Place sub-brand
here
The Barcode-Driven Lab:
Success in a Large System
Rodney Schmidt, MD, PhD
University of Washington, Seattle
April 17, 2011
Foundation.cap.org
v. #
Topics
• Why create the barcode-driven lab?
– Why in a large, complex lab?
– Overview of functionality
• Not the detailed “how”; workflow
– Achieved benefits
• Error reduction
• FTE savings
• Important factors in success
– UCLA, Sierra Pathology, NWP, NYU, OHSU
• What’s down the road?
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 revenuesharing agreement with UW.
• Dr. Schmidt has a consulting agreement with
Thermo-Fisher for educational talks.
Why barcode?
• Expensive
– $23k/gross station
– $10k/cutting station
– Software
• Workspaces change
– Wiring, networking
• Time investment
• Processes change
– Material handling
– QA
• Jobs change
– Workflow
– Change management
• Pathologists affected!
– Software fast
– Workspaces slow
– Financing slow
Who needs the hassle?!
Large Systems – Special Factors
•
•
•
•
•
•
Multiple locations
Trainees – Residents and Fellows
Personnel turnover
Outside materials (e.g. consults)
Ancillary testing
Higher fraction of complex cases
Issues: Training, complexity, communication
Need: Robust systems to help people do things right
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
Material identification (2005)
• Handwritten
specimen
labels
• Manual, offline cassette
labeling
• Hand-written
slide labels
Primary labeling errors (2004)
1000
900
800
700
600
500
400
300
200
100
0
?
Blocks
Recorded
Slides
Actual
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)
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
Reconcile with LIS
*
Transport for
processing
*
Possible errors
* QA steps
Just-in-Time Printing
Accession specimens
Bar-code specimens
Fewer handling
steps
Fewer (1) error
opportunities
Scan/print cassettes
Lay out cassettes
Fill cassettes
*
*
Fewer QA
processes
Rescan cassettes
Courtesy General Data
Rack filled cassettes
*
Transport for
processing
*
Benefits
• Efficiency
–
–
–
–
No manual pre-printing and sorting of cassettes
Quick just-in-time additional cassettes
Default cassettes from PowerPath specimen panels
Blocks automatically ordered in PowerPath
• Quality
– No manual labeling (no errors)
– Scanning specimen barcode assures correct
specimen
– Enter cutting instructions, # pieces
– Records which blocks are sent for processing
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
Pathology Offices
Sendouts
Faculty signout
File
Histology work
order completes
with scanning
Pull for
conference
Ship
Resident
review
Deliver
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 Savings
Histology
+0.5
FTE
Reduced time hunting for
mis-delivered slides
+0.5
FTE
Auto completion of outstanding orders
when slide is scanned
Office staff +.5-1
FTE
+.25
FTE
Reduced time for conference
preparation
Increased efficiency regarding send
outs
Barcodes Enable…
• Imaging
–
–
–
–
Gross photos
Photomicrographs
Documents
EM/IF
• Specimen
management
– Discards
– Locations
• Winscribe automation
• HPV workflow
– Reflex testing
– Digene/Luminex
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
Barcoding Benefits
• Direct personnel (FTE)
– 2.0
– 0.75
– 0.1
– 0.1
– TBD
Slide delivery and tracking
Cassette printing
Specimen discards
Document scanning
Fluorescence image import
~$150,000/yr assuming $50,000/FTE
Barcoding Benefits
• Indirect personnel (FTE)
– 0.5
– TBD
– TBD
Scanned consult document availability1
Scanned Req forms
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
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
Reasons for Success
• Optimized workflow
– Lean analysis
– Close ties to users
– Multiple workflows; exception trapping
• LIS interoperability
– Initially with PowerPath; now general
• Just-in-time production of materials
• Selection of appropriate equipment
Where Next?
• Specimen transport
– Within multiple sites in a large lab
– Upstream all the way from the patient
• Result transport
– All the way back to the patient
• Likely to need multiple systems
 Need an industry barcode standard
Where Next?
• Tissue banking (becoming routine)
– Unique identifiers (encrypted for research)
– Repository management
– Maintain provenance
– Pre-analytic variables
• Tissue micro-arrays
– Each sample linked back to patient
Where Next?
Patient- and time-based disease data structures
Patient
Treatment 1
Diagnosis
•Links between serial
samples of same disease
•Relation to clinical treatment
•Correlated blood samples
(Time)
Treatment 2
Persistent
Recurrence
All types of data
•IHC
•Cytogenetic
•Molecular
What does sample tracking mean for molecular testing?
Why barcode?
Expensive
Workspaces change
Process changes
… true, but reasonable ROI
… it might be time
… new processes are better
Jobs change
… but more valuable activity
Pathologists affected
Time investment
… in good ways
… pays off!
Better lab efficiency
Error/liability reduction
Inventory control
Resident autonomy
Gateway to more functions
Conclusion
• Barcoding is becoming an expectation
– Patient safety / error reduction
• It’s to your financial advantage
For success, you must be sophisticated
enough to know the difference between just
putting a barcode on something and having a
barcode-driven lab.
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!
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