate all manual labeling (and errors) • Facilitate workflow – JIT information display

Achieved Benefits

• Marked reduction in labeling errors • Improved inventory control (i.e. knowledge of where things are) • Direct savings of ~ 3 FTE • Indirect savings of >> 0.5 FTE • Improved image collection and management (paperwork, gross, micro, EMs, IF, etc) • Increased job satisfaction

Bar-coding Options

• Buy LIS-specific – Available? Capable?

• Buy 3 rd party solution (middleware) – Available? Capable?

• Build LIS-specific middleware – Can be quick. Investment.

• Build LIS-agnostic middleware – Most complex; most control

Design Principles

• No scanning without benefit – User acceptance; minimal training • No manual data entry – Eliminate human errors • Use barcodes to drive workflow – Efficiency • Make nothing until it’s needed – Eliminate handling and error opportunities • No assumptions – only trust scan events – Quality timestamps, locations, personnel • Leverage LIS • LIS-agnostic design

Material identification (2005)

• Handwritten specimen labels • Manual, off line cassette labeling • Hand-written slide labels

Primary labeling errors (2004)

1000 900 800 700 600 500 400 300 200 100 0 Blocks ?

Slides

Recorded Actual

Targets – Gross Room

• Foolproof labeling – No human labeling/data entry • Reduced dependence on support staff – Off-hours availability – Redirection of support personnel • Reduced waste of cassettes • Grossing step at least as fast as current • (Record timestamps) The unsupervised Resident!

Targets - Accession

Receive specimen and enter data into the LIS Generate a bar coded label for the specimen and laboratory request form.

Minimum extra keystrokes (one)

Accession specimens

Classic Grossing Workflow

Label specimens

Label

cassettes

Group

with specimens

Move

to staging area * * *

Move

to gross bench

Lay out

cassettes

Fill

cassettes

Request

more cassettes * *

Store

excess with specs

Rack

filled cassettes

Reconcile

with LIS *

Transport

for processing *

Handling steps

Possible errors * QA steps

Accession specimens Bar-code specimens

Just-in-Time Printing

Scan/print cassettes

Lay out

cassettes

Fill

cassettes * * Fewer handling steps Fewer (1) error opportunities Fewer QA processes

Courtesy General Data

Rack

filled cassettes *

Transport

for processing *

Handling steps Error opportunities Manual QA steps Primary labeling errors Cassette wastage Grossing efficiency Support staff

Q&E Benefits

9 7 “Classic” 11 988/yr (est.); (1.2%) ~25/d (~7%) - - 1 4 “Just-in-Time” 5 2 in 3 mo (initial); 0 in next 7 mo; (0.003%) ~0 At least as fast 0.75+ FTE saved

Histology – Embedding

• Target – View critical information about block and specimen – Efficient workflow • Block scan: – Embedding instructions – Number of pieces of tissue – Specimen info – (Record timestamps)

Histology – Cutting

• Targets – Present critical information (block, specimen) – Eliminate manual slide labeling – Block/slide verification – Multiple workflows – No clutter – Efficient • Touch-screens; no keyboards • Block scan: – JIT slide printing/labeling – Info display • Slide scan: – Block/slide match

Cutting - Benefits

• Elimination of hand labeling • Much faster than manual labeling for blocks with many slides • Fewer block/slide mismatches • Overall throughput increased ~10%

Histology

Slide Life Cycle

Pathology Offices Sendouts Faculty signout Histology work order completes with scanning Pull for conference Ship File Resident review Deliver

Slides – Benefits

• Less staff time looking for slides • Faster to find last location than make a phone call • Fewer arguments over whether slides were delivered • • Fewer recuts?

• Improved job satisfaction – ** Saved me 30 min the first day! **

Overall savings > 2.0 FTE!

Slides Benefits FTE Savings

Histology

+0.5 FTE +0.5 FTE Reduced time hunting for mis-delivered slides Auto completion of outstanding orders when slide is scanned

Office staff

+.5-1 FTE Reduced time for conference preparation +.25 FTE Increased efficiency regarding send outs

Barcodes Enable…

• Imaging – Gross photos – Photomics – Documents – EM/IF • Specimen management – Discards – Locations • Winscribe automation • HPV workflow – Reflex testing – Digene/Luminex

Targets - Specimens

• Discards – Accurate – Efficient – Documented • Track location • Drive photography

Specimen Discard

Workflow – Device scans specimen barcode – Handheld device queries AP-LIS • If case signout occurred <2wks prior • If case signout occurred >2wks prior • If note on Req Data tab, caution light and note display

Barcoding Benefits

• Direct personnel (FTE) – 2.0

Slide delivery and tracking – 0.75 Cassette printing – 0.1

Specimen discards – 0.1

Document scanning – TBD Fluorescence image import ~$150,000/yr assuming $50,000/FTE

Barcoding Benefits

• Indirect personnel (FTE) – 0.5 Scanned consult document availability 1 – TBD Scanned Req forms – TBD Slide location info (e.g. Pathologists) • Reduced loss of materials – Slide/Block tracking – Specimen discards

1 Schmidt, RA, et al. Am J Clin Pathol 126:678-83, 2006

Barcoding Benefits

• Error Reduction – Elimination of all manual labeling steps!

– Reduced labeling errors • Specimens • Blocks – ~988/yr to near 0 – “How did you manage to do that?!” • Slides • Gross photos • Scanned documents • Photomicrographs

OmniTrax – What’s new?

• Interface model for interacting with LIS • More customers – OHSU – NYU • HPV workflow implemented • Gross/Histo enhancements • (Cytology support) • (Immunostainer interfaces) – Leica Bond 3 – BioCare intelliPATH • (Archives tracking port) • (Slide tracking port)

Middleware

Software that bridges a human to one or more major systems

Advantages • Leverage the power of core systems • Deliver niche functionality • Avoid duplication of core functions • If you build your own: Independence and control – Open hardware options – Portability between LISs – Short bug/fix cycle – Implement functions you need – Tune and refine prn Disadvantages • Ongoing interoperability – LIS upgrades – Might change LISs • Negotiate interfaces – Extract data – Write data • LIS data model poor – Too simple – Missing concepts • If you build your own: Ongoing support obligation

Basic Architecture

UI/ app

OmniTrax

UI/ app UI/ app LIS Agent Agent Business objects Database QA Reports

UI/ app

Local Extensions

UI/ app

OmniTrax

UI/ app UI/ app Web app Web app LIS Agent LIS Agent Agent Business objects IIS Database Reports Reports

• • • • • •

Growth and Complexity

as of Sept 7, 2010 Lab Framework Client DLL – 22,850 lines (about 460 printed pages) OmniTrax Server – 11,554 lines (about 235 pages) Agent – 4199 lines (85 pages) Gross Room Manager – 4754 lines (97 pages) Histology Manager – 5133 lines (104 pages) That’s equivalent to: – Les Miserables – All three Lord of the Rings books Version 1: 22 tables Version 4: 48 tables

Need for a Standard

Problems 1. Multiple barcodes from diff. facilities on same item 2.

No “assigning authority” in barcode Interpreted differently by different software 3. Some proprietary uses APIII focus group suggestions (2008) 1. The barcode should contain only an identifier (e.g. “license plate”); software determines use 2. The barcode should contain something equivalent to an “assigning authority”.

ID | application | installation 12356789 | OmniTrax | UWPath98195

Why barcode?

Expensive Workspaces change Process changes Jobs change Pathologists affected Time investment … true, but reasonable ROI … it might be time … new processes are better … but more valuable activity … in good ways … pays off!

Better lab efficiency Error/liability reduction Inventory control Resident autonomy Gateway to more functions

Acknowledgements

• Phil Nguyen • Kevin Fleming • Rosy Changchien • Chris Magnusson • Victor Tobias • General Data • Thermo-Fisher • Accu-Place • Dr. Erin Grimm • Dan Luff • Steve Rath • Pam Selz • Kim Simmons • All the Techs and Office Folks!