Dr. Lavinia P. Middleton, MD
Ron A. Phipps, MBA

In the treatment of cancer:
– Personalized medicine is the use of genetic markers and/or pharmacogenomic testing to tailor an individual's therapy.
– Results of molecular tests determine course of therapy
• Based on patient’s likelihood to respond to certain targeted treatments

• Changes Implemented in Previous Project:
– Restructured LIS with Molecular test-level case type
– Developed electronic Request Form
– Increased Space & Organization for Expeditors
– Workflow changes for Pathologists & Expeditors
– Developed Electronic Whiteboard of pending cases
• Results:
– Reduced pre-analytic TAT by 45% from 2008 to 2010
– During this timeframe, growth was 88%

180000
160000
140000
120000
100000
80000
60000
40000
20000
0
FY
'0
1 A ct ua
FY
'0 l
2 A ct ua
FY
'0 l
3 A ct ua
FY
'0 l
4 A ct ua l
FY
'0
5 A ct ua
FY
'0 l
6 A ct ua l
FY
'0
7 A ct ua l
FY
'0
8 A ct ua l
FY
'0
9 A ct ua l
FY
'1
0 A ct ua l

The purpose of this project was to further reduce the turnaround time for the pre-analytic phase of
Molecular Diagnostic Lab (MDL) tests from a baseline of 7.1 days by 25% by the end of 2011.
Focus: Further improving efficiencies & eliminating waste to increase capacity

Pathology Faculty:
Dr. Lavinia Middleton, Dr. Asif Rashid, Dr. Stanley R. Hamilton
Pathology Administration / Lab Management:
Pam Puig, Kaye Barr, Donna Skidmore, Sherrie L Jackson, Javier
Guerrero
Hematopathology Faculty:
Dr. Raja Luthra, Dr. Zhuang Zuo
Hematopathology Administration / Lab Management:
Ann C Reynolds, Cindy Lewing, Christopher Bowman
Laboratory Informatics:
Dr. Mark Routbort, Lori Heydon, Judson Dunn, Huimin (Lily) Lu, Trey
Elliott
P&LM Divisional Quality Improvement:
Ron Phipps, Martha Johnson-Hamilton, Han Le, Charisse
Acosta, Joan T. Woods

MD Anderson’s Strategic Goals:
– Patient Care:
• Strategy 1.2 We will increase the quality, safety and value of our clinical care.
•
Strategy 1.5 We will enhance productivity, access and efficiency by strengthening our infrastructure and support systems.
– Research:
• Strategy 2.2 We will lead in the personalization of cancer diagnosis and treatment by detecting and targeting specific genetic and molecular abnormalities in a patient’s cancer and the tissue microenvironment, enhancing immune responses, and improving targeted radiation and surgical treatments.
– Resources:
• Strategy 7.1 We will continuously improve our administrative infrastructure to support the efforts of our people in achieving our mission through health information technology and quality improvement education and research.

– Expectation: Better outcomes can be achieved
Therefore, quick turnaround time is imperative to initiate cancer care

Turnaround time:
Start: When request is created in clinic
End: When MDL lab starts analytic processes
Average TAT:
95th Percentile TAT:
7.1 Days
19 Days
Volume: 517 requests/ month
Data entries per request: 10.6

Issues:
Lots of Scenarios
– 11 Decisions
– 105 Pathways
– 7 to 28 Process Steps
Lots of Hand-offs
– Range: 2 to 17
Lots of Data Entry
– Up to 5x for each test
All occurring before the
MDL lab gets the specimen

The number of steps in the pre-analytic process varies greatly depending on:
– the scope of testing needed
– whether DNA is already available
– where pathology specimen materials are located:
File room pathologist office off-site storage contributing hospital
– whether sufficient materials are available
– whether selected materials are appropriate

– Request Received by MDL
– MDL checks for existing
DNA / slides
– MDL Logs requested tests
– MDL Lab forwards request
}
} to Expeditors
Data Entry on Tracking
Steps

Restructure the LIS:
– Create a separate “Request-level” case type
– One transaction per patient request
• Eliminates redundant test-level data entry
• Used in all pre-analytic tracking steps
The test level “M-numbers” would now be used only during the analytical phase

Concerns: MDL Lab concerned that Expeditors would “get all the gains”
Resolution: Modify Proposed Solution:
– Ensure MDL “M-Case” entry would be less work
• Increased integration of their systems
• Pre-populated many fields from the R-Case
– Take tasks from MDL lab personnel
• Expeditors now perform initial review
• One less hand-off!
• MDL lab would only be involved when materials are ready for testing

The implementation plan included:
– Team’s detailed review of process flows
– Development of the IT application
– Multiple meetings to review application in test environment
– Comprehensive testing & validation
– Go-live planning
– Role changes / training / communications

– Removed Request
Processing duties & hand-off from MDL
– Reduced data entry needed for tracking
– Improved clinician’s visibility to request status in EMR

Interface changes in other systems
– Linked history of "R-Series" with "M-Series" to ensure complete tracking
Job function changes
– For both the MDL lab & Pathology Expeditors to support the new system
Procedures updated for the various areas
Transitioning from offline electronic Request
Form to EMR Order Entry per Order Sets

Timeframe
Prior to Sep
2008
Sep 2008
Apr 2009
Mar 2010
Feb 2011 -
Current
• N/A
Benefits
• Electronic Database
• Integrated with LIS
• Integrated with EMR
• Improved lab integration
• Simpler EMR Visibility
• Less data entry
• Improved lab integration
• N/A!
Issues
• No electronic tracking until analytic phase
• Not Integrated with LIS
• Not Integrated with EMR
• Redundant data entry
• All tracking at test level

Soft Savings: $20,290 in personnel time / year
Qualified Benefits:
– Win-Win! Saved time for MDL Lab & Expeditors
– Increased capacity to meet growing demand
– Improved tracking management of pending work
– Increased accountability
– Enhanced visibility of test request status in EMR
– Getting patients their results 1.5 days sooner…

After the solution was adopted for Molecular tests, the “R-series” case type solution was expanded throughout their pre-analytic phases for:
– Immunohistochemistry (IHC)
– Fluorescence in situ hybridization (FISH)
– Reference Labs (Oncotype DX)

70000
60000
50000
40000
30000
20000
10000
0
FY06 FY07 FY08 FY09 FY10

10000
9000
8000
7000
6000
5000
4000
3000
2000
1000
0
FY07-08 FY08-09 FY09-10

– Systematic changes made to process ensure sustainability
– TAT monitored on each request via real-time dashboard

Develop a process to prospectively obtain tissue both for diagnosis and molecular studies
– Further turnaround time improvement expected in resulting molecular tests
Continue to gain efficiencies:
– Billing verification tasks done by the lab
– Leverage increasing use of Clinic Order Sets
• Details Medical Necessity or Protocol #

Contact us: Dr. Lavinia Middleton, MD lpmiddleton@mdanderson.org
Ron A. Phipps, MBA raphipps@mdanderson.org