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Forcing Open the Pod Bay Doors

Forcing Open the Pod Bay Doors

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Forcing Open the Pod Bay Doors

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  1. Forcing Open the Pod Bay Doors Harnessing IT in the Service of an Anatomic Pathology Service Richard E. Whisnant, MD Suncoast Pathology Venice, FL

  2. Who we are • Suncoast Pathology • Three pathologist independent laboratory • William G. Roth, MD • Tamara L. Densmore, MD • Richard E. Whisnant, MD • Hospital, outpatient, cytology services • ~15,000 surgical accessions/year • Disclosures • Patent pending and ownership/financial interests Richard E. Whisnant, MD Suncoast Pathology

  3. What we set out to build Richard E. Whisnant, MD Suncoast Pathology

  4. What we set out to build A comprehensive information technology solution to the most significant problems in our own anatomic pathology practice, including quality, workflow, and staffing. Richard E. Whisnant, MD Suncoast Pathology

  5. System Overview- Auto-Dx • “AP Middleware” system • Interfaces to existing AP-LIS • Site of every interaction by every staff member with every case the laboratory handles • Technical details • Filemaker Pro 6.0 database (desktop pseudo-server) • 10 workstations • 3 pathologists, 3 grossing room, 4 histology • Barcode scanner (2D) and laptop/desktop (<$10K) Richard E. Whisnant, MD Suncoast Pathology

  6. If it were an IT challenge, it would be easy (or at least someone else’s problem) Possible IT Solutions Culture Workflow X X and over here You are here… Richard E. Whisnant, MD Suncoast Pathology

  7. Our actual starting state Culture Workflow X X Possible IT Solutions and over here You are here… Richard E. Whisnant, MD Suncoast Pathology

  8. Two projects in one, neither IT Process Redesign Culture Workflow X X Social Engineering Richard E. Whisnant, MD Suncoast Pathology

  9. User Interface Overview • User Interface • Pointing methods- mouse, touch screen, voice • Quality of interface design • Metric: total # of mouse clicks per case signed out! • Centrality of programmable bar code scanners Richard E. Whisnant, MD Suncoast Pathology

  10. Function List • Autopilot • Tasked with preventing errors and other lapses of quality at every interaction with a case • Air traffic controller • Improves workflow and efficiency • Flight Data Recorder (“Black Box”) • Collects detailed data on all near-misses and errors • Flight Simulator Richard E. Whisnant, MD Suncoast Pathology

  11. Autopilot functions • Clerical checks, broadly defined. • Production of text for gross and final diagnosis • Decision support functions. • Automated coding. • QC supervision and selection. Richard E. Whisnant, MD Suncoast Pathology

  12. Auto-Dx: operator manual • Scan slide • Follow prompts from there Richard E. Whisnant, MD Suncoast Pathology

  13. Acknowledge Header/Gross information Richard E. Whisnant, MD Suncoast Pathology

  14. Surgical/Cytology history review Richard E. Whisnant, MD Suncoast Pathology

  15. Screen for and highlight the highlights Richard E. Whisnant, MD Suncoast Pathology

  16. Diagnosis entry Richard E. Whisnant, MD Suncoast Pathology

  17. Diagnosis entry-2 Richard E. Whisnant, MD Suncoast Pathology

  18. Diagnosis entry-3 Richard E. Whisnant, MD Suncoast Pathology

  19. Review Interfaced and customized Richard E. Whisnant, MD Suncoast Pathology

  20. Richard E. Whisnant, MD Suncoast Pathology

  21. Richard E. Whisnant, MD Suncoast Pathology

  22. Review Interfaced and customized Richard E. Whisnant, MD Suncoast Pathology

  23. Interpathologist Communication Log (aka Deep Thoughts) Richard E. Whisnant, MD Suncoast Pathology

  24. Diagnosis entry revisited Richard E. Whisnant, MD Suncoast Pathology

  25. Text Generation Overview • Text Generation: Coded versus Freestyle • More efficient freestyle dictation = pyrrhic victory • Asynchronous: traditional dictation, digital dictation • Synchronous: voice recognition, self-typed • Coding challenges • Our own preconceived notions and biases (“natural language”) • Technical challenges Richard E. Whisnant, MD Suncoast Pathology

  26. Simple skin excision gross (partial) • skin_shape_text & "measuring " & skin_size1 & " x " & skin_size2 & " x " & skin_size3 & " cm. There is a" & If( skin_lesion1 <> "irregular epidermal surface", " " & skin_lesion_location & "ly located ", "n ") & If( skin_lesion_size <> "", skin_lesion_size & " cm " , "")& skin_lesion1 & " noted. " & "The specimen is inked" & If( scored_margin <> "" and scored_margin <> " ", " and the " & scored_margin & " margin is scored" & If( twelve_designation? <> "already clocked", " (relative to the " & twelve_designation? & " being designated 12:00). ", ". ") ,". ")& "Sectioned " & If( number_of_blocks= 1, "and entirely submitted in a single cassette labeled " & part_letter & ". ",If( skin_lesion1 <> "irregular epidermal surface", "with the lesion in cassette", "with central sections in cassette") ) & If( number_of_blocks= 1, "", If( (cassettes_for_lesion > 1), "s " & part_letter & "1 through " & part_letter & cassettes_for_lesion & ". "," " & part_letter & "1. ")) & If( number_of_blocks= 1, "", If( entirely_submitted? = "no", "Representative sections of the remaining tissue submitted as ", "Remaining tissue entirely submitted as ") & part_letter & (cassettes_for_lesion + 1) & If( (cassettes_for_lesion + 1) < number_of_blocks, " through " & part_letter & number_of_blocks, "") & ".¶") Richard E. Whisnant, MD Suncoast Pathology

  27. Skin excision- grossing workstation Richard E. Whisnant, MD Suncoast Pathology

  28. Coding colon resections Richard E. Whisnant, MD Suncoast Pathology

  29. Colon resection output format • B) POLYPS ASCENDING: • *INVASIVE LOW-GRADE ADENOCARCINOMA, 3 CM. • -pT2: Tumor invades into, but not through, muscularis propria. • *pN1: METASTATIC TUMOR PRESENT IN (2/17) PERICOLIC LYMPH NODES. • -Margins clear: Proximal and distal mucosal margins widely (>5 cm) • free of tumor. • Other cancer summary data: • -pMx: Status of distant metastases not known. • -Circumferential radial margin status: • -Resection type: Sigmoid colectomy. • -Tumor location: Sigmoid colon. • -Lymphatic (small-vessel) invasion: absent. • -Venous (large vessel) invasion: absent. • Note: The above report includes all data recommended by the College of American Pathologists for complete reporting of colon tumors. Richard E. Whisnant, MD Suncoast Pathology

  30. Function List • Autopilot • Tasked with preventing errors and other lapses of quality at every interaction with a case • Air traffic controller • Improves workflow and efficiency • Flight Data Recorder (“Black Box”) • Collects detailed data on all near-misses and errors • Flight Simulator Richard E. Whisnant, MD Suncoast Pathology

  31. Histology performance measures- individual (4x objective) Richard E. Whisnant, MD Suncoast Pathology

  32. Histology performance measures- individual (40x objective) Richard E. Whisnant, MD Suncoast Pathology

  33. Histology performance- group (4x objective) Richard E. Whisnant, MD Suncoast Pathology

  34. Histology performance- group (40x objective) Richard E. Whisnant, MD Suncoast Pathology

  35. Pathologist performance-individual Richard E. Whisnant, MD Suncoast Pathology

  36. Pathologist performance-group Richard E. Whisnant, MD Suncoast Pathology

  37. Function List • Autopilot • Tasked with preventing errors and other lapses of quality at every interaction with a case • Air traffic controller • Improves workflow and efficiency • Flight Data Recorder (“Black Box”) • Collects detailed data on all near-misses and errors • Flight Simulator Richard E. Whisnant, MD Suncoast Pathology

  38. Flight Data Recorder (Black Box) function • Detailed event data (timestamps, pathologist communication, changes, etc.) on errors • Allows retrospective answers to questions • Increases error identification through blinded review process. • Allows (and forces) near-miss evaluation Richard E. Whisnant, MD Suncoast Pathology

  39. Second Review Design Richard E. Whisnant, MD Suncoast Pathology

  40. Richard E. Whisnant, MD Suncoast Pathology

  41. Automated Quality Conference Cover Sheet Richard E. Whisnant, MD Suncoast Pathology

  42. Flight Simulator- work in progress • Combination of blinded review routine workflow and known baseline detailed performance characteristics allows production of meaningful quality exercises. Richard E. Whisnant, MD Suncoast Pathology

  43. Auditing effectiveness • Possible triggers • Random cases • High-risk histories • Recent performance Richard E. Whisnant, MD Suncoast Pathology