1. Optimized Document Management in Anatomic Pathology – Two Paths to a Common Workflow with Analysis of Benefits Mark Routbort MD PhD 1 ; Erin Grimm, MD 2 ; Rodney Schmidt MD PhD 2. 1 Department of Hematopathology, MD Anderson Cancer Center, Houston, TX; 2 University of Washington, Seattle, WA.

2. Imperatives Operate more efficiently Operate more efficiently Facilitate information flow Facilitate information flow Preserve records Preserve records Paper is cheap and records are stable but there are high indirect costs associated with using and managing paper. Paper is cheap and records are stable but there are high indirect costs associated with using and managing paper.

3. What are the benefits of document imaging? Scan case paperwork Scan case paperwork Instant availability of original paperwork Easily implemented Instant availability of original paperwork Easily implemented Permanent storage Permanent storage Quick retrieval Quick retrieval No xeroxing!!! No xeroxing!!! No paper storage No paper storage

4. What are possible workflows for scanning? Inside Cases Consult Cases = Possible places to scan documents

5. Baseline state UWMC UWMC Paper records only (no scanning) Paper records only (no scanning) MDACC MDACC Paper sent to outside service for scanning after cases were signed out Paper sent to outside service for scanning after cases were signed out Both used PowerPath v8.3 (Impac) with Imaging licenses (engineered for gross and micro images). Scan via TWAIN interface, store, display with case. Both used PowerPath v8.3 (Impac) with Imaging licenses (engineered for gross and micro images). Scan via TWAIN interface, store, display with case.

6. UWMC Approach Scan paper using native PowerPath function Scan paper using native PowerPath function Consult cases at accessioning Consult cases at accessioning Inside surgicals after signout Inside surgicals after signout Cost-benefit analysis Cost-benefit analysis Directly measurable benefits Directly measurable benefits User survey User survey Custom middleware to improve workflow Custom middleware to improve workflow

7. Document accumulation - UWMC

8. How does scanning help workflow? Paperwork is instantly available Paperwork is instantly available Pathologists/Residents don’t spend time searching for paperwork during: Pathologists/Residents don’t spend time searching for paperwork during: Case signout Case signout Conference preparation Conference preparation Off-site coders have access to original paper during billing Off-site coders have access to original paper during billing

9. UWMC – Financial Analysis PaperScanningNet Consumables$291$0$291 Personnel$2,200$2,111$89 Lease/licensing$0$70($70) Computer disks/tape $0$12($12)

10. UWMC – User survey after implementation of document scanning system Satisfaction(1-5) Time saved (min/day) Accessioners2.5-60 Office staff 1.060 Pathologists1.586 Residents1.4145

11. Documents – Benefits Direct benefits low Direct benefits low Takes longer to scan than copy Takes longer to scan than copy Primarily due to system login, navigation Primarily due to system login, navigation Indirect benefits high (35 hrs/wk) Indirect benefits high (35 hrs/wk) Instant 24 x 7 availability Instant 24 x 7 availability No paper retention No paper retention Easy conference preparation Easy conference preparation Integration with PowerPath Integration with PowerPath

12. Custom Middleware - UW Facilitates document scanning workflow Facilitates document scanning workflow Avoids multiple logins Avoids multiple logins Bypasses navigation to cases in PowerPath Bypasses navigation to cases in PowerPath TWAIN interface to scanner TWAIN interface to scanner Single- and multi-sheet modes Single- and multi-sheet modes Direct insertion of scanned images into PowerPath Direct insertion of scanned images into PowerPath

13. Post-middleware survey Accessioners liked using it Accessioners liked using it Subjective average score 10.0/10 Subjective average score 10.0/10 Document scanning process is faster Document scanning process is faster Subjective average score 8.3/10 Subjective average score 8.3/10 Saved 0.25 min/case Saved 0.25 min/case Doing additional work (renaming images) Doing additional work (renaming images) Scanning cases in batches (minimizes login and navigation benefits) Scanning cases in batches (minimizes login and navigation benefits)

14. MDACC Approach Bring scanning in-house Bring scanning in-house Custom middleware to facilitate scanning Custom middleware to facilitate scanning Motivated by anticipated workflow Motivated by anticipated workflow Avoid multiple logins and PowerPath navigation Avoid multiple logins and PowerPath navigation TWAIN driver for scanner TWAIN driver for scanner Direct insertion of images into PowerPath Direct insertion of images into PowerPath Assess benefits Assess benefits

16. Benefits - MDACC Cost avoidance of >$50,000/yr Cost avoidance of >$50,000/yr Timely archiving of paperwork Timely archiving of paperwork Eliminate scanning of unnecessary and redundant documents Eliminate scanning of unnecessary and redundant documents Universal access to archived images through PowerPath Universal access to archived images through PowerPath Indirect utilization benefits similar to UW Indirect utilization benefits similar to UW

17. Conclusions UWMC and MDACC both achieved large direct and indirect benefits UWMC and MDACC both achieved large direct and indirect benefits Optimal workflow is key – both compelled to write middleware to improve scanning workflow Optimal workflow is key – both compelled to write middleware to improve scanning workflow Integration with the AP-LIS (PowerPath) is enormously beneficial Integration with the AP-LIS (PowerPath) is enormously beneficial Workflow is key Workflow is key Digitization of data is beneficial Digitization of data is beneficial

18. Future Scan all paperwork at the time of accessioning Real-time availability while case is in process Real-time availability while case is in process Concurrent availability (e.g. transcription, coding, resident, pathologist) Concurrent availability (e.g. transcription, coding, resident, pathologist) Immediate archiving (no lost paper) Immediate archiving (no lost paper) Custom apps (e.g. gross room) Custom apps (e.g. gross room)

19. Acknowledgements UWMC UWMC Kevin Fleming, Rosy Changchien, Kim Simmons, Paula Reeve, Phil Nguyen, Victor Tobias Kevin Fleming, Rosy Changchien, Kim Simmons, Paula Reeve, Phil Nguyen, Victor Tobias MDACC MDACC Mike Riben, Lori Heydon Mike Riben, Lori Heydon