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Tackling the Challenge of Specimen Tracking Within and Without the Cleveland Clinic: How We Reduced Lost Specimens

Kavous Roumina, Ph.D. Cleveland Clinic

Center for Pathology Informatics (CPI)

November 6, 2012

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Overview

•!Background

•!Evaluation Process

•! Implementation Phase

•!Post-Implementation Observations: –!Problems Encountered –!Lessons Learned

•!Pre-Analytics Metrics: –!“Defect” Reduction

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Background

•!Cleveland Clinic –!Multi-specialty academic medical center –!1400 Beds –!2800 Physicians and Residents

•!Pathology and Laboratory Medicine Institute (PLMI) –!AP, CP, Molecular, and Outreach Departments –!1600 Employees –!12.9m Billable Tests (FY2012)

!!Over 100K surgical pathology accessions –!LISs: AP (Cerner CoPathPlus); CP (Sunquest Lab) –!Outreach: Atlas LabWorks –!Specimen Tracking (Gajema) at Main Campus Hospital Only

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Evaluation

•!Formed Evaluation Team (Q1 2008) –!AP/CP supervisors –!Logistics manager –!Client Services manager –!Sales & Marketing manager

•!Distributed RFPs (20+ functional requirements)

•!Other systems considered

•!Chose Gajema, Q4 2009

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Implementation

•!Formed Implementation Team (Evaluation Team Plus): –!Lab IT Hardware/Software Support Personnel –!Phlebotomy Transport Services –!Cerner CoPathPlus (CPP) Support Personnel –!Gajema Staff

•!Kickoff: March 2010

•!Employed Gajema-supplied project plan –!March Through July 2010

•!Weekly, hour-long conference calls

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Implementation (Cont.)

•!Gajema modules/features implemented: –!Tracking –!Customer Services –!Supply Management (partially) –!Fleet Management –!Interface with AP LIS (CoPath Plus)

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Implementation (Cont.)

•!Multiple system tables needed to be populated: –!Locations (possible to extract from CoPath Plus) –!Routes (partially extracted from previous automated system) –!Vehicles (partially extracted from …) –!Users (considered HRIS) –!Courier exceptions

!!“No Specimens”, “Specimens Not Ready”, “Pick-up Cancelled” –!Tests (or Procedures; for Client Services) –!Specimen Types (possible to extract from CoPath Plus)

!!“Urine”, “Pap”, “Culture”, “Fresh Tissue”, “Mixed Specimen”

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Implementation (Cont.)

•!Tasks: –!Server setup

!!Application (by Gajema) !!Database (hardware: Lab IT; schema/structure: Gajema) !!Synchronization (Central IT)

–!Workstation setup: !!Few thick clients !!Mostly thin clients (via Citrix servers)

–!Network setup: !!100 Mbps (Mega bits per second) Ethernet ports for cradles !!Wireless network connectivity (for internal couriers) !!Cellular network connectivity (Data and Voice plans; for

outreach couriers)

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Implementation (Cont.)

•!Place hardware diagram here

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Implementation (Cont.)

•!Training –!Handheld PCs (HPCs) for couriers (2 Days)

!!Outside couriers (servicing outreach clients) - 14 !!Inside couriers - 12

•! In- and Out-Patient locations (“Sneaker Patrol”) •! Intra-Lab couriers (Cyto-Micro or CPA-SurgPath)

–!Desktop Application (for monitoring and/or reporting; 3-4 Days) !!System managers (for various implemented modules) !!End-Users (container creators/un-loaders, client services reps.,

dispatchers, etc.)

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Implementation (Cont.)

•!Decisions To Make: –!Tracking ID value (i.e., Bar code)

!!Generic, or !!Patient-Related (EMR-Centric)

–!Workflow !!Keep current, or !!Modify exiting flow

–!User roles (non-couriers) !!One System Administrator, or !!Several System Managers (Logistics and Client Services)

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Implementation (Cont.)

•!Decisions To Make: –!Location (Client) ID naming convention

!!Keep existing (if any), or !!Design new

–!Duplicate specimen IDs !!Ignore, or !!Find work-around

–!Where to locate cradles

–!How many HPCs to allocate to each dept./area

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Implementation (Cont.)

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Implementation (Cont.)

•!Additional items needed: –!Bar code readers (for container packing)

–!Printers (for container packing lists)

–!“Space” to sort and separate specimens

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Implementation (Cont.)

•! Interface with AP LIS (CoPath) –!Allows for “Hand off” of specimen to AP LIS

•!No interface with CP LIS (Sunquest)!

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Implementation (Cont.)

•!Pre- Go-Live –!Perform multiple “Test-Runs”

–!Ensure users can login to the Production environment (no expired passwords!)

•!Day of Go-Live (August 2010) –!Select time of day (if 24-hour operation)

–!Expect delays in processing times (prior to reaching “steady state”)

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Pre-Analytics Specimen Tracking Workflow

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Implementation (Cont.)

•!Place the AP diagram here

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Implementation (Cont.)

•!Place the CP diagram here

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Post-Implementation - Problems Encountered

•!Duplicate specimen IDs

•!Limited characters for location/client ID naming convention (10) –!Hampering expansion to Regional/Community hospitals

•!Non-Bar coded specimens or requisitions –!Deployed generic, pre-printed, bar coded labels

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Post-Implementation - Problems Encountered

•!Some functions/tasks require excessive and, at times, inconsistent keyboard/mouse interaction (e.g. container loading/unloading)

•!Handling same volume (of specimens) initially required additional processing time

•!Managing large number of HPCs (50+) –!Identification labels –!Private wireless network communication issues –!Wireless cellular network (data carrier) issues

•! “Finicky-ness” of some HPCs –!Provided a “Trouble-Shooting” document to couriers –!Bar codes placed close to each other (2D issue?)

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Post-Implementation - Problems Encountered

•!Multiple specimen pickup scenarios –!Physician offices: 5 variations –!Family Health Centers: 7 variations –!Web portal clients: 10 variations –!Hospitals (LIS-LIS interfaced): 3 variations –!Hospitals (Non-interfaced): 2 variations

•!Contracted couriers (weekends/holidays) –!Not using Gajema –!How to train (if they were to use it)

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Post-Implementation - Lessons Learned

•!Request more HPCs than anticipated –!Keep a few charged and on reserve (for when they stop

functioning and no one is around to “fix” them)

•!Request fewer desktop licenses than anticipated –!Not everyone in departments impacted needs one

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Post-Implementation - Lessons Learned

•!Provide multiple cradles during training sessions

•!Select a meaningful tracking ID (e.g. EMR Order ID) –!Advantage: Easily associated with a patient –!Disadvantage: When not bar coded, requires many

keystrokes to record data (both on the HPCs and the desktop application)

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Post-Implementation - Lessons Learned

•!Steep learning curve for some couriers –!To help couriers and to speed up delivery times,

implemented following “rules”: !!If barcode is visible/present

•!Scan code on requisition; or •!Scan code on specimen

!!Else, •! For quantities < 5, attach generic barcode label to individual

specimen bags then scan •! For quantities >= 5, place specimens in a pre-labeled, larger

bag then scan

–!For any future expansions, introduce system to couriers individually

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Post-Implementation - Lessons Learned

•!Continue meeting with the implementation team post-live

•!Schedule additional “Best Practices” sessions for laboratory managers/supervisors (to monitor activities)

•!Hard reboot of HPCs resets date/time to a predefined date (Jan. 1, 2007)

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Post-Implementation - Successes

•!Proactive vs. Reactive –!AP pending log

•!Many “potentially” lost specimens have been located

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Pre-Analytics Metrics

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CP/MP (Main Campus) – Volumes

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CP/MP (Main Campus) – “Defects”

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AP (Main Campus) – Volumes

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AP (Main Campus) – “Defects”

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Possible Future Improvements

•! Investigate/Implement route optimization

•!Apply Continuous Improvement (CI) methodology to specimen workflow

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Questions/Comments?