September 2011
Feature Story

Anne Paxton

Some technologies are ahead of their time. Others fail to live up to their promise. And still others may gather dust as people try to figure out what to use them for. But a few turn out to be silver bullets: effective, almost magical solutions to a problem. No less in informatics than in other fields, the trouble is knowing in advance which category a particular technology will fall into. It’s an issue for anatomic pathology labs as they decide what information technology will most help their continuing evolution from manual processes and reliance on paper.

Take, for example, voice recognition software for transcribing pathology reports, an optional feature of most AP information systems. “Voice recognition software is very sophisticated compared to what was available five or 10 years ago,” says Peter E. Fisher, MD, chair of the Department of Pathology and Laboratory Medicine, Health Network Laboratories, Allentown, Pa., which tried three voice dictation systems before adopting its current system. “Ultimately, we’d like voice recognition to be used for all our transcribing. In the long run, it’s like digital imaging. It’s the way the field is going to go. But right now we’ve reached a plateau of the product itself in terms of what it can do.”

A sampling of hospital-based and private practice pathologist opinion shows that hospitals’ information technology plans, federal incentives to install EMRs in physician practices, a desire for added patient safety, and the need to improve workflow and productivity are some of the reasons why large and small pathology groups acquire AP information systems. But when employing system features like synoptic reporting, voice recognition, image handling, report formatting, and remote access capability, AP laboratories report that a number of other factors can affect their success.

For instance, at the Medical University of South Carolina, “We were using a voice recognition system for gross dictations until five years ago, but then we stopped using it,” says Jim Madory, DO, medical director, laboratory informatics, Department of Pathology and Laboratory Medicine. Since 2006, the laboratory has used the AP module of Cerner Millennium as its information system, handling about 30,000 cases a year of surgical pathology, cytology, autopsy, hematopathology, molecular pathology, and cytogenetics.

“We had multiple issues in the gross room with voice recognition because of ventilation fans, traffic, and background noise,” Dr. Madory says. “The system would put words in the text that were not dictated. We tried various microphones, including noise-canceling microphones, but it took more time to dictate and correct the dictation with voice recognition than it took to dictate the case and have the transcriptionist transcribe it.”

He still has enough reservations about the newest versions of voice recognition software to be wary. “Our grossing room is just too noisy. I think it would work well and be useful in dictating microscopic and final diagnoses in quiet locations, but for those I have templates built into Cerner. I can use shortcut keys and get cases verified much more quickly with the shortcuts than if I dictated them.”

Nor does the laboratory currently use synoptic reporting through its Millennium system. “My thinking about this has changed after several years of being in practice. Initially I felt it hindered me in being able to put the words I wanted to use on a report. Now, as someone doing a lot of data mining, I think having data elements in a synoptic format would be very useful.” Dr. Madory estimates that only about 30 percent of pathologists are using synoptic reporting. “I think you will see an increase to probably 80 percent in coming years just because of the efficiency and data mining capabilities and the standardization. In the future, I would like to add this functionality to our system.”

Changing how images are captured and stored in their current system is another upgrade in the plans: “Currently we capture only thumbnail images for use on reports. In the future we plan to capture full-size images that will allow us to do more with our images.” However, it will produce just a flat file. “We won’t yet be capturing ‘Z plane’ images that are focusable. When people start doing more with virtual slides, it will become more important to be able to focus up and down, especially for cytology cases. With virtual slides, your storage needs will increase significantly compared to single images. With ‘Z plane’ images, every plane you add multiplies the size of the image.”

Dr. Madory thinks the system is strongest in its data extracting capabilities. “That’s what I like the most. By using Cerner’s CCL [Cerner Command Language], you can actually query the Oracle database for any bits of information you’d like, and with our Millennium system having everything in the laboratory in one database, including lab results, chemistry, and blood bank as well as AP, we can link all of those things together for different searches. So if I want to look at people who had liver transplants and how much blood they used, or at prostate biopsies and what the patients’ PSA levels were, I can do that.”

His institution has chosen to go with a best-of-breed approach using interfaced systems, which has its drawbacks. “Since the systems are interfaced but do not utilize the same database,” he says, “I don’t have the ability to query all information on a patient from one database. Any time you have an integrated system, you have capabilities you wouldn’t have in an interfaced system.”

Ottawa Hospital in Ontario, Canada, however, was one that looked intentionally for a best- of-breed solution when it was ready to move to a full information system, says Gerard H. Jansen, MD, head of anatomic pathology. His laboratory, which analyzes about 45,000 surgical specimens and 25,000 cytology specimens a year in addition to conducting about 750 autopsies, switched from an old Cerner Classic reporting system to PowerPath by Elekta in July 2010.

“We wanted a much better managed system that would also increase safety, so we wanted bar coding, we wanted to integrate with a voice solution, and we wanted to enhance our reports with PDFs, and to increase our user-friendliness. We also wanted a system with a track record of improving and not just being stationary in its development.” PowerPath was the right choice, he says. “There are plenty of labs around the country with older generations of AP information systems that do not have the capabilities we’ve now just gotten.”

In Dr. Jansen’s experience, voice recognition, which was implemented by writing macros to integrate a Dragon NaturallySpeaking Professional system with the Cerner Classic system, has worked well. “In the past, we had a pretty long delay in our transcription turnaround time, more than 24 hours, and with the voice recognition we can reduce that to minutes. To our thinking, it’s a lot safer because errors in numbers transcription can be immediately corrected.” The downside is that pathologists spend more time in total on the reports. “We’re looking at ways to improve that, but it was a tradeoff to get the improvement in turnaround time.”

The strength of AP information systems, in fact, is not a gain in efficiency, in his view. “Every company tries to tell you you can push through more cases because of their system. But I think modern systems do not do that in general. Rather, they create a safer environment to practice in.” A sharp reduction in errors owing to the bar coding has been the main virtue of the hospital’s AP information system, Dr. Jansen says.

One complicating factor since January is the addition of synoptic reporting, he says. “Ontario has made usage more or less mandatory. Some pathologists are unhappy with it and blame the information system. It’s a capability of Elekta and technically working well, but it just takes more time, even though it increases patient safety.”

Despite Canada’s more centrally controlled health care systems, interfacing with the EMR is not any better coordinated in Canada than in the U.S., he says. “There’s a myriad of HISs, just like in the U.S. So every time you have to make a connection to a new system feeding in, like our pathology system, it needs to be tailored and made to work.” The laboratory is trying now to iron out one connectivity issue. “When we went live, we wanted the PDF version of reports inside our clinical record system, so what we see when we sign out a case becomes part of the medical record. Now, unfortunately, due to some issues with our EMR in the hospital, we’ve had to delay that.”

Image capture has improved tremendously for his laboratory, Dr. Jansen says. “We did not have any imaging in our previous system. Now my microscope camera finally does what it’s supposed to do. Since we don’t have PDFs yet, there’s not much impetus to currently use those cameras, because the pictures don’t transfer, but when we have PDFs we will be using them more often.”

However, the laboratory has already benefited from the system’s improved querying capability. “We started using a quality assurance correlation model that automatically pulls five-year retrospective reviews of biopsies and Pap smears, and that’s worked well for us. What we used to do was a query of all the patient’s surgical and cytology numbers and that had to be correlated manually.”

PowerPath’s electronic sign-out capability for frozen section surgical pathology is a feature that Ottawa Hospital plans to use down the line. “We used to have a paper system for putting frozen section diagnoses out, and have not had up to now a reason to change. Our hospital is going with CPOE [computerized physician order entry] within a year and a half for AP, so we’ll need to convert to a different way of reporting frozen sections and will use the sign-out feature later.”

Dahl-Chase Diagnostic Service, which has 50,000 surgical cases a year, has been using Elekta’s Power-Path for a decade and brought on the most recent version a little over a year ago, says Stephen Hardy, director of innovation for the Bangor, Me., laboratory.

Reliability is one of the system’s hall-marks. “We can measure unscheduled downtime in minutes per year,” Hardy says. Dahl-Chase is a local host so it owns the hardware PowerPath runs on, an arrangement that Hardy, who is the go-to person when things need to be fixed, recommends. “Although you see more and more remote hosting, we have chosen to maintain our own hardware. If something goes wrong, you can walk next door to the data center.”

Before the laboratory deployed the new version of PowerPath along with new hardware a year ago, performance was a little slow. “It took cases four or five seconds to open, and that’s because our server was eight years old and required more capability.” Since then, however, “performance has been very good.”

Voice recognition is on the list as a future interest. Hardy was impressed with a demonstration of it he saw at a PowerPath user group meeting last spring. “We believe it would save time for both the PA in the gross room and the pathologist. Certainly it could reduce our turnaround time by four to six hours, because quite often our pathologists might dictate a case in the morning, then return later that day to finalize the case. With voice recognition, they can review and finalize the case right away.” The quality of the voice recognition has improved, he notes, and one company offers templates designed for pathology that guide the pathologist or assistant through what needs to be dictated.

Dahl-Chase has also used the image capture capability of Power-Path to a high degree to scan documents. “We have been scanning documents into PowerPath since 2006, and it’s meant a significant improvement in quality for us because all requisitions and any other information sent to us in a case are now readily available.”

PowerPath has the CAP worksheet synoptic reports built into it, but Dahl-Chase has chosen not to use it. “We use the old-fashioned Word-type synoptic report which includes all the same questions and answers.” Is it cumbersome? Only a little, Hardy says. “Our pathologists try to make our reports elegant in formatting, and when you use the CAP worksheet function as part of PowerPath, then the general presentation of the report is not quite as nice as in the Word document.” But he and they recognize the value of structured data, he says, and plan to use the PowerPath synoptic reports on their next upgrade.

An important feature for Dahl-Chase is an optional materials-tracking module known as AMP (Advanced Materials Processing). “What it does,” Hardy says, “is uniquely label all pathology materials with a bar code. This could be a specimen, a cassette, or a slide, and every time the bar code is scanned the system records it, so we know exactly where the material has been, who has accessed it, and at what time. This very detailed material tracking can be very important when you’re trying to troubleshoot or problem-solve.”

Just-in-time generation of labels has brought Dahl-Chase at least a 10-fold decrease in slide labeling defects, Hardy says. At the microtome, the technologist scans the cassette, and slide labels automatically print out. “It really ties quite closely the transition from the specimen being in the cassette to being sectioned and placed on the slide. It’s brought a great improvement in slide labeling accuracy, and it’s also improved productivity and improved ergonomics for the histotechnologists. Prior to AMP, a histotech might have hand-labeled a hundred slides per day.”

The system also allows pathologists at the microscope to scan bar codes on the slide label and have the application open to that particular case. “One of our pathologists developed a ‘hot-key’ macro that also incorporates the dictation system. So now we have PowerPath and our dictation system all working on the exact same case.”

As to features on his wish list, automated outreach order entry is a capability that Hardy says was discussed at a recent user group meeting. “That might be a webpage system where an office could log in and order a Pap or surgical specimen, and we’d receive that order. We’d love to have something like that.” A decision support system that is an overlay of PowerPath would also be a strong tool, he says. “It would standardize practice so that, given a certain specimen type with a certain diagnosis, it might suggest a particular stain to confirm that diagnosis, or given a certain delivery location, it might detect data entry errors that we’d like to catch before the result goes out.”

Structured data and structured reports have been pushed along by the federal stimulus bill with its funds for physician EMRs that can show meaningful use, Hardy notes. “So information systems are trying to put their results into a structured format to share across platforms and use them for analysis and problem-solving.”

Until 2008, Pathologists’ Laboratory in Hermitage, Tenn., which processes about 20,000 surgical specimens and about 8,000 Pap smears a year, relied on an Access database for its information system, says Brian R. Carlson, MD, one of the practice’s five pathologists. “We could look things up, but pretty much everything was on paper.”

But as pathology in general became more complicated, the practice had started thinking more and more about information systems. The last nudge forward came when they heard their hospitals were going 100 percent EMR, Dr. Carlson says. “We figured we had to enter the computer age. We had gone about as far as we could with our kind of hit-or-miss approach, which was mainly word pro-cessing.”

So three years ago, Pathologists Laboratory acquired a NovoPath system from NovoPath (formerly Novovision). Since the practice wanted its system to be up and running in short order, “I can’t say we really went out and assessed the marketplace, but we did really want to add photomicrographs to our reports. Our competition was doing that.” The pathologists went with NovoPath in part because the vendor was interested in working with a small practice. And since the practice was on a sound financial footing, it did not have to seek out a bank loan to acquire the system. “We bought a server, made a series of payments to NovoPath, and kind of did it piecemeal. We’ve put in four workstations and we’re adding a fifth right now.”

There was a learning curve, he admits, but the system has “really worked quite flawlessly.” NovoPath has been able to connect three different hospitals using two different HIS platforms to the practice’s central lab. As to billing, “each afternoon our business manager pulls reports of cases to be billed and basically NovoPath exports a flat text file into the billing system.”

With its NovoPath system, the practice does have the ability to do PDF results, Dr. Carlson says, “so all our clients have the ability to go to our Web site and pull up cases based on their personal log-ins.” In addition, turnaround time and other management reports are generated within NovoPath without requiring third-party software such as Crystal Reports.

The practice is planning soon to incorporate gross photographs with reports.

From an IT standpoint, says the practice’s IT administrator, Richard Lee, “I would always love to see new bells and whistles, but we kind of temper what I want with the needs of my bosses. What we have works extremely well. And for now, we don’t have a need for Web access.”

Unlike Dahl-Chase and some other labs, the Henry Ford Health System in Detroit has roundly embraced synoptic reporting since 1990 and wanted to continue it through its Sunquest CoPath system, says Richard J. Zarbo, MD, DMD, senior vice president and chair, Pathology and Laboratory Medicine. In fact, in 2004, when the laboratory started with Sunquest CoPath, “creating synoptic reporting was the only condition we set for taking the system, so we worked with them and built a synoptic module. I’ve been doing quality long enough to know you have to create tools that enable synoptic or structured data reporting.” Ford then partnered with mTuitive to enhance synoptic reporting with Sunquest technology.

Another part of Henry Ford’s collaboration with Sunquest was creation of a bar-coding system for the histology lab, implemented in 2006. “Clinical labs have had bar coding for a long time, while AP was being practiced the way it was 100 years ago, without much technology or automation at all. Our vision was to change that. We partnered with General Data to develop the bar coding, then negotiated with Sunquest to have them integrate it within their information system, which gives it a lot more strength.”

As Dr. Zarbo and his colleague J. Mark Tuthill, MD, reported in an article in the American Journal of Clinical Pathology (2009;131:468–477), that bar-code–driven work standardization innovation enabled the laboratory to reduce the overall misidentification case rate by about 62 percent with a 95 percent reduction in the more common histologic slide misidentification defects, while increasing technical throughput at the histology microtomy station by 125 percent.

The Ford system is unique in many ways, not least in its cultural approach of continuous work improvement, a form of Lean management. The third largest multispecialty group practice in the country, Henry Ford seeks out any opportunity to standardize work and output. “At the main campus laboratory, we’ve done 1,128 process improvements in 2010 alone, and within that about 150 were for anatomic pathology,” Dr. Zarbo says.

In the area of EMR, Ford is distinctly in the vanguard since it has had the same EMR since 1989 and is able to track patients back over generations. “Our record of truth is our hospital information system—we don’t have a paper record in the Ford system—and CoPath is highly integrated with it.” When clinical and anatomic pathology reports are finalized, they show up within a matter of seconds in the HIS, says Dr. Zarbo. All Henry Ford hospitals share the same HIS except for one, he adds, and that hospital will be added within the next year.

Henry Ford does not use a voice recognition system. With 38 pathologists and 16 residents with native tongues from all over the world, Dr. Zarbo says, “we’re talking a diverse, complex dictating environment, and I cannot add staff to do corrections. In our Lean culture, rework is an anathema, so we build structured templates for channeling the information in, and we get a product without rework.”

Remote inquiry of reports is potentially problematic too, he says. “It’s a vision that’s coming. One issue is compliance with HIPAA as well as security. So if your iPad is stolen, does someone have access to patient information? All of those things would have to be worked through for us to be comfortable with remote inquiry. But I do think it’s coming.”

What the system does now is send PDF reports. “It depends on what your receiving system will accept, so if you have an HL7 interface, you can send PDFs with our new-generation HIS that has just come onboard. All of our reports will be issued that way, and the advantage is they look prettier. What goes across doesn’t look like it came off the Smith-Corona typewriter anymore.”

Even Henry Ford can’t say all systems proceed without hitches. Integration between CoPath and the billing and accounts receivable system is “our next challenge,” Dr. Zarbo says. “We have an outdated billing system and we’re looking for solutions for that, as well as planning for implementation of the ICD-10 diagnostic codes which will be coming our way.”

The laboratory is already working with Sunquest and will beta-test the next CoPath model shortly, including modules for tracking and routing specimens in AP. “We’re also working with them on a module they have called Diagnostic Intelligence. In this type of Lean-managed environment we look at metrics daily. Every week we look at performance by pathologist, performance by hospital rollup, and performance by critical specimen streams. The Diagnostic Intelligence module will enhance these metrics by providing real-time information on demand. It’s more than just turnaround time, but actually knowing where the specimens are in the system. We want to know what happened to the work, what needs to be tweaked, what needs to be chased down, what needs to be corrected.”

Voice recognition went live at Health Network Laboratories in Allentown, Pa., in June through a contract with Voicebrook. Elizabeth A. Dellers, MD, medical director of the Division of Breast Pathology, says it’s a mixed blessing. “We’ve had experience with prior iterations, and this is so far ahead of where those were. But my personal opinion is that there are things the human brain can do that a computer can’t do. The pathologists are doing more work that might be considered clerical than before, and probably the time the pathologist needs to sign out a case has increased somewhat,” she says.

Health Network Laboratories acquired Sunquest’s CoPath in 2000. “The reality,” says department chair Dr. Peter Fisher, “is the voice dictation system doesn’t speak perfectly to CoPath, and there are now many more voice-activated steps to getting a report in the system. Some pathologist time is now clerical time. Well, is the payoff really worth it? From a system point of view and process point of view, the answer is yes, but based on what pathologists are trained to do, it’s more cumbersome, and they’re definitely doing things other people could handle.”

In 90 percent of the cases, Dr. Dellers estimates, she has to make some kind of correction. On the other hand, if the patient is in the office, “we can very easily result the case while they are there.” In addition, down the line, “we’re looking forward to not worrying about the fact that it’s hard to find good transcriptionists in pathology.”

A feature of CoPath that the pathology staff especially likes, says Angelica Lamberton, the laboratory’s pathology systems manager, is its followup for abnormal OB/GYN Pap specimens. “We started with that about five years ago and cytology loves it. It takes some of the manual processes away, which was taking up a lot of staff time. If a pathologist signs a case out as abnormal, we obviously have to track it and see that there was followup. The system knows if a surgical sample was accessioned and will tag it for the cytotechnologist to review. If that isn’t done, then a followup letter is generated to the ordering physician asking what was done as followup for the patient.” Says Dr. Dellers, “This feature makes everyone more confident that abnormal test results are not falling through the cracks.”

Remote inquiry of reports, which is available to pathologists and clinicians, has worked well. “We’ve had pathologists working from time to time way off site, so that’s been very useful,” Dr. Fisher says. Interfacing with billing—also conducted on a Sunquest system—is fairly seamless. But interfacing with the hospital information system has been more difficult. Says Lamberton: “We are actually on different computer networks, so we have to cross two networks to transfer our data, then verify that the data was received. It’s a challenge at times.”

For example, some systems can’t handle a PDF document, Lamberton says. “Sunquest has made it possible to send reports in PDF format. But we have to ensure that the receiving EMR can accept the PDF format. If this is not possible, then we send a stripped-down report without formatting. Having things stand out in the report to draw the attention of clinicians is unavailable.”

“We do have the ability to put images in our reports,” Dr. Dellers says, “and we do it routinely for certain types of cases. But the HIS will accept only relatively simple data, so all images do not cross the interface into the HIS. We’d like to see everything done electronically, but we have different clients who want to receive the reports with images, so some go by fax and some are printed.”

As far as desirable upgrades, the laboratory would benefit if CoPath had the ability to maintain records for a biorepository in which specimens are set aside for later studies, Dr. Dellers says. “Within CoPath, while you’re handling specimens, it would be very useful to document what was taken and stored, how it was stored, time between specimen collection and start of fixation, how much tissue is left after it was accessed, and what the clinical circumstances were for that patient and tissue before the specimen arrived in the lab and subsequently.”

“To do that for a biorepository right now,” Dr. Fisher says, “you need a whole separate system. But there will be a lot of pressure on AP information systems as a whole to allow the lab to enter all this information, ideally right up front when they are handling specimens so they don’t have to go back and put it in later. My guess is that over the next few years, many of the AP information systems will be looking at this.”