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

Rodney Schmidt, MD, PhDProfessor 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 3rd 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)

0100200300400500600700800900

1000

Blocks Slides

Recorded Actual

Accession number is re-entered into a standalone cassette imprinter

Accession number is re-entered into a standalone cassette imprinter

?

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

Label specimens

Transport for processing

Reconcile with LIS

Move to staging area

Rack filled cassettes

Request more cassettes

Fill cassettes

Lay out cassettes

Move to gross bench

Group with specimens

Label cassettes

Store excess with specs

Classic Grossing Workflow

**

*

*

*

*

* * QA steps

Possible errors

Handling steps

Just-in-Time PrintingAccession specimens

Bar-code specimens

Transport for processing

Rack filled cassettes

Fill cassettes

Lay out cassettes

*

**

*

Scan/print cassettes

Courtesy General Data

Fewer handling steps

Fewer (1) error opportunities

Fewer QA processes

Q&E 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

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%

Slide Life Cycle

Histology work order

completes with scanning

Ship

Resident review

Deliver

Faculty signout

File

Pull for conferenc

e

Sendouts

Histology

Pathology Offices

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 SavingsFTE Savings

HistologyHistology +0.5 +0.5 FTEFTE

Reduced time hunting for Reduced time hunting for mis-delivered slidesmis-delivered slides

+0.5 +0.5 FTEFTE

Auto completion of outstanding orders Auto completion of outstanding orders when slide is scannedwhen slide is scanned

Office staffOffice staff +.5-1 +.5-1 FTE FTE

Reduced time for conference Reduced time for conference preparationpreparation

+.25 +.25 FTE FTE

Increased efficiency regarding send Increased efficiency regarding send outsouts

Barcodes Enable…

• Imaging– Gross photos– Photomics– Documents– EM/IF

• HPV workflow– Reflex testing– Digene/Luminex

• Specimen management– Discards– Locations

• Winscribe automation

Targets - Specimens

• Discards

– Accurate

– Efficient

– Documented

• Track location

• Drive photography

Specimen Discard

WorkflowWorkflow

– Device scans Device scans specimen barcode specimen barcode

– Handheld device Handheld device queries AP-LIS queries AP-LIS

• If case signout If case signout occurred <2wks prioroccurred <2wks prior

• If case signout If case signout occurred >2wks prioroccurred >2wks prior

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

• 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

Barcoding Benefits

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

• 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

Barcoding Benefits

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

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

Software that bridges a human to one or more major systems

Basic Architecture

UI/ app

UI/ app

UI/ app

Business objects

Database

OmniTrax

QA Reports

AgentLIS Agent

UI/ app

AgentLIS

Web app

Reports

Local Extensions

UI/ app

UI/ app

UI/ app

Business objects

Database

OmniTrax

IIS Web app

Reports

AgentLIS Agent

Growth and Complexity• 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

as of Sept 7, 2010

Version 1: 22 tables

Version 4: 48 tables

Need for a Standard

Problems1. Multiple barcodes from diff. facilities on same item2. 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 use2. The barcode should contain something equivalent

to an “assigning authority”.

ID|application|installation

12356789|OmniTrax|UWPath98195

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

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!