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, PA
of Pittsburgh, Department of Pathology, Pittsburgh, PA
3University of Pittsburgh, Department of Dermatology, Pittsburgh, PA
2University
Disclosures
Stratman – Employee of Omnyx
Ho
– Research Grant from Omnyx
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
Histology Lab T&M Study Context
Physical Workflow
Accessioning / Grossing / Histology
Case Assembly
Quality Check
Pathologist
Slide Creation
Transport
Enter Patient
Enter Case
Enter Slides
Case Entry
Stain and coverslip slides
Imaging
Sort slides to Cases
Case Assembly
Review slide quality
Review case quality
Quality Check
Pathologist
0
Enter Patient
Enter Case
Enter Slides
Load slides
Generate images
Unload slides
Sort images to cases
Review slide quality
Review image quality
Review case quality
Histology Lab T&M Study Context
Digital Workflow – Standalone Imaging Solution
Accessioning / Grossing / Histology
Case Assembly
Quality Check
Pathologist
Slide Creation
Transport
Enter Patient
Enter Case
Enter Slides
Case Entry
Stain and coverslip slides
Imaging
Sort slides to Cases
Case Assembly
Review slide quality
Review case quality
Quality Check
Pathologist
0
Enter Patient
Enter Case
Enter Slides
Load slides
Generate images
Unload slides
Sort images to cases
Review slide quality
Review image quality
Review case quality
Histology Lab T&M Study Context
Digital Workflow – Standalone Imaging Solution
Accessioning / Grossing / Histology
Case Assembly
Quality Check
Pathologist
Slide Creation
Transport
Enter Patient
Enter Case
Enter Slides
Case Entry
Stain and coverslip slides
Imaging
Sort slides to Cases
Case Assembly
Review slide quality
Review case quality
Quality Check
Pathologist
0
Enter Patient
Enter Case
Enter Slides
DUP TASKS
Load slides
Generate images
Unload slides
NEW TASKS
Sort images to cases
Review slide quality
Review image quality
Review case quality
EQUIVALENT TASKS
Histology Lab T&M Study Context
Digital Workflow – APLIS Integrated
Accessioning / Grossing / Histology
Case Assembly
Quality Check
Pathologist
Slide Creation
Transport
Enter Patient
Enter Case
Enter Slides
Case Entry
Stain and coverslip slides
Imaging
Sort slides to Cases
Case Assembly
Review slide quality
Review case quality
Quality Check
0
Eliminate
Enter Patient
Enter Case
Enter Slides
DUP TASKS
Pathologist
Load slides
Generate images
Unload slides
NEW TASKS
Sort images to cases
Review slide quality
Review image quality
Review case quality
EQUIVALENT TASKS
Histology Lab T&M Study Context
Digital Workflow – APLIS & Barcode Integrated
Accessioning / Grossing / Histology
Case Assembly
Quality Check
Pathologist
Slide Creation
Transport
Enter Patient
Enter Case
Enter Slides
Case Entry
Stain and coverslip slides
Imaging
Eliminate
Enter Patient
Enter Case
Enter Slides
DUP TASKS
Sort slides to Cases
Case Assembly
Review slide quality
Review case quality
Quality Check
0
Eliminate
Load slides
Generate images
Unload slides
NEW TASKS
Sort images to cases
Pathologist
Review slide quality
Review image quality
Review case quality
EQUIVALENT TASKS
Histology Lab T&M Study Goals
Standalone
APLIS
Integrated
APLIS & Barcode
Integrated
Case Entry
+ Tasks
Imaging
- Tasks
Imaging
Imaging
Case Assembly
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 Methodology
Case Entry Time
1.
2.
3.
Entered 17 randomly selected cases into Omnyx application
Recorded time to enter Patient, Case, and Histology information
Performed regression to model component times
Data Component
Average Time (Each)
Patient & Case
68 seconds
Histology Part(s)
25 seconds
Histology Slide(s)
3 seconds
Average Case (1 Part, 10 Slides)
Support Average Pathologist (3500 cases / year)
Average Lab FTE (2000 hrs / year)
= 2:03 minutes / case
= 119.6 hours / year
= 6.0% FTE / pathologist
= ~1 FTE / 16 pathologists
Histology Lab T&M Study Summary
Standalone
APLIS
Integrated
APLIS & Barcode
Integrated
Case Entry
6.0% FTE/Path
+ Tasks
Imaging
(TBD)
Imaging
(TBD)
- Tasks
Imaging
(TBD)
Case Assembly
18.5% FTE/Lab
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 Methodology
Case Assembly Time
1.
2.
3.
Observed histology lab for entire shift
Recorded time to spent on tasks between coverslipping and courier
Extracted time spent on Case Assembly tasks:
•
•
Sorting and matching slides to cases
Sorting and matching cases to pathologists or services
Academic Center Labs
Number of Labs Observed
4
Number 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
Average Lab FTE (8 hours / day)
= 18.5% FTE
PATHOLOGIST
TIME AND MOTION STUDY
Pathologist T&M Study Context
Experience from Radiology
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.
15
Pathologist T&M Study Context
Similarity of Pathology and Radiology
The challenges pathologist experience from managing slides is
similar to the challenges radiologists experienced with film.
16
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.
17
Pathologist T&M Study Methodology
1.
2.
3.
4.
5.
Observe pathologists across multiple days, subspecialties, and sites
Record time spent on each discrete task
Bucket the tasks into common activities
Identify the buckets impacted by an all digital workflow
Calculate opportunity as a percentage of total time spent on cases
Subspecialty Pathologists in Academic Setting
Number of Pathologists Observed
6
Number of Total Observations
12 (days)
Average Time on Case Work / Day
5:22:44
NOTE: Results varied significantly across observations, both across and within pathologists.
18
Pathologist T&M Study Results
Identified Opportunities for Time Savings
Matching:
Organizing Cases:
•
•
•
•
•
•
•
•
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
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
Pathologist T&M Study Results
Breakdown of Time Working Cases
Other
16.0% (0:51:43)
Slide Review
36.0% (1:56:13)
Workflow Opportunities
13.4% (0:43:09)
Reporting
34.6% (1:51:38)
Pathologist T&M Study Results
Breakdown of Workflow Opportunities
Workflow Opportunities
Other
16.0% (0:51:43)
Slide Review
36.0% (1:56:13)
13.4%
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
Reporting
34.6% (1:51:38)
17.0% (0:07:21)
100% (0:43:09)
Pathologist T&M Study Results
Additional Opportunities for Time Savings
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
Administrator preparing cases
Prior case retrieval and re-storage
Slide transportation
(observed 1:26:11)
(observed 1:35:43)
Pathologist T&M Study Summary
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 opportunity
Reducing 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.
T&M Study Conclusions
Routine use of an all-digital workflow shows…
Opportunity to increase available pathologist time from workflow savings
Observed 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 effects
Clinician Efficiency and Patient Care
• Patient satisfaction, timely treatment, reduced length of stay
Contact
curtis.stratman@omnyx.com