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

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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

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Todays 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

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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.

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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?!
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Why barcode?

• Error reduction and patient safety
• Errors labeling things
• 1/300 (manual) to lt 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

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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

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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

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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 gtgt 0.5 FTE
• Improved image collection and management
  (paperwork, gross, micro, EMs, IF, etc)
• Increased job satisfaction

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Bar-coding Options

• Buy LIS-specific
• Available? Capable?
• Buy 3rd party solution (middleware)
• Available? Capable?
• Build LIS-specific middleware
• Can be quick. Investment.
• Build LIS-agnostic middleware
• Most complex most control

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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 its needed
• Eliminate handling and error opportunities
• No assumptions only trust scan events
• Quality timestamps, locations, personnel
• Leverage LIS
• LIS-agnostic design

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Material identification (2005)

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

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Primary labeling errors (2004)
?
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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!
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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)

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Classic Grossing Workflow
Accession specimens
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
Handling steps
Rack filled cassettes
Possible errors


Transport for processing
Reconcile with LIS
QA steps
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Just-in-Time Printing
Fewer handling steps Fewer (1) error
opportunities Fewer QA processes
Courtesy General Data
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QE Benefits
Classic Just-in-Time
Handling steps 11 5
Error opportunities 9 1
Manual QA steps 7 4
Primary labeling errors 988/yr (est.) (1.2) 2 in 3 mo (initial) 0 in next 7 mo (0.003)
Cassette wastage 25/d (7) 0
Grossing efficiency -- At least as fast
Support staff -- 0.75 FTE saved
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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)

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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

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Cutting - Benefits

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

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Slide Life Cycle
Histology
Pathology Offices
Sendouts
Faculty signout
File
Pull for conference
Resident review
Histology work order completes with scanning
Deliver
Ship
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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 gt 2.0 FTE!

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Slides 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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Barcodes Enable

• Imaging
• Gross photos
• Photomics
• Documents
• EM/IF
• HPV workflow
• Reflex testing
• Digene/Luminex

• Specimen management
• Discards
• Locations
• Winscribe automation

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Targets - Specimens

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

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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
• If note on Req Data tab, caution light and note
  display

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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
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Barcoding Benefits

• Indirect personnel (FTE)
• 0.5 Scanned consult document availability1
• TBD Scanned Req forms
• TBD Slide location info (e.g. Pathologists)
• Reduced loss of materials
• Slide/Block tracking
• Specimen discards

1Schmidt, RA, et al. Am J Clin Pathol 126678-83,
2006
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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

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OmniTrax Whats 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)

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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

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Basic Architecture
OmniTrax
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Local Extensions
OmniTrax
Web app
Reports
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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)
• Thats equivalent to
• Les Miserables
• All three Lord of the Rings books

Version 1 22 tables
Version 4 48 tables
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Need for a Standard

• Problems
• Multiple barcodes from diff. facilities on same
  item
• No assigning authority in barcode
• Interpreted differently by different software
• Some proprietary uses
• APIII focus group suggestions (2008)
• The barcode should contain only an identifier
  (e.g. license plate) software determines use
• The barcode should contain something equivalent
  to an assigning authority.
• IDapplicationinstallation
• 12356789OmniTraxUWPath98195

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Why barcode?
Expensive true, but reasonable ROI
Workspaces change it might be time
Process changes new processes are better
Jobs change but more valuable activity
Pathologists affected in good ways
Time investment pays off!
Better lab efficiency
Error/liability reduction
Inventory control
Resident autonomy
Gateway to more functions
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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!