Title: Anatomic Pathology Information
1Anatomic Pathology Information The Challenge of
Tracking and Routing at MGH
Information Received, I Understand
- Thomas M. Gudewicz, MD
- Massachusetts General Hospital
- Harvard Medical School
2Summary
- 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
3Outline
- Mission, Vision and Driving Forces
- From 1896 to 2010 - The Contrast
- The Challenge
- Tracking and Routing Defined
- MGH Tracking and Routing Today
- 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
5The Mission and Vision of the MGH Pathology
Service
6To deliver the highest quality pathology services
and to move the field of pathology forward
7Healthcare - 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
8MGH 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.)
9MGH 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- Mission, Vision, and Driving Forces
- From 1896 to 2010, the Contrast
- The Challenge
- Tracking and Routing Defined
- MGH Tracking and Routing Today
- Building the Foundation
112010
1896
12Roles 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
13MGH 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
15Sunquest 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.
16Collaboration Project Requirements
- Retire PowerPath Implement Sunquest CoPath 5.0
AP-LIS. - Analyze, re-design, optimize workflow top to
bottom. - 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
18Tracking 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.
19Assets - 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
20Assets - 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
21Tracking 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
22Routing 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
23Routing 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
25MGH 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.
26MGH 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.
27MGH 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
28Barcode Use - Surgical Pathology
At patient point of collection a specimen barcode
is (often) generated from the ADT system
Gross Lab
Histology Lab
29Barcode Use - Cytology and Autopsy
Cytopathology
Autopsy Pathology
30Existing 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
32Building 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
33Building the Foundation
Success is based on
- Detailed documented knowledge of the workflow
from specimen collection to final storage or
disposal of assets. - Use of analytical tools to identify and remove
causes of defects (errors) and minimize
variability. - Employee ownership and strong management and
leadership support.
Sounds like
Lean Six Sigma
34Building 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
35Previous 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.
36Foundation Building 1st Step
Document workflow from specimen collection to
final storage or disposal of assets.
37Foundation 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
38Foundation Building 2nd Step
Use analytical tools to identify and remove
causes of defects (errors) and minimize
variability.
39Foundation 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
40Analysis Methodology
- Map work flow analyses by functional areas
identifying all decision points and hand-offs. - Identify how the system falters or fails (failure
modes). - Confirm process by direct observations.
- Incorporate time-motion analysis, Spaghetti
diagrams, etc. as necessary. - Simulate alternative work flows with available
data (iGrafx).
41Workflow Chart Back Bench
The Devil in the Details
42Failure 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.
43FMEA Cycle
Implement Actions Check Results
44FMEA Small Gross Bench
- QA Assistant Web-based application
- Download to PDF or MS Excel
- Document management
- Generates reports
45FMEA Failure Modes Summation
46Initial 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
47Summary of 27 Functional Areas (FA)
Steps Decision Points Hand Off's
Total 466 81 233
Ave/FA 17 3 9
48Simple 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
49Acknowledgments
- Carlos Alaya
- William Amin
- Denise Bland-Piontek
- Maya Daderling
- James Happel
- Chris Oberg
- David McClintock
- Michelle Schwab-Macdonald
50Questions?