digital pathology in the clinical workflow: a time & motion study pathology visions

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, PA2University of Pittsburgh, Department of Pathology, Pittsburgh, PA3University of Pittsburgh, Department of Dermatology, Pittsburgh, PA

Stratman – Employee of OmnyxHo – Research Grant from Omnyx

Disclosures

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

Imaging Case Assembly

0

Pathologist

Load slidesGenerate imagesUnload slides

Sort images to cases

Accessioning / Grossing / HistologySlide Creation

Pathologist

Stain and coverslip slides Sort slides to Cases

Case Assembly

Review slide qualityReview case quality

Quality Check

Transport

Quality Check

Review slide qualityReview image qualityReview case quality

Case Entry

Enter PatientEnter CaseEnter Slides


Histology Lab T&M Study ContextPhysical Workflow


0

Pathologist




Pathologist


Case Assembly


Quality Check

Transport

Quality Check


Case Entry



Histology Lab T&M Study ContextDigital Workflow – Standalone Imaging Solution


0

Pathologist




Pathologist


Case Assembly


Quality Check

Transport

Quality Check


Case Entry



Histology Lab T&M Study ContextDigital Workflow – Standalone Imaging Solution

NEW TASKS EQUIVALENT TASKSDUP TASKS


0

Pathologist




Pathologist


Case Assembly


Quality Check

Transport

Quality Check


Case Entry



Histology Lab T&M Study ContextDigital Workflow – APLIS Integrated


Eliminate


0

Pathologist




Pathologist


Case Assembly


Quality Check

Transport

Quality Check


Case Entry



Histology Lab T&M Study Context Digital Workflow – APLIS & Barcode Integrated


Eliminate Eliminate

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 Goals

Case Entry

Imaging Imaging Imaging

Case Assembly

+ Tasks

- Tasks

Standalone APLIS Integrated

APLIS & Barcode Integrated

1. Entered 17 randomly selected cases into Omnyx application2. Recorded time to enter Patient, Case, and Histology information3. Performed regression to model component times

Average Case (1 Part, 10 Slides) = 2:03 minutes / caseSupport Average Pathologist (3500 cases / year) = 119.6 hours / yearAverage Lab FTE (2000 hrs / year) = 6.0% FTE / pathologist

= ~1 FTE / 16 pathologists

Histology Lab T&M Study MethodologyCase Entry Time

Data Component Average Time (Each)

Patient & Case 68 seconds

Histology Part(s) 25 seconds

Histology Slide(s) 3 seconds

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 Summary

Case Entry6.0% FTE/Path

Imaging(TBD)

Imaging(TBD)

Imaging(TBD)

Case Assembly18.5% FTE/Lab

+ Tasks

- Tasks

Standalone APLIS Integrated

APLIS & Barcode Integrated

1. Observed histology lab for entire shift2. Recorded time to spent on tasks between coverslipping and courier3. Extracted time spent on Case Assembly tasks:

• Sorting and matching slides to cases• Sorting and matching cases to pathologists or services

Average Lab FTE (8 hours / day) = 18.5% FTE

Histology Lab T&M Study MethodologyCase Assembly Time

Academic Center LabsNumber of Labs Observed 4Number 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

PATHOLOGIST TIME AND MOTION STUDY

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.

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Pathologist T&M Study ContextExperience from Radiology

The challenges pathologist experience from managing slides is similar to the challenges radiologists experienced with film.

16

Pathologist T&M Study ContextSimilarity of Pathology and Radiology

17

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.

1. Observe pathologists across multiple days, subspecialties, and sites2. Record time spent on each discrete task3. Bucket the tasks into common activities4. Identify the buckets impacted by an all digital workflow5. Calculate opportunity as a percentage of total time spent on cases

NOTE: Results varied significantly across observations, both across and within pathologists.

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Pathologist T&M Study Methodology

Subspecialty Pathologists in Academic SettingNumber of Pathologists Observed 6Number of Total Observations 12 (days)

Average Time on Case Work / Day 5:22:44

Pathologist T&M Study ResultsIdentified Opportunities for Time Savings

Matching: • 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

Organizing Cases:• 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

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Workflow Opportunities13.4% (0:43:09)

Slide Review36.0% (1:56:13)

Other16.0% (0:51:43)

Reporting34.6% (1:51:38)

Pathologist T&M Study ResultsBreakdown of Time Working Cases

Slide Review36.0% (1:56:13)

Other16.0% (0:51:43)

Reporting34.6% (1:51:38)

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 17.0% (0:07:21)

Workflow Opportunities

100% (0:43:09)

13.4%

Pathologist T&M Study ResultsBreakdown of Workflow Opportunities

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 (observed 1:26:11)• Administrator preparing cases (observed 1:35:43)• Prior case retrieval and re-storage• Slide transportation

Pathologist T&M Study ResultsAdditional Opportunities for Time Savings

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 opportunityReducing 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.

Pathologist T&M Study Summary

Routine use of an all-digital workflow shows…

Opportunity to increase available pathologist time from workflow savingsObserved 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 effectsClinician Efficiency and Patient Care• Patient satisfaction, timely treatment, reduced length of stay

T&M Study Conclusions

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