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!