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Pursuit of an Optimized Surgical Pathology Workflow with Digital Pathology Integration

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Pursuit of an Optimized Surgical Pathology Workflow with Digital Pathology Integration Pursuit of an Optimized Surgical Pathology Workflow with Digital Pathology Integration J. Mark Tuthill, MD Division of Pathology Informatics Henry Ford Hospital Detroit, MI 48202 [email protected] Digital Pathology and AI Workshop Pittsburgh, PA December 13-14, 2019 Objectives 1. Understand digital integration prerequisites and opportunities 2. Present examples of operational systems used and digitally integrated at HFHS 3. Highlight common strategies the lead to success 4. Describe the integration of WSI 5. Recognize challenges and points of failure in digitial workflow and WSI Philosophical Hypothesis • “We can integrate AP workflow so that it models efficiency of the clinical laboratory” – What are the pre-requisites? – What is the low hanging fruit? • Sequence – What are the technology gaps? • Advanced robotics and pipeline development – Automation of manual processes Operational Systems Digital Integration Information Technology Lab Information System PATHOLOGISTS TECHNICAL & SUPPORT STAFF Epic Wired Sunquest : Lab and CoPath Histotrak HLA MAS POC Syapse Aqueduct Hematology Lane Faxing LAB PORTAL SCANNING APOLLO Digital Pathology Atlas ARCC Roche Scantron MikroScan − Surg Path Reqs − Store AP Req Scans Digital Cameras − Cytopath Reqs − Store Clin Path Req Scans − Clin Path Reqs − Integrate External AP Results − Outreach Documents − Telepath Integration HEALTHSTREAM − Associate Imaging to Reports Training (HFHS U) − Interface to acquisition devices Competency Cameras (1-2 M records/yr) - Gels LAB USER’S Molecular Pathology and NGS -Microbiology GUIDE pathology.hfhs.org/lug TISSUE DOCUMENT BIOREPOSITORY CONTROL Master Control Clinical Pathology Systems Functional Areas Applications • Chemistry • SunquestLab • Hematology • SMART – barcoded specimen tracking, • Coagulation management. and archiving • >170 Instrument Interfaces via Sunquest • Urinalysis Instrument Manager (SIM) • Blood Bank • Autovalidation • Microbiology • Macroscheduler automated jobs • Serology • Histotrac: HLA laboratory system • Virology • MSQL Report Writer w/ Crystal • HLA • Results transmitted to EPIC • Molecular • Beckman Automation Line; Conexus; • Genomic Pathology Remisol • Point of Care – Glucometers >650 – Coagulation clinics Anatomic Pathology Systems Functional Areas Applications • Histology • Sunquest CoPath • Molecular Pathology • Biomaterial tracking system (BTM) – Illumina NGS • Scantron: requisition scanning • Cytology • mTuitive: synoptic checklists • Frozen Room • JFCC reporting via ePath • Autopsy • Barcoded LEAN production • CP Integration • Apollo Digital photography – Special Hematology • Telepathology: Mikroscan – Flow Cytometry • WSI: Ventana Virtuoso, Mikroscan – Immunohistochemistry – Ventana Connect – Microbiology • Dako Connect • Tens of molecular pathology applications Other LIS Applications and Operations Functions • Atlas Portal: Outreach EMR; order entry and result reporting • Scantron: Document scanning for regulatory retention • LUG: Laboratory Users Guide • Lane Faxing: supports all Health system laboratory faxing • BTM: Tissue Biorepository • IT Service Now: Helpdesk; PI Change Control database for compliance • Apollo ARCC: Image storage integrated with both Sunquest systems (Lab & CoPath) • Cytovision Cytogenetics imaging system for Karyotyping and FISH analysis • Hologic Automated pap smear screening Road Map for Digital Workflow The Big Picture • Pre analytic – Prior to receiving or analyzing the sample – Preparing samples for analysis • Analytic – The process of analyzing the tissue • Post analytic – The reporting of diagnostic information – Preparing for additional analytic studies Prerequisites for Anatomic Pathology Digital Workflow • Sophisticated electronic medical records system – Electronic orders interface for Anatomic Pathology • Bar code labeled assets with the laboratory – Assets with unique identifiers • Development of robotic technologies – *Grossing* – Embedding, Sectioning – Tissue transport – Sampling – Storage systems: cassettes and slides Prerequisites for Anatomic Pathology Digital Workflow • Electronic orders interface to the Anatomic Pathology Laboratory Information System (AP-LIS) – Similar to the clinical laboratory, a flow of orders to the LIS will enable: • Sample receipt • Tracking • Routing • Analytic Processing • Automation of several elements of case accessioning – Decrease errors – Increased throughput Prerequisites for Anatomic Pathology Digital Workflow • Bar code labeled assets within the laboratory – This is most essential early prerequisite to achieve automation within the laboratory – Bar coding of assets allows for: • Bar code driven workflow • Identification error reduction due to mislabeling • Improved efficiency by reducing manual labeling • Automation of subsequent activities – Integration whole slide imaging, interface devices – This is the key requirement for all automation Prerequisites for Anatomic Pathology Digital Workflow • Bar code labeled assets within the laboratory – Critical for each asset to have an unique ID embedded in the bar code – This will allow each block and slide to be managed uniquely supporting (Assets) • Sophisticated routing • Tracking of assets • Digital Pathology (unique ID on slides will be essential!) • Systems interfaces • Without uniquely identified assets the clinical laboratory could not have achieved the level of automation currently experienced Examples of Anatomic Pathology Digital Workflow Real World Examples and Status Updates Examples of AP Digital Workflow • Automation of histology orders (stain protocols) • Interfaced immunostain orders to automated immunostain platform • Bar code labeling automation – Automated production of cassettes at accessioning – Cassette driven generation of labeled slides • Tracking, routing and storage • Automated tissue embedding, Sakura AutoTEC • Automated microtome's Examples of AP Digital Workflow • Automated block sampling • Automated slide sampling – Laser capture micro dissection • Conveyor belt systems, tubes, roving robots: routing • Slide collation robotics • Automatic diagnostics – Whole slide imaging algorithms for immunostains quantification – Automated pap smear readers Examples of AP Digital Workflow Histology Protocols • Automated ordering histology protocols for different sample types at case accession – When a particular part is accession the appropriate blocks and initial stain orders are generated – Initial billing fee codes are applied – Histology logs are electronically sent and printed providing early notification of work • This has increases efficiency and allows for LEAN processes – Work is standardized – Revenues were enhanced through better charge capture • This is not easy and required iterative re-work and constant attention to defects to get the most satisfactory end result Examples of AP Digital Workflow Real Time Labeling • Essential first step to widespread AP automation • As previously stated the implications of bar code labeled assets drives all other processes • By themselves, the impact of automation of cassette labeling following by slide label generation are profound Barcode Specified Work Processes 1 This case is submitted in 3 specimen containers consisting of: part A - sigmoid colon biopsy, part B - transverse colon biopsy and 2 part C - stomach biopsy with standing preorder for Helicobacter pylori immunostain. Protocol driven information is reflected in the 3 slide labels dictating 2 levels cut for each part. The stomach biopsy protocol, part C, calls for an additional 2 blanks slides to be cut, 4 one for the immunostain & a 4th left unstained. 20 Outcome • With 'real-time labeling' the batch slide label printing process has now been entirely eliminated • Specimen misidentification rates have been reduced • Workflow efficacy in the histology lab has increased as cassette reading defects have been eliminated – Barcode reading defects required the histotechnologist to manually type in cases numbers, leading to increased risk of patient misidentification Results: Misidentification Rates 45 45 40 35 1.67% 30 25 20 0.62% 18 Number Mis-ID 15 10 Defects Percent of Cases 5 0.02% 0 1 Baseline Linear Bar 2D Bar Codes Codes (Jan. (June 2007) 2012) Examples of AP Digital Workflow Specimen Tracking and Routing • Allows us to record the location and status of specimen assets (parts, blocks, slides, etc.) as they are processed and move through the pathology laboratory • All components of a case can be tracked from when they are accessioned on through to storage or eventual disposal • Tracking allows for us to locate case assets and identify who has handled them and where assets have been (i.e. history) • I will not address routing and processing protocols as it applies to conveyance systems which we are not yet using Specimen Tracking Technology AP-LIS: CoPath Plus v6.3 (Sunquest Information Systems, Tuscon, AZ) CoPath Specimen Management Routing and Tracking (SMART) module InfoMaker reports were created using PowerBuilder software (Sybase, Dublin, CA). SpecimenDesign Tracking • We defined specimen points of tracking (SPOTs) in the AP- LIS dictionary . Each SPOT is linked to a specific workstation as defined on the health system’s internal network • As each asset is scanned and processed – location, scan time, status, and associated user data are automatically recorded • Standard tracking tools allowed us to monitor assets in real- time AP Workflow Design * * * * * * * * * * * * * * Design: SPOT Implementation Histology Lab Pathologists • Currently 145 SPOTs have been defined
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