Anatomic Pathology Information

1
Anatomic Pathology Information The Challenge of
Tracking and Routing at MGH
Information Received, I Understand

• Thomas M. Gudewicz, MD
• Massachusetts General Hospital
• Harvard Medical School

2
Summary

• The complexity of pathology information workflow
  can be optimized by the application of automated
  systems, including asset tracking and routing
• Automating a system requires detailed information
  on workflow to optimize analysis and design
  considerations
• The collection and analysis of such information
  is in itself a definable process that assists
  design
• Iteration is a key component of optimizing
  analysis and design

3
Outline

1. Mission, Vision and Driving Forces
2. From 1896 to 2010 - The Contrast
3. The Challenge
4. Tracking and Routing Defined
5. MGH Tracking and Routing Today
6. Building the Foundation

4

• 1. Mission, Vision and Driving Forces
• 2. From 1896 to 2010 The Contrast
• 3. The Challenge
• 4. Tracking and Routing Defined
• 5. MGH Tracking and Routing Today
• Building the Foundation

5
The Mission and Vision of the MGH Pathology
Service
6
To deliver the highest quality pathology services
and to move the field of pathology forward
7
Healthcare - The Driving Forces
Revenue
Revenue
Increase productivity Cut costs Reduce waste
Customers
Customers
Customers

• External
• Patients
• Health care providers
• Other diagnostic specialists
• Researchers

• External
• Patients
• Health care providers
• Other diagnostic specialists
• Researchers
• Internal
• Technical staff
• Administrative staff
• Residents and fellows
• Pathologists

Regulatory
Regulatory
Governmental Insurance
8
MGH Pathology Products and Services

• Pathology and clinical laboratory results and
  reports (clinicians, patients)
• Education and training (technologists, residents,
  fellows)
• Research materials (tissue, blocks, slides, data)
  
• Therapeutic modalities (blood and blood products,
  therapeutic phlebotomy, plasmapheresis, etc.)

9
MGH Pathology Products and Services
Information

• Pathology and clinical laboratory reports
  (clinicians, patients)
• Education and training (technologists, residents,
  fellows)
• Research materials (tissue, blocks, slides, data)
  
• Therapeutic modalities (blood and blood products,
  therapeutic phlebotomy, plasmapheresis, etc.)

10

1. Mission, Vision, and Driving Forces
2. From 1896 to 2010, the Contrast
3. The Challenge
4. Tracking and Routing Defined
5. MGH Tracking and Routing Today
6. Building the Foundation

11
2010
1896
12
Roles and Functions of the MGH Pathology Service
Divisions
Execute Mission
Support Function
Research
Finance Admin
Clinical Services
Informatics
Educational Programs
Quality and Safety
Services
Core Clinical Laboratories
Surgical PathologyService
Microbiology Laboratory
Cytology Service
AutopsyService
Blood Transfusion Services
Point of Care Testing
Diabetes Laboratory
HealthCare Center Laboratories
ResearchLaboratories
Histo- compatibility Laboratory
Immunology Laboratory
13
MGH Pathology Service Workload

• Employees
• 700 staff
• 85 faculty
• 80 trainees
• Budget
• MGH 100M
• MGPO 25M

• Services
• Clinical laboratories gt10 million tests
• Surgical pathology 80,000 specimens
• Cytopathology 61,000 specimens
• Autopsy 300
• Microbiology 400,000 specimens
• Blood transfusion service
• Donor center
• 70,000 total blood component transfusions
• 35,000 RBC units transfused
• 3000 outpatients treated

14

• 1. Mission, Vision, and Driving Forces
• 2. From 1896 to 2010 The Contrast
• 3. The Challenge
• Tracking and Routing Defined
• MGH Tracking and Routing Today
• Building the Foundation

15
Sunquest CoPath / MGH Collaboration
Aug 2009 10-yr. joint development agreement
with Sunquest Information Systems on the next
generation AP/CP based LIS.

• Software co-development efficient, flexible
  work, specimen information flow.
• Strengthen the informatics infrastructure use
  advanced diagnostic information management (IM)
  technologies.
• Provide a revenue stream commercial
  distribution of the software.

16
Collaboration Project Requirements

1. Retire PowerPath Implement Sunquest CoPath 5.0
   AP-LIS.
2. Analyze, re-design, optimize workflow top to
   bottom.
3. Apply automation, advanced diagnostic IM
   technologies, digital pathology, molecular tests,
   operational Business Intelligence (dashboards)

17

• Mission, Vision, and Driving Forces
• From 1896 to 2010 The Contrast
• The Challenge
• 4. Tracking and Routing Defined
• MGH Tracking and Routing Today
• Building the Foundation

18
Tracking and Routing
Tracking - system to determine at what point an
asset is located (and where it has been) in the
case life cycle.
Systems may be manual or automated.
Routing - system to determine where an asset is
directed during the life cycle given the status
of the system.
19
Assets - Defined

• Hard Assets Any identified physical item
  assigned to a case
• Tissue, blocks, slides.
• Paper requisitions, documents and reports
• x-ray film.

• Soft Assets Non-physical (electronic, virtual)
  information
• EMR, PACS Images
• CDs (?)

• Unidentified (Hidden) Assets Any asset created
  or required for production not assigned a system
  ID
• Just-in-case unstained slides
• Electronic image not linked to system
• Tissue blocks for IPX controls

20
Assets - Defined
Whether machine readable or not, assets must be
assigned a fixed, unique, traceable ID
S10-02341 A2 L-3 Doe, John MBH Pathology
https//Archive132/Shared20Documents/Proc34A
21
Tracking Where is the Asset?

• SPOT Specimen Point of Tracking
• A station or location at which an asset is
  recorded or logged (time in, receipt by,
  condition, etc.,)
• Ideally, define SPOTs at hand-off points
• human-human
• human-machine
• machine-machine

22
Routing Where Do Assets Go?

• Route User defined criteria outlining the SPOTs
  that an asset must enter
• exit for processing

3 Types 1. Standard Process 2. Contextual
Process 3. Business Intelligence (BI) Process
23
Routing Where Do Assets Go?
Standard Route pre-defined at receipt by limited
criteria (e.g., prostate core bx Route routine
process, 3L HE slide/block). Contextual
Standard route modified by pre-defined data that
drive special considerations (e.g., priority, day
of week or time, pathologist, consult case,
associated assets, phone requests). BI
Real-time redirected routes based on up- down-
stream conditions (optimized Work in Progress
(WIP), i.e., dashboard driven).
24

• Mission, Vision, and Driving Forces
• From 1896 to 2010 The Contrast
• The Challenge
• Tracking and Routing Defined
• 5. MGH Tracking and Routing Today
• Building the Foundation

25
MGH Tracking and Routing - Today
Automated Tracking
Automatic Routing

• No existing software or automated rules.

• Barcode technology.
• Limited SPOTs (7).
• Begins at accessioning.
• Ends in histology prior to delivery of slides to
  pathologist.
• After that all bets are off.

26
MGH Barcoded Asset Tracking System

• Program Interfaces
• PowerPath/AMP (Advanced Materials Processing)
• Transcription Service Server (SoftScript)
• MS Access Program
• Custom programs (Visual Basic, etc.)

• System
• MGH internally customized system.
• Implemented late 2004 and fine tuned through
  2006.
• Linear barcodes.
• Scanners (Symbol, Orbit) single line and
  omnidirectional keyboard wedge.

27
MGH Barcoded Asset Tracking System

• Barcodes printed
• Requisitions
• Gross transcription service
• Specimen containers
• Cassettes
• Slides
• Ventana
• FocalPoint

• System Functions
• 1 use is task automation
• Limited tracking information (PowerPath Specimen
  Tab)
• Manual PowerPath tracking function exists

28
Barcode Use - Surgical Pathology
At patient point of collection a specimen barcode
is (often) generated from the ADT system
Gross Lab
Histology Lab
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Barcode Use - Cytology and Autopsy
Cytopathology
Autopsy Pathology
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Existing System Strengths and Weaknesses

• Strengths
• Marginal Cost
• Asset IDs generated and distributed
  electronically
• Limited tracking possible
• (Who, What, When, Where)
• Automation of routine tasks
• Good reliability
• Reduced errors

• Weaknesses
• Limited SPOTs
• Customized programs
• LIS/equipment interface
• Succession planning difficult (programers)
• Linear barcode
• Manual action
• Not readable through objects
• Limited data capacity, ruggedness
• Orientation dependent

31

• Mission, Vision, and Driving Forces
• From 1896 to 2010 The Contrast
• The Challenge
• Tracking and Routing Defined
• MGH Tracking and Routing Today
• 6. Building the Foundation

32
Building the Foundation
Implementing an Automated Tracking Routing
System
The overlay of automation technology on an
existing inefficient, sub-optimized manual
tracking system will result in . . .
Processing Storage
Garbage Out
Garbage In
33
Building the Foundation
Success is based on

1. Detailed documented knowledge of the workflow
   from specimen collection to final storage or
   disposal of assets.
2. Use of analytical tools to identify and remove
   causes of defects (errors) and minimize
   variability.
3. Employee ownership and strong management and
   leadership support.

Sounds like
Lean Six Sigma
34
Building the Foundation

• LEAN principles
• Just in time supply
• Right person right job
• Work flow continuity up-stream processes in
  direct proximity to down-stream processes

• LEAN - The Seven Wastes
• Overproduction
• Waiting
• Transportation
• Processing
• Inventory
• Motion
• Defects

35
Previous MGH LEAN Experience

• Results
• Reduced average routine surgical TAT from 48 hr
  to 20 hr.
• Reduced average Biopsy TAT from 24 hr to 16 hr.
• Reduced overtime from 3.5 FTEs in 2005 to 0.97
  FTEs in 2006
• Improved morale.

Mar 2005 Aug 2006 Histology Redesign Project
Incorporated Lean concepts of workflow
analysis, re-design, standardization, including
the barcode system.
36
Foundation Building 1st Step

Document workflow from specimen collection to
final storage or disposal of assets.
37
Foundation Building 1st Step

• Present system strengths, weaknesses,
  preferences.
• PowerPath LIS Analysis
• Exit interviews with users at all steps of
  production.
• Workflow Analysis
• Map workflow of existing production system.
• Future system capabilities, requirements and
  desires.
• Sunquest CoPath 5.0 requirements and
  specifications
• Generate Gap analysis
• Workflow
• Idealized workflow design

38
Foundation Building 2nd Step

Use analytical tools to identify and remove
causes of defects (errors) and minimize
variability.
39
Foundation Building 2nd Step

• Methods
• Work flow charts
• Failure Modes and Effects Analysis (FMEA)
• Time motion analysis
• Workflow simulation
• Fishbone (Ishikawa) diagrams
• Histograms
• Pareto charts

• Check sheets
• Run charts
• Spaghetti diagrams
• Value Stream Map
• Project management tools
• Charter
• Change management
• Resource plans

40
Analysis Methodology

1. Map work flow analyses by functional areas
   identifying all decision points and hand-offs.
2. Identify how the system falters or fails (failure
   modes).
3. Confirm process by direct observations.
4. Incorporate time-motion analysis, Spaghetti
   diagrams, etc. as necessary.
5. Simulate alternative work flows with available
   data (iGrafx).

41
Workflow Chart Back Bench
The Devil in the Details
42
Failure Mode and Effects Analysis (FMEA)

• Product development and operations management
  tool for analysis of failure modes (FM) in
  various phases of a product life cycle.
• FMs are errors or defects in a process, design,
  or item.
• Team approach used to identify failure modes
  (potential or actual) based on experience and
  risk analyses.
• Drives designs by prioritizing highest risk
  failures for early attention.

43
FMEA Cycle
Implement Actions Check Results
44
FMEA Small Gross Bench

• QA Assistant Web-based application
• Download to PDF or MS Excel

• Document management
• Generates reports

45
FMEA Failure Modes Summation
46
Initial Project Results

• 27 Functional Areas (FA) mapped for workflow
• Workflow confirmation by observation complete in
  1 area and ongoing in 2nd but largest functional
  area
• 1 FMEA completed

47
Summary of 27 Functional Areas (FA)
Steps Decision Points Hand Off's
Total 466 81 233
Ave/FA 17 3 9

48
Simple Sign-Out 1 HE slide
Functional Area Steps Decision Points Hand Offs
Accession Gross 53 18 21
Histology 28 2 13
Embedding 29 6 8
Microtomy/Stain 11 1 4
Signout 15 2 3
Total 136 29 49
Ave 27 6 10

49
Acknowledgments

• Carlos Alaya
• William Amin
• Denise Bland-Piontek
• Maya Daderling
• James Happel
• Chris Oberg
• David McClintock
• Michelle Schwab-Macdonald

50
Questions?