Histology Asset Tracking March 3, 2013

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1 Block and Slide Tracking in Anatomic Pathology Professor of Pathology Associate Director, Anatomic Pathology Director, Pathology Informatics Yale University School of Medicine 2012 College of American Pathologists. Materials are used with the permission of the faculty. This Talk Underlying principles of histology tracking solutions Things to look for in vendor s tracking solutions Things to look for in your practices which may compromise the success of a tracking solution Things we have done at Yale o We investigated the solution available for our LIS o We decided it was lacking in: Comprehensiveness ability to deal with exceptions Monitoring tools Philosophy: tracking vs driving workflow o We decided to build our own solution Where do Mislabeling Errors Occur? Tissue cutting/mounting Block labeling Before accessioning Accessioning Grossing/dissection Microscope Embedding + Transcription 30.4% 21.7% 20.9% 12.4% 10.2% 2.4% 1.9% College of American Pathologists Q-Probes (QP094), 2009 John Sinard 1

2 What does Tracking Software Track? Barcodes identify the asset to the tracking system, but the system does not track identities Tracking systems do NOT typically track the location of the assets Tracking systems track the status of the assets o Status implies location o Variability in workflow breaks the association between status and location, defeating the tracking system o Careful examination of the workflow with elimination of inappropriate variability can significantly improve the success of a tracking solution Barcodes in Tracking Software Barcodes are not magical o Simply allow easy and accurate entry o Makes it feasible to enter asset at many time points o Entry can change the status of an asset Human readable ID vs an internal key? o Usability outside of the system holding the key o Resistance to damage of the barcode o Backward compatibility with unlabeled assets o Conversion from one LIS to another Uniquely identify each asset Identify ALL assets to be tracked Assure assets are labeled correctly Get buy-in from users Compatibility with workflow and resources John Sinard 2

3 Uniquely identify each asset o Blocks already done (probably) o Slides: block and stain not sufficient Levels cut up front and recuts Extra levels ( That section wasn t very good I cut an extra one ) Unstained slides Repeat specials Identify ALL assets to be tracked o Can t have blocks or slides the computer doesn t know about Extra tissue blocks for research? Negative controls ( When we cut immunos, we cut an extra slide for the negative control ) That was a small biopsy; I cut some extra unstained slides Assure assets are labeled correctly o DANGER: Containers with tissue but no label on container Can put wrong label on the container Containers with label but no tissue in container Can put wrong tissue in the container o Just-in-time labeling: generate label & asset at same time One piece workflow no batching Eg. Label cassettes at the time tissue is put in them Eg. Label slides at the microtome station o If asset and label generated asynchronously, always verify label before associating the tissue with it John Sinard 3

4 Get buy-in from users o Scanning assets at various steps is new work o Conceptual workflow change batches to single piece workflow o Savings/efficiency comes from: Total solution (more work in one area yields much less in another) Not wasting time looking for work lists or logs to check off Not wasting time looking for missing assets Filing blocks, pulling blocks, filing blocks, pulling blocks o Emphasize patient safety o Collect labeling error data before and after to show improvement; emphasize time spent correcting errors Compatibility with workflow and resources o Need enough workstations to prevent waiting in line to scan o Phase-in should be for whole portions of the workflow at a time, not for a subset of the assets at a time i.e., first cassettes in gross room, then processing, then embedding...; NOT first biopsies then GI cases, then Gyn cases... Otherwise, have two different workflows in the lab o Clever people will find a way to circumvent constraints; alternate solutions propagate through staff o If system can t handle common exceptions to the normal workflow, and users have to circumvent system, they will circumvent the system even when they should not Costs Associated with Tracking Software Implementation Cost of the software IT personnel, time, management, leadership Cassette labelers Computers at each microtome/embedding station o Network lines, electricity, computers, monitors, keyboards? o Reconfiguration of the stations to accommodate; furniture? Many label printers Many barcode scanners Additional seat licenses for the LIS (if integrated) Significant changes in workflow o Productivity, resistance, persuasion, coercion John Sinard 4

5 Tracking Software Complexity Level I: Auditing o Post events for each asset (what, when, who) o Allows audit trail (when was asset last seen) and workflow analysis Level II: Constrained Status Progression o Assures appropriate asset used at appropriate time o Promotes patient safety Level III: Drive Workflow o Dynamic to-do lists o Identify delayed assets real-time Tracking Software Complexity There is a play-off between level of control and flexibility in tracking software o Highest level of control provides greatest safety and reliability but constrains dealing with exceptions Two slides cannot have the same slide number If no slides have been ordered, no labels will print Exceptions to standard status progression of assets disrupt workflow o The vast majority of blocks/slides follow a standard workflow path through the lab o A small number of exceptions can consume significant time & resources o A tracking system with a high level of control can increase the time needed to address these exceptions unless allowances for these exceptions are made in the software design Individually Identified Assets Blocks: o Barcode matches human readable designation: PPYY eg: S (17 characters max) Slides: o Block + stain +/- date not sufficient o Add sequential number PPYY (20 characters max) If adding a number, may as well make it meaningful John Sinard 5

6 Slide Number Sequentially number slides as they are cut from the block o Can follow lesions through successive levels o When ordering a stain on an unstained slide, can specify the level to be used o Places additional constraints on tracking system Assign slide number at the time of cutting, not ordering Using an existing slide (eg unstained) requires modifying the information about that slide; can t add a new stain with a comment of use level 5 Assuring Accuracy of Asset Labeling Blocks: o Ideally, generate labeled cassettes as they are used Requires cassette labeler at each grossing stations o Pre-make cassettes with unique block numbers Enter blocks into LIS by scanning (verify that label appropriate for asset) Assures correct case number (patient safety) Confirms uniqueness of block number Assuring Accuracy of Asset Labeling Slides: o Scan block at microtome: print labels for slides o Tentative slide numbers locked in by scanning the cut, labeled slide to confirm successful cutting Just because a label prints doesn t mean there is a slide John Sinard 6

7 Asset Status Progression Control / Constrain Workflow o Only allow assets to progress to a new status from an appropriate old status(es), and in the correct context o Need additional statuses to accommodate alternative workflow pathways Drive Workflow o Use asset status to determine not where it has been but rather where it is going o Status of asset (and perhaps associated assets) should determine next process, independent of asset history Block Status Progression CheckedOut Cassette Printed Block CheckedIn Ordered Received OnBatch Embeded Filed Missing Cancelled ReProcess ReEmbed Block Status Monitoring Think where is the asset going next?, not where is it now? Ordered Received OnBatch Embeded Filed ReProcess ReEmbed CheckedIn CheckedOut Processor batch not yet started Processor batch started; not marked finished Processor batch marked finished No slide for this block has a status of Ordered At least one slide for this block has a status of Ordered John Sinard 7

8 Hidden Practices in Histology Hidden practices o The production, use, and/or distribution of a tracked asset without the computer and/or tracking system knowing about it o Most histology labs have many of these These practices need to be identified and either formally integrated into the tracking process or eliminated o Consequence of not doing so: development of a culture that the tracking software is optional and can be circumvented if necessary Hidden Practices Negative controls from immunos Re-embedding and re-processing blocks Slides from re-embedded blocks Ordering stains on unstained slides Bonus sections Repeat specials or immuno stains Three levels ordered on one slide, but don t fit Segmented workflow (who cuts specials, immunos, recuts) Frozen section slides Broken/destroyed slides Blocks/slides from outside labs Archival material (pre-barcodes) Variability in attending preferences for chromagens Negative Immuno Controls Practice When cutting a slide(s) for immunohistochemistry, an extra slide is cut for the negative control. However, only one negative control is cut, no matter how many immunos are being done. Problem Negative control has not been ordered in the LIS label won t print. John Sinard 8

9 Negative Immuno Controls Solution Checkbox in the microtome module to allow on-the-fly ordering of one negative control if any of the slides being cut are for immunohistochemistry Ordering Stain on Unstained Slides Practice For many small biopsies, unstained slides are cut at the time of initial cutting. Stains can be ordered on these later. This was done by adding the new stain to the list of stains and entering a comment of please use unstained slide Problem If a new stain is added with a status of ordered, tracking system expects the block to be cut and a new slide made If simply use unstained slide, label is not correct If take label from new order and place it over the label on the unstained slide, slide level number sequence will be incorrect Ordering Stain on Unstained Slides Solution New slide statuses o Ordered on Unstained -> Relabeled LIS Customization o Field protection for Stain field after slide has been cut o Field protection does not apply for unstained o User selects desired level; status set to OrdUnst o Slide shows up in Dashboard as To be Relabeled John Sinard 9

10 Realized Benefits of Asset Tracking Solution Slides come out earlier Histology staff feel more hi-tech Nearly complete elimination of logs in histology Histology staff feel like the case volume has decreased significantly when in fact it has stayed the same Marked reduction in labeling errors Fewer arguments between gross room staff and histology staff Real time response to recut requests Realized Benefits of Asset Tracking Solution Cost Savings Direct o Reduction in overtime hours o Did not replace a histotech who left o Fewer recuts / redos from lost slides Cost Savings Indirect o Less time looking for missing assets * * * o Less time managing paperwork / logs o Less time filing blocks, then pulling the same blocks o Fewer interruptions of histology workflow by attendings/residents checking on status of slides Effect on Overtime in Histology John Sinard 10

11 Block/Slide Tracking Errors Pearls of Pathology Tracking software can improve patient safety and efficiency in the histology lab A variety of tracking solutions may be available they are not all created equal Implementation is not as simple as paying money and installing Getting ready by analyzing and standardizing workflow is crucial Associated costs and hidden practices need to be considered While 90% control can be achieved relatively easily, 100% control is far more difficult John Sinard 11

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