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Bar-coding in AP: OmniTrax as a Full Middleware Solution. Rodney Schmidt, MD, PhD Professor of Pathology, Director of Medical Informatics (Pathology) University of Washington, Seattle. Today’s Story. Lessons from OmniTrax Lean processes and workflow Deeper understanding of barcoding

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Bar coding in ap omnitrax as a full middleware solution l.jpg

Bar-coding in AP: OmniTrax as a Full Middleware Solution

Rodney Schmidt, MD, PhD

Professor of Pathology, Director of Medical Informatics (Pathology)

University of Washington, Seattle


Today s story l.jpg
Today’s Story

Lessons from OmniTrax

  • Lean processes and workflow

  • Deeper understanding of barcoding

    • Different levels of barcoding with different benefits

  • Measures of benefits

    • Quality and efficiency

    • Workflow dependent!

  • Current capabilities

    Trade-offs using a middleware solution

    Need for a bar-code standard


Disclosure l.jpg
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 revenue-sharing agreement with UW.

  • Dr. Schmidt has a consulting agreement with Thermo-Fisher for educational talks.

  • No other financial relationships with hardware or software manufacturers.


Why barcode l.jpg

Expensive

$23k/gross station

$10k/cutting station

Software

Workspaces change

Wiring, networking

Time investment

Software fast

Workspaces slow

Financing slow

Processes change

Material handling

QA

Jobs change

Workflow

Change management

Pathologists affected!

Why barcode?

Who needs the hassle?!


Why barcode5 l.jpg
Why barcode?

  • Error reduction and patient safety

    • Errors labeling things

    • 1/300 (manual) to < 1/10,000,000 (datamatrix)

  • Reduced medical-legal liability

  • Custodial responsibility & inventory control

  • Self-interested reasons

    • Helps you do your job faster

    • Reduced time wasted on error resolution

    • Indirect efficiencies because of better knowledge about where things are


What is bar coding l.jpg
What is Bar-coding?

  • Labeling

    • Putting barcodes on things

    • Technically easy, cheap (some methods)

  • Tracking

    • Location updates; inventory control

    • Added work; needs software; modest cost

  • Driving

    • Using barcodes to expedite workflow

    • Disruptive technology; expensive; LIS interoperability


Bringing bar coding to ap l.jpg
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


Achieved benefits l.jpg
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


Bar coding options l.jpg
Bar-coding Options

  • Buy LIS-specific

    • Available? Capable?

  • Buy 3rd party solution (middleware)

    • Available? Capable?

  • Build LIS-specific middleware

    • Can be quick. Investment.

  • Build LIS-agnostic middleware

    • Most complex; most control


Design principles l.jpg
Design Principles

  • No scanning without benefit

    • User acceptance; minimal training

  • No manual data entry

    • Eliminate human errors

  • Use barcodes to drive workflow

    • Efficiency

  • Make nothing until it’s needed

    • Eliminate handling and error opportunities

  • No assumptions – only trust scan events

    • Quality timestamps, locations, personnel

  • Leverage LIS

  • LIS-agnostic design


Material identification 2005 l.jpg
Material identification (2005)

  • Handwritten specimen labels

  • Manual, off-line cassette labeling

  • Hand-written slide labels



Targets gross room l.jpg
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 l.jpg

Receive specimen and enter data into the LIS

Generate a bar coded label for the specimen and laboratory request form.

Minimum extra keystrokes (one)

Targets - Accession


Slide15 l.jpg

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

Possible errors

*

*

Reconcile with LIS

Transport for processing

* QA steps


Slide16 l.jpg

Accession specimens

Bar-code specimens

Scan/print cassettes

*

Lay out cassettes

*

Fill cassettes

Rack filled cassettes

*

*

Transport for processing

Just-in-Time Printing

Fewer handling steps

Fewer (1) error opportunities

Fewer QA processes

Courtesy General Data



Histology embedding l.jpg
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 l.jpg
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 l.jpg
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 l.jpg
Slide Life Cycle

Histology

Pathology Offices

Sendouts

Faculty signout

File

Pull for conference

Resident review

Histology work order completes with scanning

Deliver

Ship


Slides benefits l.jpg
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 benefits23 l.jpg
Slides Benefits

FTE Savings


Barcodes enable l.jpg

Imaging

Gross photos

Photomics

Documents

EM/IF

HPV workflow

Reflex testing

Digene/Luminex

Specimen management

Discards

Locations

Winscribe automation

Barcodes Enable…


Targets specimens l.jpg
Targets - Specimens

  • Discards

    • Accurate

    • Efficient

    • Documented

  • Track location

  • Drive photography


Specimen discard l.jpg
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 l.jpg
Barcoding Benefits

  • Direct personnel (FTE)

    • 2.0 Slide delivery and tracking

    • 0.75 Cassette printing

    • 0.1 Specimen discards

    • 0.1 Document scanning

    • TBD Fluorescence image import

~$150,000/yr assuming $50,000/FTE


Barcoding benefits28 l.jpg
Barcoding Benefits

  • Indirect personnel (FTE)

    • 0.5 Scanned consult document availability1

    • TBD Scanned Req forms

    • TBD 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


Slide29 l.jpg

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


Omnitrax what s new l.jpg
OmniTrax – What’s new?

  • Interface model for interacting with LIS

  • More customers

    • OHSU

    • NYU

  • HPV workflow implemented

  • Gross/Histo enhancements

  • (Cytology support)

  • (Immunostainer interfaces)

    • Leica Bond 3

    • BioCare intelliPATH

  • (Archives tracking port)

  • (Slide tracking port)


Middleware l.jpg

Advantages

Leverage the power of core systems

Deliver niche functionality

Avoid duplication of core functions

If you build your own:

Independence and control

Open hardware options

Portability between LISs

Short bug/fix cycle

Implement functions you need

Tune and refine prn

Disadvantages

Ongoing interoperability

LIS upgrades

Might change LISs

Negotiate interfaces

Extract data

Write data

LIS data model poor

Too simple

Missing concepts

If you build your own:

Ongoing support obligation

Middleware

Software that bridges a human to one or more major systems


Basic architecture l.jpg

UI/ app

UI/ app

UI/ app

Business objects

LIS

Agent

Agent

Database

QA Reports

Basic Architecture

OmniTrax


Local extensions l.jpg

UI/ app

UI/ app

UI/ app

UI/ app

Business objects

LIS

Agent

IIS

Web app

Agent

Agent

LIS

Database

Reports

Local Extensions

OmniTrax

Web app

Reports


Growth and complexity l.jpg
Growth and Complexity

as of Sept 7, 2010

Version 1: 22 tables

Version 4: 48 tables

  • Lab Framework Client DLL – 22,850 lines (about 460 printed pages)

  • OmniTrax Server – 11,554 lines (about 235 pages)

  • Agent – 4199 lines (85 pages)

  • Gross Room Manager – 4754 lines (97 pages)

  • Histology Manager – 5133 lines (104 pages)

  • That’s equivalent to:

    • Les Miserables

    • All three Lord of the Rings books


Need for a standard l.jpg
Need for a Standard

Problems

  • Multiple barcodes from diff. facilities on same item

  • No “assigning authority” in barcode

    Interpreted differently by different software

  • Some proprietary uses

    APIII focus group suggestions (2008)

  • The barcode should contain only an identifier (e.g. “license plate”); software determines use

  • The barcode should contain something equivalent to an “assigning authority”.

    ID|application|installation

    12356789|OmniTrax|UWPath98195



Acknowledgements l.jpg

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!

Acknowledgements


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