ManyBlessingsandSomeCurseswithanLISThat'sFullyIntegratedwiththeEHR:
UsingEpictoSupportClinicalCollaborationsandContributetoImprovePatientCare
RajC.Dash,MD
ExecutiveWarCollegeApril30,2019
Agenda
• AboutDuke:Enterprise,ITandLabconfiguration
• Beaker/LIShistory• Blessings&ChallengesofanintegratedEHRwithspecificexamples
• FutureOpportunities
Disclosures
The following speaker has relationships with interests to disclose: Raj C. Dash, MD • College of American Pathologists, member of Board of Governors, Informatics Committee,
Council of Scientific Affairs, Information Technology Leadership Committee • Leica Biosystems, member of Digital Pathology Advisory Board • Epic Beaker, member of Pathology Steering Board
BackgroundComputerscience>softwaredeveloper>medicalschool>pathologyresident>fellowships–informatics,cytopathology>biobankinginformatics+diagnosticpathology>clinicalinformatics+dxpathRolesVice-Chair,PathologyIT,DepartmentofPathologyDirector,LaboratoryInformaticsStrategy,DukeHealthTechnologySolutionsMedicalDirector,LaboratoryInformationSystems,DukeUniversityHealthSystem
Duke Health
Beaker:TechnologyHypeCurveExpectationsvsFunctionality
WhyDiscussBeaker?
• Laboratorytestingcomprisesasmallpercentageofthetotalhealthsystemspendbutgeneratesalargepercentageofactionabledata
• You(should)beabletoprovidemorevaluethananyotherphysicianasthepathology/laboratorydatasubjectmatterexpertforyourhospital
• YouneedyourEHR/LIStohelpyouframetherightquestionssuchthatyourexpertreviewofthedataaddsvaluethatcannoteasilybegeneratedfromothersources
TheValueofLaboratoryScreeningandDiagnosticTestsforPreventionandHealthCareImprovement.TheLewinGroup,Inc.September2009.
DukeITHistory
• DukeUniversityHealthSystemITdevelopmentbeganwithcustomsoftwarefordoctor’snotes(DHIS)
• Alabsystemfollowedshortlythereafter• CERNERPATHNETinstalledintheearly1990s
• WebbasedEMR,eBrowserwentlivein1997.• ExplorednewLISin2000,2005• EPICwentliveasEMRonJune232013
• EPICLabsystemliveinsmallhospitalMar2014
7
BeakerLISEvolutionatDuke
• 2012– Aglorifiedwordprocessor?
• 2014– WYSIWYG(richtextformatting)– MaturingCPmodule,workableMicrobiologyandAPmodules
– Solidcancersynopticimplementation• 2015-2018
– Minorworkflowimprovements
ConfigurationConsiderations
• Orders• Results• DepartmentStructure• SpecimenAnnotationandTracking• Labels
• Site,Source,Specimen• Point-of-Care
• ClinicalPathology• Autoverification• Middleware• Automation• SpecialtyLabs
• AnatomicPathology• SurgicalPathology• Cytopathology• Autopsy
9
BuildingLaboratoryOrders
• Themostimportantpartofalaborderisthenameoftheorder
• Thelaborderbuildshouldincludeevaluationofspecimen-centricandtest-centricordering(APvsCP?)
• Add-Onordersrequiressomethought– Specimenexistsvsmustbecollected– Encountercurrent,closed,veryold
Departmentvs.SectionStructure• Designingyourvirtuallaboratoriesusing“DEPs”vsSections
(latterfavored!)• DifferentDEPsallowforgranulartrackingofspecimensas
theyenter/leaveDEP• DifferentDEPsrequirespecimenstobeputonpackingliststo
transfer• DifferentDEPscannotbydefaultseeeachother’spending
lists
Specimen,Source,Description
• “Source”– PhlebotomyCollection“Source”
• Centrallinevsantecubitalvein– MicrobiologyCulture“Source”
• Throatswabvsabscessvsblood– TissueSpecimenAnatomic“Source”
• Leftvsrightbreast
SpecimenAnnotation
• TestCentricOrdering– Designedforbloodspecimens
– Source,Orderinglocationhelpful
– Canworkforsingletissuespecimen(inversion2014)
– Multiplespecimensget“enumerator”
– Improvedin“version2015”
• SpecimenCentricOrdering– Facilitatesefficientcollectionofmultipletissuespecimens
– Canhavepresetbuttonsforrapiddataentry
– Specimenscanbe“duplicated”
– Distinctlabelforeachspecimen
TestCentricOrdering
SpecimenCentricOrdering
SpecimenTracking
• Orderedbutnotcollected• Collectedbutnotreceived• Receivedbutnotresulted
– Receivingmultiplespecimensatonce– Supportingadistributioncenter(kindof)
• Packinglistcontainingpackinglists
• Specimeninquiry• Caseinquiry
LabelPrinting
• Labeldesign– Specimen-centricordering(HSC#)– Test-centricordering(Julian#)
• Labelstock– Regular– Xyleneresistant
• Labelhardware(Z4MvsQLN220vsGX430T)• Labelprinterorientationconfiguration
ClinicalPathology–KeyIssues
• Improperlyplacedorders– Ordersnotcollected(inEpic)cannotbereceivedinlab
– Wrongtest
• Autoverification• SettingupinstrumentQC• Criticalcallbacks
SurgicalPathology
SurgicalPathology–ORDERINGIHC
SnapshotRep
orts
PathologyReporting
SynopticReporting
SynopticReporting
SynopticReporting
LegacyData
• HistoricalPathologyCases
• HistoricalPathologySummary
• LegacyAddendums&Amendments
LegacyData
• NewBeakerreportforaddendumsandamendments
• Scan+orderlinking
• Assignedsamecollectdate
BuildConsiderations:SpecialtyLabs
• ImageCytometry• FlowCytometry• MolecularDiagnostics• BiochemicalGenetics• HLA• TransfusionMedicine
ImageCytometryFreeText(withsmartphrases)
DiscreteData
Reporting
• ReportingWorkbench(Chronicles)• Clarity• Buildingareport
– Functionalspecifications– Therightexpertise(SME,IT,report)– Validation– Performance
ReportingWorkbenchvsClarityvsUniverse
• ReportingWorkbench– Accesstoreal
timedata– Access<30
daysofdata– User
configurable– Designedfor
smalldatasets
• Clarity– Onedayold
data– AccessallEpic
generateddata– BuiltbySQL
programmers– Userscanenter
parametersbutnotveryconfigurablebeyondthat
• Universe– 3dayolddata– AccessallEpic
andlegacydata
– Portalcreatedbyprogrammers
– Userscanconfigure!
– Canhandlelargedatasets
ReportingWorkbench
Universe
TheNewSelfServiceDataTool:SlicerDicer
TheNewSelfServiceDataTool:SlicerDicer
MakingUseoftheData:ExampleScenario
• ThepatientportalITfolkswouldliketoknowifroutinelabresultscouldbereleasedimmediatelytopatientsand/orifitshouldoccuratvarioustimesduringtheday.Ifso,atwhattimes?
• Themedicaldirectoroflabsindicatesthatsomesmallpercentoflabs(lessthan1%)arecorrectedinsomewayafterthefinalresultispublished(usuallytoaddcommentsorclarificationsbutrarely,resultvalueschange).Itwouldbenicetohavecorrectionsinplacebeforesendingontothepatient.
• Howtodrivethedecisionmakingprocess?
AskingQuestions:WhatshouldbethedelaybeforereleaseofresultstoMychart?(Timetocorrectioninstatlabfor1mo)
AskingQuestions:Whattimeofdayareresultsreleased?(statlabfor1mo)
AskingQuestions:Whattimeofdayareresultsreleased?(microlabfor1mo)
WillMyPracticeLoseMoneywithBeaker?
ChargeCaptureProcess(aka“amIbillingproperly?”)
• BuildingprotocolswithcorrectCPTcodes• Ensuringtasksarecompleted• Ensuringchargesarereviewed• Validatingthatchargesdroponverification• Ensuringrollupiscorrect• Working“workqueues”• Eliminating“errorqueues”• Reconcilingresultsvscharges
ReasonsWhyaChargeMayNotDropatVerification
• Chargeswerenotreviewedbypathologist– Tasksandprotocolscanbeaddedafterverification!– Example:specialstainsorderedbutneverresulted!
• Task/protocolchargesnotconfirmedbylabstaff– Veryeasytomisstasksnotconfirmed.– Chargecanbereviewedbypathologistsbutwillstillnotdropiftaskisnotconfirmed
ReasonsWhyaChargeMayNotReconcile
• Task/protocolchargemanuallydeleted• Task/protocolchargemanuallyedited• Chargeaddedwithoutaddingtaskorprotocol
Task/ProtocolChargesnotReviewed
TasksNotConfirmed
APReconciliationConcept
ProtocolchargesTaskcharges
thatshoulddrop
Actualchargesthatdropped
DevilisintheDetails
• RegulatoryCoding(LOINC,CPT,ICD10)• Hardwareconfiguration• Barcodechoices• Labeldesigns• Ordernamestandardization• ElectronicLabManual• Decisionsupportrules• Integratedworkflows• Governance
ITIOC(Oversight,$$$)
EOCEnterpriseStrategy
CITOCClinical
Optimization
StakeHolderGroups(19)Prioritization
ClinicalInformaticsandITGovernance
ClinicalInformaticsArchitect
ITDirectorforPathology&LaboratoryServices
EpicSeniorDirector
LabInformaticsStrategyDirectorAP/LabsMedical
Director
TechnologySeniorDirector
ContentCaptureSpecialists(SMEs)
ClinicalSuperUsers
TechnicalAnalysts
TechnicalManagers
LabManagement
Pathology/LabsInformaticsOrgChart
ClinicalArchitectTechnicalArchitect
CentralIT,ClinicalLeads,BillingMultidisciplinaryWorkTeams
FieldSupport
Developer
TechnicalAnalyst
InterfaceSupport
RevenueSpecialist
ClinicalSuperUser
ContentCaptureSpecialist(SME)
CoreLeadership
ExpertsPulledinAsNeeded
CoreWorkUnit
CustomizingBeakerForYourOrganization
CaseScenario:ServiceLineAnalysis
• OurcasesareassignedtoDuke“clinicalservices”atthetimeacaseisbeingexaminedgrossly
• Thepathologistconfirmsthecorrectserviceassignmentpriortoverificationofthecase
• Thisdiscretefieldcanprovideasurprisingamountofinformationtoguidepracticedecisions
CaseScenario:ServiceLineAnalysis• Basicreportparameters– Month-Year
– Accession#– ServiceCode(IDandtext)
– Taskname– Count
CaseScenario:ServiceLineAnalysis
• Tasknameandoutputexamples
CaseScenario:ServiceLineAnalysisCompareBlockQtyAcrossMajorServices
SummaryBlessings Curses
• GreaterfunctionalityleveragingEHRdata
• Rapidimprovementovertime
• Highlevelofcustomizabilityandconfigurability
• Specimentracking,barcodedrivenworkflowanddataprovenancetransparency
• Fewerinterfaces
• Datamodelcomplexityandinformationoverloadleadsto:– Increased“clicks”,time– Unexpecteddependenciesandsystemfragility
– IncreasednumbersofFTEstomaintain
– Greatercoordinationamongteamsforchanges
– Increasedoverheadforchangecontrol
– Potentialfor“epic”downtimes
FutureOpportunities
• Betterdesignedworkflow,particularlyforAP/SurgicalPathology– DigitalPathologyworkflowsupport
• Betterdesignedworkflowanddatamodelformoleculardiagnostics
• GreaterintegrationamongEpicmodules(e.g.OpTime<->Beaker<->Beacon)
• OpportunitytopositionPathology/Pathologiststocreatemorevaluefortheorganization!