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How LIS tweaks can enhance efficiency, patient safety

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Kevin B. O’Reilly

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November 2014—So, you have a great idea that will improve laboratory workflow and reduce errors? Chances are the change will depend on automation of some sort, and will involve the LIS. But upgrades to laboratory information systems may not come fast enough, and the middleware may not be available to accomplish what you need. Then the question becomes how to customize the LIS to achieve your aims.

That is what the six-member pathology informatics team at the University of Pittsburgh Medical Center Health System has had to do—work on their own, with middleware providers, and with their LIS vendor to meet the demands of their laboratory colleagues.

Dr. Pantanowitz

Dr. Pantanowitz

“That’s the philosophy we have. Our users ask, and we aim to deliver,” Liron Pantanowitz, MD, tells CAP TODAY. An associate professor of pathology at the University of Pittsburgh School of Medicine, Dr. Pantanowitz also directs cytopathology at UPMC Shadyside, heads UPMC’s pathology informatics fellowship program, and is associate director of Pitt’s Pathology Informatics Division.

Dr. Pantanowitz and his colleague Anil V. Parwani, MD, PhD, detailed several innovative UPMC projects in a CAP ’14 session, “Customizing the Laboratory Information System to Improve Patient Safety and Workflow in the Pathology Laboratory.” These include using the LIS to drive improvements in anatomic pathology quality control, synoptic reporting, and specimen tracking, while exploring the promises—and challenges—of digital pathology and next-generation sequencing.

Drs. Pantanowitz and Parwani together serve as editor-in-chief of the Journal of Pathology Informatics. The journal is published by the Association for Pathology Informatics, which cosponsored the CAP ’14 session.

Dr. Parwani, who specializes in anatomic pathology informatics, says AP has for too long lagged behind clinical pathology when it comes to automation.

“If you look at the clinical pathology lab, it’s about 20 years ahead of the AP lab in a lot of ways,” he said at the CAP ’14 session in September. “In many cases, we don’t have barcoding. And how many AP labs have standardized and structured reports? These are some of the things that are the key players in this transformation to automation.”

Dr. Parwani, professor of pathology and a genitourinary pathologist, expands on the point in an interview with CAP TODAY.

“Every time I look at what’s in AP and then walk into the CP lab, I think, ‘Wow, if we had that in the AP lab it would be great.’”

The view that anatomic pathology is more qualitative than the highly quantitative nature of clinical pathology has contributed to AP’s lagging on LIS-driven automation, Dr. Pantanowitz says.

“We are at least a decade behind CP when it comes to automation,” he says. “We in AP are moving toward being more quantitative, with more accurate grading, more image analysis. All of that is being built into the LIS, especially as we are getting higher volumes of cases and are being asked to do more quantitative work.”

One of the customizations the UPMC team worked on with its vendor, Cerner, has enabled review of AP reports before sign-out. UPMC had many ways to spot errors in pathology reports, but detection came after the case was signed out. These included comparing frozen section diagnoses with final diagnoses, amended reports, intra- and extradepartmental consultations, tumor boards, clinician requested reviews, and autopsies.

“There is a lot of good retrospective QA after the fact, but then it’s obviously too late,” Dr. Pantanowitz said. “You may spot an error at a tumor board, but it may be too late because the patient already had surgery or received chemotherapy.”

Cerner enabled a functionality in its CoPathPlus product that would randomly select eight percent of cases for secondary review by another pathologist. At the sign-out stage, a message will pop up that reads, “This specimen has been selected for QC.” The case is sent to a quality control work list. “Then you have another pathologist review the case entirely and the report,” Dr. Pantanowitz said. The reviewing pathologist can note different levels of disagreement, ranging from minor to major.

“That major disagreement basically means, come and talk with me about this case,” Dr. Pantanowitz said. “It could be that you missed that a flow cytometry was pending on a case. And we want to avoid such a case being called negative, when the flow comes back later as positive.”

Using this tool, “we can prevent an error before it actually happens,” Dr. Pantanowitz said. The LIS customization, implemented in 2009, enabled an 8.4 percent rate of secondary, pre-sign-out case review, more than double the 3.7 percent rate before the functionality was implemented. Dr. Pantanowitz presented data from more than a year of use of the functionality at UPMC. Random review of 3,165 cases before sign-out prevented 73 errors, he said.

And the turnaround time for surgical pathology cases selected for review was 2.08 days, compared with 2.17 days for cases not subjected to the quality control process. That time difference was not statistically significant, but the pre-sign-out QA process was a major improvement on the 62 days it typically took to review cases under UPMC’s retrospective audit system. Results from Pitt’s work in this area were published in the Journal of Pathology Informatics (Kamat S, et al. 2011;2:42).

“The number of amended reports went down by 30 percent,” Dr. Pantanowitz added. “The major errors go way down just by making a simple change in the LIS. And we actually changed the culture among our pathologists. The culture now is that it’s good to share your cases. They share more and more cases, independent of the QC. Basically, by improving a small functionality in the LIS, we replaced this manual thing and it involves hardly any clerical work. It’s hands free. It’s not affecting the workflow, it didn’t affect turnaround time, but it did improve patient safety.”

UPMC has also taken advantage of the LIS in synoptic reporting. In his portion of the CAP ’14 talk, Dr. Parwani said the traditional, narrative pathology report is to the structured, template-based synoptic report as a messy clothes closet is to an organized closet.

“In the messy closet, things are hard to find,” Dr. Parwani said. “In the neat closet, you can find the things you need easily. If I have a pathology report that looks like [the neat closet], it’s easier to put information in there and take information out of there. You can store things in a standardized way. And you make sure all that information is stored in the report in the LIS, and you can search for it.”

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