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

1. 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

2. 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

3. 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.

4. 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! Why barcode? Who needs the hassle?!

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. Material identification (2005) • Handwritten specimen labels • Manual, off-line cassette labeling • Hand-written slide labels

12. Primary labeling errors (2004) ?

13. 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!

14. Receive specimen and enter data into the LIS Generate a bar coded label for the specimen and laboratory request form. Minimum extra keystrokes (one) Targets - Accession

15. 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 * * Reconcile with LIS Transport for processing * QA steps

16. Accession specimens Bar-code specimens Scan/print cassettes * Lay out cassettes * Fill cassettes Rack filled cassettes * * Transport for processing Just-in-Time Printing Fewer handling steps Fewer (1) error opportunities Fewer QA processes Courtesy General Data

17. Q&E Benefits

18. 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)

19. 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

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

21. Slide Life Cycle Histology Pathology Offices Sendouts Faculty signout File Pull for conference Resident review Histology work order completes with scanning Deliver Ship

22. 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!

23. Slides Benefits FTE Savings

24. Imaging Gross photos Photomics Documents EM/IF HPV workflow Reflex testing Digene/Luminex Specimen management Discards Locations Winscribe automation Barcodes Enable…

25. Targets - Specimens • Discards • Accurate • Efficient • Documented • Track location • Drive photography

26. 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

27. 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

28. 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 126:678-83, 2006

29. 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

30. 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)

31. 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 Middleware Software that bridges a human to one or more major systems

32. UI/ app UI/ app UI/ app Business objects LIS Agent Agent Database QA Reports Basic Architecture OmniTrax

33. UI/ app UI/ app UI/ app UI/ app Business objects LIS Agent IIS Web app Agent Agent LIS Database Reports Local Extensions OmniTrax Web app Reports

34. Growth and Complexity as of Sept 7, 2010 Version 1: 22 tables Version 4: 48 tables • 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

35. 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”. ID|application|installation 12356789|OmniTrax|UWPath98195

36. Why barcode?

37. 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! Acknowledgements