1. Straddling the Clinical and Anatomic Pathology Divide
The UCLA Molecular Diagnostic Laboratory’s experience transitioning to the AP and CP Epic 2014 Beaker Module
Valerie A. Arboleda MD, PhD
Cora Au, Ameer Helmi, Samuel Strom PhD, Kingshuk Das MD
Pathology Informatics Summit
May 22, 2016

2. Disclosures
No financial disclosures to report

3. Outline Build Decisions: AP vs. CP Workflow changes
Post Go-Live Optimization
Like many have said at this conference, trying to fit molecular diagnostics into an LIS is like round peg in a square hole
MDL is unique. At UCLA, its sort of bridges both AP and CP. We have an active Exome Sequencing programs in addition to and up and ocmin
Make a point that optimization is ongoing,

4. Beaker AP or Beaker CP? Distinction is mostly based on test complexity
Next Generation Sequencing + cancer tests = Beaker AP
Sanger, RFLP, Genmark, etc = Beaker CP
Main Points:
AP : better for X
CP is better for X
Many of the distinctions between CP and AP hinge on this tissue source. Traditionally, tissue sources collected directly by the physicians caring for the patient (non-pathologists) are blood and bone marrow, and now in moelcular fluids etc.
However, in molecular genetics, we have seen the influx of molecular genetic testing on tissues that are performed on traditionally AP type speciements: FFPE fixed tissue

5. Blood Workflow Molecular Diagnostic Laboratory (MDL)
Pre-Beaker Workflow
Powerpath:
Re-order the test
Epic: Physician Order (CPOE)
Powerpath:
Result the test
Meditech:
Re-ordered and phlebotomy
Main Points:
In our workflow for blood specimens: the specimen actually existed in THREE DIFFERENT IS
Clinicaians really like
1_ can track speciments to lab to ensure receipt
2_ pathologyists can see where any given test is in the pipeline through beaker (i.e. DNA extraction, scheduled for batcg 1, 2, 3
3- batch reporting. i.e. for highvolume testing that is primarily negative, batch reporting is much easier.
Molecular Diagnostic Laboratory (MDL)
Beaker Workflow
Epic Beaker CP:
Test Resulted
Epic: Physician Order (CPOE)
Epic Beaker CP

6. Tissue-based workflow
Molecular Diagnostic Laboratory (MDL)
Powerpath:
Build Case
Pre-Beaker Workflow
Powerpath:
Result the test
Paper: Physician Order
Anatomic Pathology:
Case creation in Powerpath
Grossing
Histology
Epic: Patient Chart
Pre beaker, from the MDL perspectie, the most troubling part is that we never knew if a phyciian placed a paper order. If the system worked, it was great. But the backup system is a physician calling and saying I ordered a test and that the
Resident/Fellow Review
Pathology Signout
Histology order: Powerpath to cut slides for molecular pathology testing

7. Tissue-based workflow
Beaker Workflow
Molecular Diagnostic Laboratory (MDL)
Epic Beaker AP
Build Case
Anatomic Pathology:
Case creation Epic Beaker AP
Grossing
MDL places task for cutting slides
Epic Beaker AP:
Result the test
Histology
Epic: CPOE
Resident/Fellow Review
Main Points:
Many of the distinctions between CP and AP hinge on this tissue source. Traditionally, tissue sources collected directly by the physicians caring for the patient (non-pathologists) are blood and bone marrow, and now in moelcular fluids etc.
However, in molecular genetics, we have seen the influx of molecular genetic testing on tissues that are performed on traditionally AP type speciements: FFPE fixed tissue
Pathology Signout
Pathology places an order (CPOE) with block specified

8. Multiple changes with Beaker
Discrete fields for entering test results
Ability to perform batch reporting for high-volume CP tests
Ability to track workflow within Beaker for easy access by directors
Clinicians can ensure that the specimen was received by the molecular lab
Decreased number of excel spreadsheets used to track items

9. Post-go live, March 5, 2016
Difficult to pinpoint problems given complexity of the workflows
Cancer sequencing test were frequently misordered or dropped
People having trouble ordering (who, what was the problem) what was the problem with ordering: specific example

10. Still making changes
Originally, for each cancer NGS test we built a different order
Instead we built a SINGLE test with cascading questions

11. Lots of information, Difficult to mis-order

12. Scenario-specific reflex testing
Cascading Questions
Easy for ordering clinicians to identify the correct test
Provides a reflex option, but only for specific scenarios

13. Test Reporting: Discrete Fields
It breaks up single blob of text into distinct components
We piloted this on a small subset of tests that outputted a quantitative result (i.e. quant BCR-ABL)
For the more complex NGS tests, this is a problem as there is no direct interface into Beaker
Building specialized treatment modules for oncology (Epic- Beacon) and transplant (Epic-Phoenix) rely heavily on a systematic and discrete result reporting.
Some of the biggest changes on the end user side, with the transition to beaker is the use of discrete fields of test reporting.

14. Conclusions
The decision to span both AP and CP were rooted in the diverse requirements for our testing repertoire
Providing a “fail-proof” ordering mechanism requires optimization and testing
Encourage discrete resulting as it has a wide impact within the hospital system and generation of integrated reports
Integrated: molecular reports and smart links into addendum
Overall, for MDL this is an improvement???

15. Thank You Department of Pathology and Lab Medicine at UCLA
Association of Pathology Informatics
UCLA Resident Informatics Program
Cora Au, CLS
Ameer Helmi,
Epic Boost services
Sam Strom, PhD FACMG
Kingshuk Das, MD