I am in the process of accomplishing one of my new years resolutions to become Black Belt certified in Lean Six Sigma. I am two thirds of the way done. I became certified as a Six Sigma Green Belt in April and Lean certified in June; both with a focus in healthcare.  I am currently in the process of taking my black belt course and working on a project for certification.  These days Lean Six Sigma methods are constantly running through my head and I have applied several methods to my consulting work.

The power of Post-It's and moveable whiteboards!

One of my favorite tools are Post-its and take anywhere, disposable white boards.  I use them on-site with clients and I also use them in my office, ALL over my office.  So in an ongoing effort to immerse myself more in Lean Six Sigma for the lab I turned to one the leaders of Lean Six Sigma in pathology, Henry Ford Hospital.

Dr. Mark Tuthill, Division Head of Pathology Informatics, was kind enough to give me a tour and WOW was I impressed.  Yes.. it was a big WOW! My last blog post was about creating WOWs instead of waiting for them to happen.  This is exactly what Henry Ford’s department for Pathology and Laboratory Medicine has done and continues to do, because striving to improve is never complete!  You know from the moment you enter the department you have walked into a remarkable place.  Placards are prominently displayed with powerful messages including:

Every Life Deserves World-Class Laboratory Service”

Lean Six Sigma is a management philosophy and their department is lead by prominent pathologist Dr. Richard Zarbo, who clearly embraces the power of Lean Six Sigma.  The entire department is involved and committed to continuous improvement; a fact that would make their founder, and the father of Lean, Henry Ford proud.

Here are some of my take-aways from my visit.

• Silence is golden! Dr. Tuthill brought to my attention, while standing in the gross lab, how quiet everything was. This quite and calm environment continued throughout the AP lab too.  The department has moved away from transcription and voice dictation and developed templates that integrate into their LIS.
• Process improvement takes time and really is continuous. This is a fundamental of Lean Six Sigma but was reinforced throughout my department tour.  White boards are all over to illustrate how new processes are mapped, monitored, and certain boards engage employees to document defects on an ongoing basis.  Defects, as defined in their publication “Effective Reduction of Process Defects and Waste In Surgical Pathology,” are forms of waste including flaws, imperfections, or deficiencies in specimen processing that required work to be delayed, stopped, or returned to the sender.  Here are some pictures of their whiteboards and process flow charts:

Gross Room: Process Flow Chart

Defect Tracking

• A very visual environment. Everything, and I mean EVERYTHING was labeled- even gauze.  The department loves 5S and Kanbans and you can tell.  You never have to question where something is, where it should go, or if there is more available.  It’s a straight forward concept but is your lab like that?
• A foundation for success! Henry Ford has been working hard to prepare their lab and department for their digital future over the past few years (while also reducing costs, improving patient safety, and laboratory efficiency). Their entire process is barcoded from accession to sign-out.  The laboratory uses barcode technology from General Data, and even assigns barcodes to requisition forms that are scanned to eliminate paper in the lab.  The gross lab is set up with a Milestone gross imaging system,  digital cameras are mounted on grossing tables and pathologists microscopes.  The cameras are then connected via a TWAIN interface to PathPacs, their middleware software by Apollo.  PathPacs is integrated with their Sunquest CoPath Plus LIS and allows the pathologist to choose and select images to be in the LIS and reports.

Can you guess their next step for their digital future? Digital Pathology!   With the foundation described above, a Lean Six Sigma culture, and a management team with vision I have no doubt that they will be successful.  Thank you Henry Ford Hospital for your level of excellence, you truly are a gold standard.

The digital pathology industry faces a complex challenge of combining new technology with well-established beliefs and practices.  As a result, digital pathology faces significant psychological adoption barriers- it is the “elephant in the room.”

The famous futurologist Alvin Toffler conducted a detailed study of the acceleration of change and its psychological effects in 1970 for his book Future Shock (Random House, 1971). He suggested that it would lead to a set of severe physical and mental disturbances, which he called the “future shock” syndrome. Just like people exposed to war or disaster may develop a nervous breakdown (“shell-shock”), people exposed to the rapid changes of modern life may develop a state of helplessness and inadequacy.

Digital pathology will introduce new, modern methods to supplement and eventually replace routine diagnosis by microscope. But with the “gold standard” of diagnosis by microscope in use for over 150 years is it not fair to say that the change to digital pathology could put many pathologists into a state of future shock?  Pathologists themselves joke of their archaic methods and dependency on antiquated technology but this dependency could result in feeling helpless or inadequate when faced with the new digital, modern methods of pathology.

Furthermore, the workplace has become a breeding ground for information overload. A worldwide survey (Reuters, 1996) found that two thirds of managers suffer from increased tension and one-third from ill health because of the huge amounts of information they must cope with. So will digital pathology cause pathologists to call in sick?  I hope not, but to avoid additional job stress we must start to discuss how to overcome the psychological barriers of digital pathology.

I recently read an article titled, Managing Innovation Complexity, by Braden Kelly.  Braden says,

The changes required by minor innovations are easier for customers and organizations to absorb. But the large changes generated by major innovations often disrupt not only the market, but the internal workings of the organization as well. This requires organizations to become increasingly flexible and adaptable.

Is your organization “flexible and adaptable?” I imagine many of you are shaking your heads no.  Creating a healthcare organization that is flexible and adaptable is not an easy feat. But Braden continues to say “…with proper planning, organizational learning, and adaptation over time, any organization can improve its ability to cope with, and even anticipate, the change and complexity that come with implementing their next major innovation.”

As healthcare organizations face the major innovation of digital pathology and hopefully take the right steps to prepare and plan, do yourself a favor and create a personal plan to prepare yourself mentally for this transformation and avoid “future shock.”  Do not ignore that tiny voice, your fears, or the elephant sitting on top of your microscope.  Not sure where to begin? Give me a call! I would be happy to help you adjust and prepare for the inevitable compromise between the old way (microscopy) and the new way (digital pathology) of doing things.

It’s true, anyone can benefit from knowing more!  Knowledge is power, even in the confusing world of healthcare.  I have talked about this before in my post Go Above And Beyond The Dx: Participatory Medicine.  I firmly believe that the blind faith patients have in their doctors and the healthcare system is a major problem.  Doctors “practice” medicine; they are not perfect.  Everyone has the right to ask questions or search the internet for more information. But what if a doctor proactively came to you and explained how they achieved their diagnosis and why they support a certain treatment option? What if they could show you pictures (maybe whole slide images on an iPad) to support their findings?

Well that is exactly what Dr. Jennifer Hunt, Pathologist and Dr. Lori Wirth an Oncologist at MGH are trying to do and document in a new study.  The study will track the value of a pathologist providing patient consultations.  I just finished reading about it in the November Issue of CAP Today, “Face Value- pathologists one on one with patients.” The article discusses the vision and preliminary experiences of the study.  There are several statements I love in this article, but my favorite comes from Dr. Hunt who answers the question Is this for everyone?

The “yes” argument is that any patient can become more knowledgeable about his or her health care.  It’s not about the patient being smart; it’s not knowing nothing or knowing everything about your disease.  It’s the idea that anyone could benefit from knowing more, and working more closely with their clinician- which includes their pathologist.”

Bravo! This is exactly the type of transformation we need and a wonderful example of Participatory Medicine.

As for me, I have chosen to act on this belief by volunteering for a patient advocacy program at a local hospital in Denver called the Reconnect Leadership Project.  I have just finished my training as a Reconnect Leader and will start working with patients next week.  The goal of our program is to reduce readmission rates to the hospital and empower patients to take charge of their health.  Patient engagement is another thing (in addition to digital pathology) that I am very passionate about.

Once again, I applaud the work of Dr. Hunt and Dr. Wirth.  I cannot wait to see the results of this study!

After my article last month, Advance offered me the opportunity to write a web article to compliment their vendor roundtable article.  Below is the article.

The Digital Transformation of Pathology

by Amanda Lowe

When does the future become a reality?

Imagine your digital future. You walk into your office, and on the desk is a computer; your microscope is covered and untouched; on the shelves are books and journals, and nothing is on the floor. Paper and glass do not cover every inch of your office. Gone are the numerous external hard drives filled with countless images. All that remains is you, your knowledge and a computer.

This computer is your diagnostic workstation, customized to you and providing you with resources to improve diagnostic outcomes, advise on treatments and monitor patient response to those treatments. Digital pathology will enable and frame our digital future. However, forging this vision has not been easy, and realization of the vision is a constant work in progress.

History
In the 1990s, the first robotic microscope was controlled over the Internet by Ronald S. Weinstein, MD,¹ and the first slide scanner was invented to measure preinvasive cancer by James W. Bacus, MD, and his son Jim V. Bacus Jr.² At about the same time, Dirk G. Soenksen, founder of Aperio, was imagining a world where microscopists looked at computer monitors rather than microscopes.³ These four inventors established the foundation for our digital future. As visionaries and advocates, they have brought digital pathology to life.

Resistant to Change

Ask around and the consensus is that digital pathology is our future. However, the timeline of when our future becomes a reality is widely debated. The digital pathology industry, pathology organizations and consumer crusaders have worked hard over the past 15 years to educate the market on the benefits of digital pathology, yet they are often met with a fierce resistance to change. The resistance is often driven by fear–not of change but of being changed.

No one pathologist, department or company can be forced to adopt and learn something new. Therefore, we must continue to educate and create an understanding of the tangible advantages, which instills a desire to change. Change is hard, but if we overestimate the importance of pathology’s capabilities today, we will underestimate the significance of what the field could become tomorrow.

Tangible Advantages

Digital pathology can reduce subjectivity, increase diagnostic confidence and ensure diagnoses are reproducible–all important advantages, especially when incidences of misdiagnosis have been publicized lately and the practice of pathology and laboratory medicine scrutinized. It is well-known that risk for human error in slide preparation and patient identification is greatly reduced when the histology process is bar coded.

A 2009 publication in the American Journal of Clinical Pathology about the Henry Ford Health System surgical pathology lab highlights a 62% reduction in the overall misidentification case rate.³ Add digital pathology to the picture, and you will enable scanning of glass slides, software (instead of technicians) correlating patient data and whole slide images, and electronic delivery of patient information and slides to the pathologist. Risk of error will continue to drop while powerful tools will support the pathologist throughout the diagnostic process.

Have a difficult case? No problem. The pathologist can simply assign the case or send an e-mail request to a specialized pathologist for a second opinion. This digital consultation process, often described as telepathology, is more secure and eliminates the risk of patient slides being lost or damaged, decreases the turnaround time to hours rather than days and reduces subjectivity while controlling costs. Still want more diagnostic support? Search the digital pathology slide database to review relevant clinical slides, quickly retrieve historical patient data, perform image analysis to obtain quantitative support, or easily set up a tumor board with physicians to illustrate the patient case and create a forum to discuss the next step or design a treatment plan.

All the tangible advantages described above can be done today and are being done, although the process is not perfect. Yet to achieve perfection you must find imperfections and then take time to transform those imperfections for the better.

Transformation

Government demands and consumer expectations are growing for transparency in medicine, improvements in patient safety and identification, electronic medical records and more personalized treatment plans. At the same time, the perception of laboratory medicine and pathology needs to improve, especially given its essential and significant role in patient care.

Digital pathology supports this healthcare evolution and enables the digital transformation of pathology and laboratory medicine. Our transformation is not easy. The process is not perfect, but the benefits are powerful and will outweigh the fears. Do not resist the transformation, embrace it.

Click here read the vendor roundtable print article and web article.

It is time; time to change how you give a diagnosis.

Participatory Medicine, defined by the Society for Participatory Medicine, is a cooperative model of health care that encourages and expects active involvement by all connected parties (patients, caregivers, healthcare professionals, etc.) as integral to the full continuum of care.  The patient role has evolved, therefore the role of a pathologist must evolve too.  Pathologists must start to go above and beyond the diagnosis and become a key advisor to physicians and patients on the prevention of disease, therapeutic treatments, and the progression of disease within patients.

I have written a post before about my dad, a resident of Colorado, who had a liver transplant in August 2009 at Cleveland Clinic (CC).  As soon as he returned home to Colorado, he had to have bi-weekly blood draws for review by his clinical care team at CC.  The initial plan was for my dad’s family medicine office to do the blood draw with kits that were shipped from the Cleveland Clinic’s lab, and package them up in a pre-paid envelope (also provided by CC ) and ship them back to CC’s lab for analysis.  The turnaround time would be about 36-48 hours for the result, plus the cost and risk of shipping the blood to CC.

After trying this out and realizing it was a logistical nightmare, my parents decided to have all the blood work done by the University of Colorado lab, which would post the results within 8 hours to their hepatology patient care system.  My parents could then simply access the results securely online, print and fax them to Cleveland Clinic.   This new process brought the turnaround time to 8-12 hours; saving 24-36 hours over the original method.  Overall, a great example of participatory medicine!

In Pathology, the use of a participatory model is a greater challenge since pathologists rarely interact with the growing numbers of patients they diagnosis everyday.  However transformation to a new model of care must be accepted, and the College of American Pathologists (CAP) has two programs “Transforming Pathologists” and  ”Every Number Is A Life” where the evolving role of pathologists and value of pathology are being advocated for.  CAP says on the transformation website,

…As health care changes quickly and on all fronts, Pathologists must step up and embrace transformation, pursue new roles in the workplace, and re-position themselves as the center of the clinical care team.  This is an urgent call to action and we must take action now. If Pathologists are to survive, we must adapt….Pathologists must have an understanding of their changing role – they must NOT be defined by the tools they use. We have a bright future as researchers/innovators, test providers, interpreters, clinical data integrators, clinical consultants, business developers and practice leaders.

However, pathologists often do not know where to begin.  Try these steps:

1. Identify two or three cases where your role as diagnostician is crucial to the patients care and outcome
2. Arrange a meeting with the primary physician for that patient
3. Discuss your involvement with the clinical team and how you would like to engage with the patient directly
4. Follow through! Do what you say you are going to do. Build credibility with the clinical team and your patients
5. Document your successes and struggles and think about ways to make the process better
6. Share your successes! Click here to share
7. Repeat the process

Proponents of the participatory model of care believe that adoption can increase patient satisfaction, save time, reduce costs, improve care, and lower liability risks for physicians.  Although change is difficult, pathologists must seize the opportunity they have been given! It is time, time to go above and beyond the diagnosis.

In the middle of difficulty lies opportunity.

~Albert Einstein

Are you a patient who has a great story about a pathologist? Share your story today! Click here

Want to learn how to become an organ donor? Click here

A great read on participatory medicine by American Medical News- Participatory medicine:  A high-tech alliance with patients