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The Barcode-Driven Lab: Success in a Large System

Rodney Schmidt, MD, PhDUniversity of Washington, Seattle

April 17, 2011

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Topics

• Why create the barcode-driven lab?– Why in a large, complex lab?– Overview of functionality

• Not the detailed “how”; workflow

– Achieved benefits• Error reduction• FTE savings

• Important factors in success– UCLA, Sierra Pathology, NWP, NYU, OHSU

• What’s down the road?

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.

Why barcode?

• 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!

Who needs the hassle?!

Large Systems – Special Factors

• Multiple locations• Trainees – Residents and Fellows• Personnel turnover• Outside materials (e.g. consults)• Ancillary testing• Higher fraction of complex cases

Issues: Training, complexity, communication

Need: Robust systems to help people do things right

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

Material identification (2005)

• Handwritten specimen labels

• Manual, off-line cassette labeling

• Hand-written slide labels

Primary labeling errors (2004)

0100200300400500600700800900

1000

Blocks Slides

Recorded Actual

Accession number is re-entered into a standalone cassette imprinter

Accession number is re-entered into a standalone cassette imprinter

?

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

Receive specimen and enter data into the LIS

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

Minimum extra keystrokes (one)

Accession specimens

Label specimens

Transport for processing

Reconcile with LIS

Move to staging area

Rack filled cassettes

Request more cassettes

Fill cassettes

Lay out cassettes

Move to gross bench

Group with specimens

Label cassettes

Store excess with specs

Classic Grossing Workflow

**

*

*

*

*

* * QA steps

Possible errors

Handling steps

Just-in-Time PrintingAccession specimens

Bar-code specimens

Transport for processing

Rack filled cassettes

Fill cassettes

Lay out cassettes

*

**

*

Scan/print cassettes

Courtesy General Data

Fewer handling steps

Fewer (1) error opportunities

Fewer QA processes

Rescan cassettes

Benefits

• Efficiency– No manual pre-printing and sorting of cassettes– Quick just-in-time additional cassettes– Default cassettes from PowerPath specimen panels– Blocks automatically ordered in PowerPath

• Quality– No manual labeling (no errors)– Scanning specimen barcode assures correct

specimen– Enter cutting instructions, # pieces– Records which blocks are sent for processing

Q&E Benefits

“Classic” “Just-in-Time”

Handling steps 11 5

Error opportunities 9 1

Manual QA steps 7 4

Primary labeling errors 988/yr (est.);

(1.2%)

2 in 3 mo (initial);

0 in next 7 mo; (0.003%)

Cassette wastage ~25/d (~7%) ~0

Grossing efficiency -- At least as fast

Support staff -- 0.75+ FTE saved

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

• 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

• 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

Histology work order

completes with scanning

Ship

Resident review

Deliver

Faculty signout

File

Pull for conferenc

e

Sendouts

Histology

Pathology Offices

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 Benefits

FTE SavingsFTE Savings

HistologyHistology +0.5 +0.5 FTEFTE

Reduced time hunting for Reduced time hunting for mis-delivered slidesmis-delivered slides

+0.5 +0.5 FTEFTE

Auto completion of outstanding orders Auto completion of outstanding orders when slide is scannedwhen slide is scanned

Office staffOffice staff +.5-1 +.5-1 FTE FTE

Reduced time for conference Reduced time for conference preparationpreparation

+.25 +.25 FTE FTE

Increased efficiency regarding send Increased efficiency regarding send outsouts

Barcodes Enable…

• Imaging– Gross photos– Photomicrographs– Documents– EM/IF

• HPV workflow– Reflex testing– Digene/Luminex

• Specimen management– Discards– Locations

• Winscribe automation

Specimen Discard

WorkflowWorkflow

– 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

• 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

• 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

Barcoding Benefits

1Schmidt, RA, et al. Am J Clin Pathol 126:678-83, 2006

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

Barcoding Benefits

Reasons for Success

• Optimized workflow– Lean analysis– Close ties to users– Multiple workflows; exception trapping

• LIS interoperability– Initially with PowerPath; now general

• Just-in-time production of materials

• Selection of appropriate equipment

Where Next?

• Specimen transport– Within multiple sites in a large lab– Upstream all the way from the patient

• Result transport– All the way back to the patient

• Likely to need multiple systems

Need an industry barcode standard

Where Next?

• Tissue banking (becoming routine)– Unique identifiers (encrypted for research)– Repository management– Maintain provenance– Pre-analytic variables

• Tissue micro-arrays– Each sample linked back to patient

Where Next?

Patient- and time-based disease data structures

Diagnosis RecurrencePersistent

(Time)Patient

•Links between serial samples of same disease•Relation to clinical treatment•Correlated blood samples

All types of data•IHC•Cytogenetic•Molecular

Treatment 1 Treatment 2

What does sample tracking mean for molecular testing?

Why barcode?Expensive … true, but reasonable ROI

Workspaces change … it might be time

Process changes … new processes are better

Jobs change … but more valuable activity

Pathologists affected … in good ways

Time investment … pays off!

Better lab efficiency

Error/liability reduction

Inventory control

Resident autonomy

Gateway to more functions

Conclusion

• Barcoding is becoming an expectation– Patient safety / error reduction

• It’s to your financial advantage

For success, you must be sophisticated enough to know the difference between just putting a barcode on something and having a barcode-driven lab.

Acknowledgements

• 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!

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