the integration of amp (barcode / scanning) and voice dictation into the pathology process

2011 PowerPath® Users Conference May 18 - 20, 2011The Clement Monterey • Monterey, California

2011 PowerPath® Users Conference May 18 - 20, 2011The Clement Monterey • Monterey, California

The integration of AMP and Voice dictation into the pathology

process and how it has benefited The Ottawa Hospital in turn around

times, efficiencies and quality

Dr. Gerard JansenHead of Pathology, Ottawa Hospital

Chris GodinManager of Information Services and Technology, Eastern Ontairo Regional Labratory Association (EORLA) @ChrisWGodin

Experience the Elekta Difference

The Ottawa Hospital and EOALA

• The Ottawa Hospital:– 3 campus, academic health sciences centre– Serving 1.5 million residents of Ottawa and Eastern Ontario, both in English and

French. – Specialty centres in cancer, heart, kidney and vision care, and rehabilitation

services. – Prime research collaborator: Ottawa Health Research Institute, the University of

Ottawa, and many others

• Eastern Ontario Regional Laboratory Association (EORLA):– The most advanced laboratory transformation project in the province of Ontario. – 16 hospitals in the Champlain region (including TOH): area 9000 mi2

– Regional, integrated hospital laboratory services system. – TOH is the EORLA reference laboratory for the region.


Pathology at TOH

• Pathology Stats 2010

• TOH was using Cerner Classic for Pathology reporting.

• Pathology lab follows the LEAN process initiative which PowerPath and AMP fit in well.

Reports Specimens Blocks Slides

Surgical 44,600 63,000 203,000 375,000

Cytology 24,000 2,500 43,000

Autopsy 780 7,000 7,500

Consults 1,800


AMP Hardware

• What hardware is required to take full advantage of AMP

45 Label Printers3 Cassette Printers (High Volume)

5 Cassette Printers (Low Volume)

100 Barcode Scanners


AMP Consumables

• Cassettes – depending on the brand of cassette printer, specific cassettes may be required.

• Labels – label stock of sizes required. Slide labels must be resistant to the chemical baths.

• Ribbons – Label ribbon must work well with the label material to ensure the ink remains on the slide.


Voice Recognition

• PowerPath is integrated with VoiceOver which uses the Dragon Medical Naturally speaking engine.

• Pathologists dictate their diagnosis and microscopic into the integrated WORD template.

• Pathologists Assistants will dictate the Gross Descriptions

• VoiceOver has provided the hands free operations necessary to navigate PowerPath by issuing voice commands.


Accessioning

• The accessioning process step does not use AMP, but it is still an important step as it kick’s off the entire process.

Once a case is accessioned, the PowerPath system produces document labels and specimen labels.


Document Scanning

• Requisitions are scanned into the PowerPath document management component and linked to the patient case by bar code.


Gross Technician

• A Gross Room technician prepares the case.

– Barcode Labels are affixed to the specimen containers

– Containers are scanned in AMP using the grossing station configuration which produces the pre-configured amount of cassettes for that specimen.


Specimen 1 – Liver is scanned & Cassettes are Printed


• Specimen 2 – Colon is scanned and Cassettes are printed


Grossing

• Total of 11 grossing stations across 3 campuses.

• When the PA begins the case the specimen is scanned, resulting in PowerPath and AMP bringing up the correct case.

• The case is dictated, and the cassettes are scanned out using AMP.


• PA scans specimen 1 and opens report to dictate


• After dictation PA scans all the cassettes, A&B scanned


• Specimen 2 scanned, dictated and cassettes scanned out


• Gross is totally completed and sent to histology.


Histology: Embedding

• All 4 embedding stations are equipped with a barcode scanner and touch screen display.

• Cassettes are scanned thenembedded providing indication of the number of cassettes making up the case.

• Cases are kept together as much as possible through the process.


• Blocks are scanned as they are embedded.


• Embedding instructions are carried from the Grossing


• Case Complete indication once all blocks are scanned.


Histology: Cutting

• 16 cutting stations are equipped with a barcode scanner touch screen display, and zebra label printers.

• Cassettes are scanned a label is printed in real time

• The block is cut and the section is placed on the slide

• The label is then affixed to the slide• The use of AMP at this workstation has

greatly improved efficiencies and increased quality.


• Cassette is scanned and slide labels are printed in real time


Slide Distribution

• Slides are distributed to pathologists or cytotechnologists by scanning the slides into virtual PowerPath folders, that co-inside to the physical folder.


• Folder is created, slides are scanned into it, then folder is assigned to the pathologist.


Pathologist

• Pathologist will scan one of the slides in the folder and the case will appear in PowerPath and AMP simultaneously.

• The pathologist will examine the slides for the case and dictate the report and sign it out.

• If there is more than one case in the folder the pathologist will simply scan the next slide and the correct case will appear.


• Pathologist Scans slide and folder appears. This case is split between 2 folders.


• Pathologist dictates using VoiceOver into the report. Voice commands are issues to navigate within PowerPath.


Cytology

• The version of AMP currently being used by TOH has very limited Cytology functionality, however it is the understanding that some missing functionality has been built into the next AMP release.

• Cytology uses AMP for Slide Distribution and Specimen Discarding.


Specimen Discard

• Knowing if a specimen can be discarded by a simple scan is a HUGE time saver in the LAB.


Real Time -Amp Material Log

• Find Materials inthe lab quickly

• Know who wasworking with thematerial

• Know where itwas scanned.


What parts of AMP do we not use

• TOH uses almost all the AMP functionality except for the General Scanning station as there was a configuration we could use for every workstation.

• Slide/Block Storage did not provide enough configuration flexibility to to meet desired storage and filing requirements.


What’s next with AMP

• The EORLA reference lab at TOH has worked very closely with the PowerPath team to bring out new features made to this release.– Cytology Station addition– Cutting station improvements– Enhanced Printing options – Specimen discard improvements

• I would encourage you all to attend the Elekta AMP session focused on the new version of AMP.


Realizing the Benefits

• Bar codes; why bother…

• The virtues of Voice Reporting/Recognition


Bar codes are everywhere…

• So why not welcome them…….

• However do you really want them/need them, – on your desk– in your lab– in your gross room– in your LIS……..


Purpose of Bar Coding

• Retail:– Maintain track of inventory in real time (tracking)– Reduce losses (correct pricing by avoiding manual entry)– Increase efficiency (no time wasted with data entry)– Enable self check-out

• Health care:– Increase safety by:

– Unique machine readable identifier (no manual data entry)– Track-able in process

– Increase efficiency


Gains of Bar Coding?

• Time:

Area Issue Gain/Losses

Gross room Large specimen

Gross room Biopsy 1 min/case (x 20K cases)

Histo lab Machine labelling 7s/slide (x 350k slides)

Histo lab No second label 12s/slide (x 350k slides

Pathologist All cases


Surgical specimen TAT after introduction of bar coding in days

0.00

2.00

4.00

6.00

8.00

10.00

Jul Aug Sep Oct Nov Dec

2009

2010

Average TAT increase is 0.01 day/case = 1.2 cumulative wait year for 44,600 cases


Gains of Bar Coding – 1

• Patient safety: most errors in gross room with extra blocks, block numbers etc.

0

20

40

60

80

100


2009

2010

Approx 1/3 errors caught in gross room using elaborate checklist costing 2 hrs per day—leaving 53 errors/mo

Blo

ck e

rror

s pe

r m

onth


• 2 major mix-ups in the lab caught and ‘reconstructed’ before sign out.

• 1 case mix-up at pathologist desk: wrong sign out diagnosis….bar coding had not been used.

• No cases signed out in wrong case when bar coding was used for sign out (…10 months and counting)

• Easy traceability of case in process• Potential for process specific TAT (TAT gross room, TAT

lab, TAT individual pathologist after slide receipt)• Etc.

Gains of Bar Coding – 2


• Gross room: biopsies take longer (together with voice).

• Potential solution: photograph container and specimen and automate processes.

Gains of Bar CodingWho pays the price?


Gains of Voice Recognition/Reporting

• Before implementation of voice recognition/reporting:

– Retrospective study wait time for transcription only mean 27.25 hrs/case

– Prospective study mean dictation time per case to be 3 mins 41 s, and wait time for transcription to be 13 h and 23 mins (the latter time is very likely biased).

– So a minimum cumulative annual wait time of 66.2 patient wait years per year.

– If VR would be implemented with self review/correction then this would be reduced to 0.


Time gain with voice

0

2

4

6

8

10


2008

2009

Average gain = 0.83 days/case = cumulative 101 patient wait years (44,600 cases)


Gains voice recognition/reporting

• Hospital: savings $300,000 (5 transcriptionists)

• Patients: reduction of TAT with almost 1 day

• Who pays the price:– Gross room: efficiency small specimen lower. Solution: ‘gross by

picture’.– Pathologist: different way of correcting takes more time about 3-4

min per specimen = ¾ to 1 hour per day extra on a surgical day: counter balance: improve template reporting


Conclusions

• Voice recognition and bar coding can be introduced in a very busy mid to large scale anatomical pathology laboratory. Investment in equipment is substantial.

• Voice recognition in the AP lab leads to reduced turn around time. Paying the price by pathologists and gross room staff needs to be avoided by using templates and ‘gross by photo’.

• The gain of bar coding is in:– Considerable patient safety enhancement– Specimen/block/slide tracking improvement– Improved management reports

• Bar coding of specimen does not necessarily lead to a reduced turn around time or increased productivity.


Questions / Comments

WHY NOTASK A QUESTION

Thank YouDr. Gerard Jansen – [email protected]

Chris Godin – [email protected]

mailto:[email protected]

mailto:[email protected]

the integration of amp (barcode / scanning) and voice dictation into the pathology process

Documents

elekta difference

grossing experience

scanned cassettes

ab scanned experience

scanned outusing amp

scanned alabel

amp consumables cassettes

specimen labels