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Digital Pathology in the Clinical Workflow: A Time & Motion Study Pathology Visions October 26, 2011. Curtis Stratman, MBA 1 Laura Drogowski, BS 2 Jonhan Ho, MD 2,3. 1 Omnyx, LLC, Pittsburgh, PA 2 University of Pittsburgh, Department of Pathology, Pittsburgh, PA - PowerPoint PPT Presentation
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Digital Pathology in the Clinical Workflow:A Time & Motion Study
Pathology Visions
October 26, 2011
Curtis Stratman, MBA1
Laura Drogowski, BS2
Jonhan Ho, MD2,3
1Omnyx, LLC, Pittsburgh, PA2University of Pittsburgh, Department of Pathology, Pittsburgh, PA3University of Pittsburgh, Department of Dermatology, Pittsburgh, PA
Stratman – Employee of OmnyxHo – Research Grant from Omnyx
Disclosures
Goal of the Studies
How would the migration to an all-digital workflow impact staffing across an organization, including both pathologists and the histology lab?
Understanding this impact is significant for evaluating digital pathology solutions for high-volume uses.
3
HISTOLOGY LAB TIME AND MOTION STUDY
Imaging Case Assembly
0
Pathologist
Load slidesGenerate imagesUnload slides
Sort images to cases
Accessioning / Grossing / HistologySlide Creation
Pathologist
Stain and coverslip slides Sort slides to Cases
Case Assembly
Review slide qualityReview case quality
Quality Check
Transport
Quality Check
Review slide qualityReview image qualityReview case quality
Case Entry
Enter PatientEnter CaseEnter Slides
Enter PatientEnter CaseEnter Slides
Histology Lab T&M Study ContextPhysical Workflow
Imaging Case Assembly
0
Pathologist
Load slidesGenerate imagesUnload slides
Sort images to cases
Accessioning / Grossing / HistologySlide Creation
Pathologist
Stain and coverslip slides Sort slides to Cases
Case Assembly
Review slide qualityReview case quality
Quality Check
Transport
Quality Check
Review slide qualityReview image qualityReview case quality
Case Entry
Enter PatientEnter CaseEnter Slides
Enter PatientEnter CaseEnter Slides
Histology Lab T&M Study ContextDigital Workflow – Standalone Imaging Solution
Imaging Case Assembly
0
Pathologist
Load slidesGenerate imagesUnload slides
Sort images to cases
Accessioning / Grossing / HistologySlide Creation
Pathologist
Stain and coverslip slides Sort slides to Cases
Case Assembly
Review slide qualityReview case quality
Quality Check
Transport
Quality Check
Review slide qualityReview image qualityReview case quality
Case Entry
Enter PatientEnter CaseEnter Slides
Enter PatientEnter CaseEnter Slides
Histology Lab T&M Study ContextDigital Workflow – Standalone Imaging Solution
NEW TASKS EQUIVALENT TASKSDUP TASKS
Imaging Case Assembly
0
Pathologist
Load slidesGenerate imagesUnload slides
Sort images to cases
Accessioning / Grossing / HistologySlide Creation
Pathologist
Stain and coverslip slides Sort slides to Cases
Case Assembly
Review slide qualityReview case quality
Quality Check
Transport
Quality Check
Review slide qualityReview image qualityReview case quality
Case Entry
Enter PatientEnter CaseEnter Slides
Enter PatientEnter CaseEnter Slides
Histology Lab T&M Study ContextDigital Workflow – APLIS Integrated
NEW TASKS EQUIVALENT TASKSDUP TASKS
Eliminate
Imaging Case Assembly
0
Pathologist
Load slidesGenerate imagesUnload slides
Sort images to cases
Accessioning / Grossing / HistologySlide Creation
Pathologist
Stain and coverslip slides Sort slides to Cases
Case Assembly
Review slide qualityReview case quality
Quality Check
Transport
Quality Check
Review slide qualityReview image qualityReview case quality
Case Entry
Enter PatientEnter CaseEnter Slides
Enter PatientEnter CaseEnter Slides
Histology Lab T&M Study Context Digital Workflow – APLIS & Barcode Integrated
NEW TASKS EQUIVALENT TASKSDUP TASKS
Eliminate Eliminate
Study Case Entry time to: • understand incremental staff costs for standalone implementation• quantify value of APLIS interface
Study Case Assembly time to: • understand opportunity to offset increment staff costs from imaging• quantify value of barcoding interface
Histology Lab T&M Study Goals
Case Entry
Imaging Imaging Imaging
Case Assembly
+ Tasks
- Tasks
Standalone APLIS Integrated
APLIS & Barcode Integrated
1. Entered 17 randomly selected cases into Omnyx application2. Recorded time to enter Patient, Case, and Histology information3. Performed regression to model component times
Average Case (1 Part, 10 Slides) = 2:03 minutes / caseSupport Average Pathologist (3500 cases / year) = 119.6 hours / yearAverage Lab FTE (2000 hrs / year) = 6.0% FTE / pathologist
= ~1 FTE / 16 pathologists
Histology Lab T&M Study MethodologyCase Entry Time
Data Component Average Time (Each)
Patient & Case 68 seconds
Histology Part(s) 25 seconds
Histology Slide(s) 3 seconds
Analyzing total impact requires additional study of actual time for imaging tasks• Highly variable with scanner design
APLIS Integration avoids actual incremental 6% lab FTE per pathologist
APLIS + Barcode Integration potentially reduces 18.5% lab FTE to offset some of the incremental time required by imaging tasks
Histology Lab T&M Study Summary
Case Entry6.0% FTE/Path
Imaging(TBD)
Imaging(TBD)
Imaging(TBD)
Case Assembly18.5% FTE/Lab
+ Tasks
- Tasks
Standalone APLIS Integrated
APLIS & Barcode Integrated
1. Observed histology lab for entire shift2. Recorded time to spent on tasks between coverslipping and courier3. Extracted time spent on Case Assembly tasks:
• Sorting and matching slides to cases• Sorting and matching cases to pathologists or services
Average Lab FTE (8 hours / day) = 18.5% FTE
Histology Lab T&M Study MethodologyCase Assembly Time
Academic Center LabsNumber of Labs Observed 4Number of Total Observations 8 (days)
Range of Case Assembly Time 0:57:20 – 1:53:46
Average of Case Assembly Time / Day 1:29:16
PATHOLOGIST TIME AND MOTION STUDY
Radiology realized significant improvements in productivity as the most significant value-add from PACS implementation.
“Since the introduction of PACS, reporting times have decreased by 25% and the productivity improved by 18%.”
Mackinnon AD, Billington RA, Adam EJ, et al. Picture archiving and communication systems lead to sustained improvements in reporting times and productivity: results of a 5-year audit. Clinical Radiology 2008; 63; 796-804.
“…overall Radiology Department productivity increased by 12%, TAT improved by more than 60%. Timelier patient care resulted in decreased lengths of stay.... A well-planned PACS deployment simplifies imaging workflow and improves patient care throughout the hospital while delivering substantial financial benefits.”
Nitrosi A, Borasi G, Nicoli F, et al. A filmless radiology department in a full digital regional hospital: quantitative evaluation of the increased quality and efficiency. Journal of Digital Imaging 2007; 20(2); 140-148.
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Pathologist T&M Study ContextExperience from Radiology
The challenges pathologist experience from managing slides is similar to the challenges radiologists experienced with film.
16
Pathologist T&M Study ContextSimilarity of Pathology and Radiology
17
Pathologist T&M Study Goal
Hypothesis: Inefficiencies exist in the pathologists’ workflow that can be improved by an all digital workflow.
A before-and-after study of actual impact in pathology is in-progress, therefore the first study goal was to identify the potential opportunity.
1. Observe pathologists across multiple days, subspecialties, and sites2. Record time spent on each discrete task3. Bucket the tasks into common activities4. Identify the buckets impacted by an all digital workflow5. Calculate opportunity as a percentage of total time spent on cases
NOTE: Results varied significantly across observations, both across and within pathologists.
18
Pathologist T&M Study Methodology
Subspecialty Pathologists in Academic SettingNumber of Pathologists Observed 6Number of Total Observations 12 (days)
Average Time on Case Work / Day 5:22:44
Pathologist T&M Study ResultsIdentified Opportunities for Time Savings
Matching: • Matching paperwork to case• Matching new stains ordered upon arrival• Tracking receipt of ordered slides• Re-checking slide to case match
Reduced Error Correction: • Transporting case to correct pathologist• Obtaining correct or missing paperwork• Reducing duplicate slides ordered • Picking up wrong slides / missing slides
Retrieving Prior Cases: • Sending request for prior case• Context switch away from current case• Tracking receipt of requested prior cases
Transporting Cases:• Giving for Pre-Signout Q/A• Packaging cases for consult
Organizing Cases:• Prioritizing cases for review• Dividing with residents and fellows• Tracking which cases are ready for review• Tracking cases for conferences
Querying for Cases:• Checking mailbox for new cases• Checking if STAT cases have arrived• Checking if Frozen Section cases are ready• Visibility of overdue cases
Searching for Cases:• Searching for cases when receiving phone call• Searching for “orphan” slides• Pulling cases for re-review at final sign-out• Passing cases between residents and fellows
Communication:• Sending ROI images vs. co-scheduling time at scope
19
Workflow Opportunities13.4% (0:43:09)
Slide Review36.0% (1:56:13)
Other16.0% (0:51:43)
Reporting34.6% (1:51:38)
Pathologist T&M Study ResultsBreakdown of Time Working Cases
Slide Review36.0% (1:56:13)
Other16.0% (0:51:43)
Reporting34.6% (1:51:38)
Organizing Cases 24.1% (0:10:25)
Querying for Cases 18.5% (0:07:59)
Waiting for Delivery 11.2% (0:04:49)
Matching 10.5% (0:04:32)
Searching for Cases 9.4% (0:04:04)
Transporting Cases 9.2% (0:03:58)
Other 17.0% (0:07:21)
Workflow Opportunities
100% (0:43:09)
13.4%
Pathologist T&M Study ResultsBreakdown of Workflow Opportunities
Common current uses:• Tumor boards• Frozen sections• Consultations
Secondary effects caused by delays from noted opportunities:• Time re-orienting to case after waiting for prior case• Phone-tag with ordering clinician after retrieving case
Level-loading work:• Continuous flow of cases from lab to pathologist• Distribute workload across locations
Surrounding personnel:• Resident matching (observed 1:26:11)• Administrator preparing cases (observed 1:35:43)• Prior case retrieval and re-storage• Slide transportation
Pathologist T&M Study ResultsAdditional Opportunities for Time Savings
13.4% opportunity for increase in available pathologists’ time from Workflow is a significant value-add opportunity for implementing digital pathology in routine use
Example options for utilizing this time:• Increase volumes without additional staff• Increase utilization of patient history• Increase rate of quality assurance review• Improve recruiting and retention
Impact of secondary effects has opportunity to show significant additional opportunityReducing dependence on surrounding personnel drives efficiency across department
Scoped for analysis in before-and-after study
Additional analysis of Slide Review efficiency opportunities is suggested from radiology
“Time-motion analysis showed a reduction of 16.2% in the overall time required for soft-copy interpretation of CT compared with that of film.”
Reiner BI, Siegel EL, Hooper FJ, et al. Radiologists’ Productivity in the Interpretation of CT Scans: A Comparison of PACS with Conventional Film. AJR 2001; 176; 861-864.
Pathologist T&M Study Summary
Routine use of an all-digital workflow shows…
Opportunity to increase available pathologist time from workflow savingsObserved average 13.4% per pathologist in addition to savings from secondary effects, frozen sections, tumor boards, consults, slide review• Quality, Profitability, Lifestyle
Opportunity to eliminate case assembly tasks in the lab Observed average 18.5% FTE per lab• Offset some of the additional time required for new Imaging tasks
Efficiency of pathology department has downstream effectsClinician Efficiency and Patient Care• Patient satisfaction, timely treatment, reduced length of stay
T&M Study Conclusions
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