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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
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Disclosures No financial disclosures to report
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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,
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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
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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
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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
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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
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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
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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
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Still making changes Originally, for each cancer NGS test we built a different order Instead we built a SINGLE test with cascading questions
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Lots of information, Difficult to mis-order
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Scenario-specific reflex testing
Cascading Questions Easy for ordering clinicians to identify the correct test Provides a reflex option, but only for specific scenarios
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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.
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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???
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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
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