Forcing Open the Pod Bay Doors

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Forcing Open the Pod Bay Doors

• Harnessing IT in the Service
• of an Anatomic Pathology Service

Richard E. Whisnant, MD Suncoast
Pathology Venice, FL
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Who we are

• Suncoast Pathology
• Three pathologist independent laboratory
• William G. Roth, MD
• Tamara L. Densmore, MD
• Richard E. Whisnant, MD
• Hospital, outpatient, cytology services
• 15,000 surgical accessions/year
• Disclosures
• Patent pending and ownership/financial interests

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What we set out to build
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What we set out to build
A comprehensive information technology solution
to the most significant problems in our own
anatomic pathology practice, including quality,
workflow, and staffing.
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System Overview- Auto-Dx

• AP Middleware system
• Interfaces to existing AP-LIS
• Site of every interaction by every staff member
  with every case the laboratory handles
• Technical details
• Filemaker Pro 6.0 database (desktop
  pseudo-server)
• 10 workstations
• 3 pathologists, 3 grossing room, 4 histology
• Barcode scanner (2D) and laptop/desktop (lt10K)

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If it were an IT challenge, it would be easy (or
at least someone elses problem)
Possible IT Solutions
Culture
Workflow
X
X
and over here
You are here
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Our actual starting state
Culture
Workflow
X
X
Possible IT Solutions
and over here
You are here
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Two projects in one, neither IT
Process Redesign
Culture
Workflow
X
X
Social Engineering
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User Interface Overview

• User Interface
• Pointing methods- mouse, touch screen, voice
• Quality of interface design
• Metric total of mouse clicks per case signed
  out!
• Centrality of programmable bar code scanners

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Function List

• Autopilot
• Tasked with preventing errors and other lapses of
  quality at every interaction with a case
• Air traffic controller
• Improves workflow and efficiency
• Flight Data Recorder (Black Box)
• Collects detailed data on all near-misses and
  errors
• Flight Simulator

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Autopilot functions

• Clerical checks, broadly defined.
• Production of text for gross and final diagnosis
• Decision support functions.
• Automated coding.
• QC supervision and selection.

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Auto-Dx operator manual

• Scan slide
• Follow prompts from there

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Acknowledge Header/Gross information
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Surgical/Cytology history review
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Screen for and highlight the highlights
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Diagnosis entry
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Diagnosis entry-2
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Diagnosis entry-3
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Review
Interfaced and customized
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Review
Interfaced and customized
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Interpathologist Communication Log (aka Deep
Thoughts)
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Diagnosis entry revisited
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Text Generation Overview

• Text Generation Coded versus Freestyle
• More efficient freestyle dictation pyrrhic
  victory
• Asynchronous traditional dictation, digital
  dictation
• Synchronous voice recognition, self-typed
• Coding challenges
• Our own preconceived notions and biases (natural
  language)
• Technical challenges

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Simple skin excision gross (partial)

• skin_shape_text "measuring " skin_size1 "
  x " skin_size2 " x " skin_size3 " cm.
  There is a" If( skin_lesion1 ltgt "irregular
  epidermal surface", " " skin_lesion_location
  "ly located ", "n ") If( skin_lesion_size ltgt
  "", skin_lesion_size " cm " , "")
  skin_lesion1 " noted. " "The specimen is
  inked" If( scored_margin ltgt "" and
  scored_margin ltgt " ", " and the "
  scored_margin " margin is scored" If(
  twelve_designation? ltgt "already clocked", "
  (relative to the " twelve_designation? "
  being designated 1200). ", ". ") ,". ")
  "Sectioned " If( number_of_blocks 1, "and
  entirely submitted in a single cassette labeled "
  part_letter ". ",If( skin_lesion1 ltgt
  "irregular epidermal surface", "with the lesion
  in cassette", "with central sections in
  cassette") ) If( number_of_blocks 1, "", If(
  (cassettes_for_lesion gt 1), "s " part_letter
  "1 through " part_letter cassettes_for_lesion
  ". "," " part_letter "1. ")) If(
  number_of_blocks 1, "", If( entirely_submitted?
  "no", "Representative sections of the remaining
  tissue submitted as ", "Remaining tissue entirely
  submitted as ") part_letter
  (cassettes_for_lesion 1) If(
  (cassettes_for_lesion 1) lt number_of_blocks, "
  through " part_letter number_of_blocks, "")
  ".")

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Skin excision- grossing workstation
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Coding colon resections
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Colon resection output format

• B) POLYPS ASCENDING
• INVASIVE LOW-GRADE ADENOCARCINOMA, 3 CM.
• -pT2 Tumor invades into, but not through,
  muscularis propria.
• pN1 METASTATIC TUMOR PRESENT IN (2/17)
  PERICOLIC LYMPH NODES.
• -Margins clear Proximal and distal mucosal
  margins widely (gt5 cm)
• free of tumor.
• Other cancer summary data
• -pMx Status of distant metastases not known.
• -Circumferential radial margin status
• -Resection type Sigmoid colectomy.
• -Tumor location Sigmoid colon.
• -Lymphatic (small-vessel) invasion absent.
• -Venous (large vessel) invasion absent.
• Note The above report includes all data
  recommended by the College of American
  Pathologists for complete reporting of colon
  tumors.

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Function List

• Autopilot
• Tasked with preventing errors and other lapses of
  quality at every interaction with a case
• Air traffic controller
• Improves workflow and efficiency
• Flight Data Recorder (Black Box)
• Collects detailed data on all near-misses and
  errors
• Flight Simulator

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Histology performance measures- individual (4x
objective)
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Histology performance measures- individual (40x
objective)
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Histology performance- group (4x objective)
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Histology performance- group (40x objective)
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Pathologist performance-individual
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Pathologist performance-group
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Function List

• Autopilot
• Tasked with preventing errors and other lapses of
  quality at every interaction with a case
• Air traffic controller
• Improves workflow and efficiency
• Flight Data Recorder (Black Box)
• Collects detailed data on all near-misses and
  errors
• Flight Simulator

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Flight Data Recorder (Black Box) function

• Detailed event data (timestamps, pathologist
  communication, changes, etc.) on errors
• Allows retrospective answers to questions

• Increases error identification through blinded
  review process.
• Allows (and forces) near-miss evaluation

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Second Review Design
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Automated Quality Conference Cover Sheet
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Flight Simulator- work in progress

• Combination of blinded review routine workflow
  and known baseline detailed performance
  characteristics allows production of meaningful
  quality exercises.

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Auditing effectiveness

• Possible triggers
• Random cases
• High-risk histories
• Recent performance