John H. Sinard, MD, PhDJohn H. Sinard, MD, PhDDepartment of PathologyDepartment of PathologyYale University School of Yale University School of MedicineMedicine

Semi-automated Archiving Semi-automated Archiving of Scanned Requisition of Scanned Requisition Documents in Anatomic Documents in Anatomic

PathologyPathology

John H. Sinard, MD, PhD

Document ImagingDocument Imaging

•Electronically imaging documents yields many Electronically imaging documents yields many of the same advantages as “going digital” of the same advantages as “going digital” does for imagesdoes for images•AccessibilityAccessibility•AvailabilityAvailability•StorageStorage

John H. Sinard, MD, PhD

Requisition Handling IssuesRequisition Handling Issues

•Sometimes contain useful clinical informationSometimes contain useful clinical information

•Would never “embed” in a report, so no “need” Would never “embed” in a report, so no “need” to import into LISto import into LIS

•Desirable to have available at time of Desirable to have available at time of signoutsignout

•Frequent sortingFrequent sorting•Primary copy sorted to allow collating with working draftsPrimary copy sorted to allow collating with working drafts

•Gross room copy sorted for filingGross room copy sorted for filing

•Billing copy transferred to Accounting service for Billing copy transferred to Accounting service for RegistrationRegistration

•Sorted after signout for filingSorted after signout for filing

•Removed from working drafts and sent for microfilmingRemoved from working drafts and sent for microfilming

•Need to be retained for minimum of 2 yearsNeed to be retained for minimum of 2 years

John H. Sinard, MD, PhD

Requisition CostsRequisition Costs•With >90,000 cytology specimens and >45,000 With >90,000 cytology specimens and >45,000 surgical specimens per year, represents about surgical specimens per year, represents about 150,000 unique documents, most of which are 150,000 unique documents, most of which are copied at least once to support our workflowcopied at least once to support our workflow

•Department was spending $15-25K per year for Department was spending $15-25K per year for microfilming or contracted digital archiving microfilming or contracted digital archiving servicesservices

•The major cost is man-hours spent sorting, The major cost is man-hours spent sorting, copying, collating with working drafts, copying, collating with working drafts, distributing, resorting, removing from working distributing, resorting, removing from working drafts, removing staples, resorting, sending drafts, removing staples, resorting, sending for microfilmingfor microfilming•Minimum of 5-10 hrs / day department-wide, or approximately 1 Minimum of 5-10 hrs / day department-wide, or approximately 1 FTEFTE

•Does NOT include time spent looking for/retrieving documentsDoes NOT include time spent looking for/retrieving documents

John H. Sinard, MD, PhD

““Electronic” Requisition FormsElectronic” Requisition Forms

•We do not get the information We do not get the information electronicallyelectronically

•Scanning solutions must consider:Scanning solutions must consider:•Workflow needsWorkflow needs

•Scanning speedScanning speed

•Appropriate/accurate labeling of files Appropriate/accurate labeling of files (scanned documents) to allow retrieval(scanned documents) to allow retrieval

•Error handlingError handling

•Availability of scanned documents for review Availability of scanned documents for review by attendingsby attendings

•Long term storage of scanned documentsLong term storage of scanned documents

John H. Sinard, MD, PhD

Document Archiving SolutionDocument Archiving Solution

•Create barcode labels and affix to Create barcode labels and affix to documentsdocuments

•Scan documentsScan documents

•Use software to read barcode labels and Use software to read barcode labels and rename documentsrename documents

•Resample/downsize the documentsResample/downsize the documents

•Use existing image filing solution to Use existing image filing solution to file the documents in a separate file file the documents in a separate file repositoryrepository

•Use existing image “Upload” software for Use existing image “Upload” software for manually addressing unreadable barcodesmanually addressing unreadable barcodes

John H. Sinard, MD, PhD

Document Labeling Before Document Labeling Before ScanningScanning

•Want to label documents with barcodesWant to label documents with barcodes•Requisition forms do not arrive pre-barcoded; significant Requisition forms do not arrive pre-barcoded; significant outreach materialoutreach material

•Would like to label with the accession number; not known in Would like to label with the accession number; not known in advanceadvance

•Human readable as well as machine readable Human readable as well as machine readable desireddesired•Confidence in filingConfidence in filing•Allows manual filing of unreadable barcodesAllows manual filing of unreadable barcodes

•Solution: System-generated barcode “slide”-Solution: System-generated barcode “slide”-labelslabels•Required creating a custom application object in CoPathRequired creating a custom application object in CoPath•Can make on the fly; ability to make moreCan make on the fly; ability to make more•Can use existing label printersCan use existing label printers•Label size small enough not to obscure documentLabel size small enough not to obscure document•Barcode labels can also be used on other things (eg specimen Barcode labels can also be used on other things (eg specimen containers)containers)

John H. Sinard, MD, PhD

Creating Document Labels in Creating Document Labels in CoPathCoPath

John H. Sinard, MD, PhD

Document ScanningDocument Scanning

•Document Scanning RequirementsDocument Scanning Requirements•Produce images of sufficient resolution to allow Produce images of sufficient resolution to allow resolving small barcodesresolving small barcodes

•Fast; automatic feedFast; automatic feed•Easy to use without trainingEasy to use without training•Accommodate variability in paper weight, quality, and Accommodate variability in paper weight, quality, and smoothnesssmoothness

•Reliable; maintained (preferably by someone else)Reliable; maintained (preferably by someone else)•Redundant and Multi-siteRedundant and Multi-site

•Solution: Upgraded our rented copiers to Solution: Upgraded our rented copiers to ones with scanning capabilitiesones with scanning capabilities•Copier can create TIFF files (black and white) and scan Copier can create TIFF files (black and white) and scan to a networked driveto a networked drive

•Small incremental costSmall incremental cost•In some cases, needed to run new network linesIn some cases, needed to run new network lines

John H. Sinard, MD, PhD

Labeling RealityLabeling Reality

John H. Sinard, MD, PhD

Requisition Image FilingRequisition Image Filing•Automate the filing process: have software read the Automate the filing process: have software read the barcodesbarcodes

•Barcode Reading Software issuesBarcode Reading Software issues•Barcode size must accommodate 11 alphanumeric charactersBarcode size must accommodate 11 alphanumeric characters

•Small barcode font requires high resolution label printer and scannerSmall barcode font requires high resolution label printer and scanner

•Software needs to be “resistant” to variations in label placement and Software needs to be “resistant” to variations in label placement and alignmentalignment

•Solution: Custom SoftwareSolution: Custom Software•Scanned document (5100x6600 550KB TIFF) placed in a “Requisition Drop” Scanned document (5100x6600 550KB TIFF) placed in a “Requisition Drop” folderfolder

•Folder action immediately detects file and runs a Perl scriptFolder action immediately detects file and runs a Perl script

•Perl script uses Barcode Reading Software from Softek to read accession Perl script uses Barcode Reading Software from Softek to read accession numbernumber

•Also uses Image Processing software to down-sample the image into a Also uses Image Processing software to down-sample the image into a 1000x1294 pixel, ~270KB JPEG image1000x1294 pixel, ~270KB JPEG image

•New JPEG image file renamed to image file naming convention and placed New JPEG image file renamed to image file naming convention and placed into the Image Drop folderinto the Image Drop folder

•Image filing engine files the document in the requisition repository Image filing engine files the document in the requisition repository

John H. Sinard, MD, PhD

Image Drop Image Drop Folder Folder

Gross Image Gross Image CaptureCapture

Ad hoc Ad hoc ImagesImages

Electron Electron MicrographsMicrographs

Manual Manual NamingNaming

PhotomicrographsPhotomicrographs Custom Custom Image Image

Uploading Uploading ProgramProgram

Image RepositoryImage Repository

Image Filing Engine

Intranet Intranet AccessAccess

Images in Images in ReportsReports

Lab Info SystemLab Info System

DatabaseDatabase Image FilesImage Files

Yale Pathology Clinical Yale Pathology Clinical ImagingImaging

Step 1Step 1 Step 2Step 2

John H. Sinard, MD, PhD

Getting Images into the Image Getting Images into the Image Drop FolderDrop Folder(Image File Naming (Image File Naming Convention)Convention)

To assure that images are uniquely identified, associated with the correct To assure that images are uniquely identified, associated with the correct case, and readily located, a standardized naming convention is used for case, and readily located, a standardized naming convention is used for

ALL CLINICAL IMAGESALL CLINICAL IMAGES

PPYYYY-AAAAAAcNN-dddd.fffPPYYYY-AAAAAAcNN-dddd.fff

1 or 2 Letter 1 or 2 Letter Specimen Prefix Specimen Prefix

(eg, S, A, SB)(eg, S, A, SB)

4 digit 4 digit yearyear

6 digit accession 6 digit accession number (with number (with leading zeros)leading zeros)

1 character 1 character lower case lower case

image type codeimage type code

2 digit sequential 2 digit sequential number (start number (start

with 01 for each with 01 for each type code)type code)

[OPTIONAL][OPTIONAL]Dash plus up to 4 Dash plus up to 4

character (lower case) character (lower case) description abbreviationdescription abbreviation

File extension: File extension: image file format image file format (should be .jpg)(should be .jpg)

g: gross photographg: gross photographm: photomicrographm: photomicrographc: cytologyc: cytologyi: immunofluorescencei: immunofluorescencee: electron micrographe: electron micrographr: imaging studyr: imaging studyf: FISH studyf: FISH studyd: documentd: documenta: additional studya: additional studyu: unknownu: unknownx: external reportx: external reporty: Yale Path reporty: Yale Path reportz: requisition formz: requisition form

John H. Sinard, MD, PhD

Image Drop Image Drop FolderFolder

Gross Gross ImagesImages

Electron Electron MicrographsMicrographs

Photo-Photo-micrographsmicrographs

Image Upload Image Upload ProgramProgram

Image RepositoryImage RepositoryImage Filing Engine

Intranet Intranet AccessAccess

Images in Images in ReportsReports

CoPathCoPath

DatabaseDatabase Image FilesImage Files

Yale Pathology Clinical Yale Pathology Clinical ImagingImaging Requisition Requisition

RepositoryRepository

Copier/ScannerCopier/Scanner

Req Drop Req Drop FolderFolder

S05-1234

Smith, John01234567

Barcoded Barcoded LabelLabel

Requisition FormRequisition Form

File Naming/

Resampling Engine

UnreadableUnreadableBarcodesBarcodes

John H. Sinard, MD, PhD

Requisitions Available via Requisitions Available via Existing Web InterfaceExisting Web Interface

John H. Sinard, MD, PhD

OutcomeOutcome•We are currently accumulating:We are currently accumulating:

•~2,500 images per month~2,500 images per month•~5,000 requisition forms per month from Sept 2005 through ~5,000 requisition forms per month from Sept 2005 through Apr 2007 (Surg Path only)Apr 2007 (Surg Path only)

•>12,000 requisition forms per month since implementing in >12,000 requisition forms per month since implementing in CytologyCytology

•~ 4 document scans per day have to be ~ 4 document scans per day have to be manually filed because “the bar-code could manually filed because “the bar-code could not be read”not be read”•In most cases, the person scanning forgot to put the bar-In most cases, the person scanning forgot to put the bar-code label oncode label on

•No more sending of requisitions for No more sending of requisitions for microfilmingmicrofilming

•Unexpected benefit: requisitions readily Unexpected benefit: requisitions readily available for responding to insurance denialsavailable for responding to insurance denials

•Have also created a final report repositoryHave also created a final report repository

John H. Sinard, MD, PhD

Thank you for your Thank you for your time and attentiontime and attention

The Yale Pathology ITS The Yale Pathology ITS TeamTeam

Dr. Peter GershkovichDr. Peter GershkovichAggie DaleyAggie DaleyJJáános Lnos Lööbbbb

Katie HendersonKatie HendersonBrian PaquinBrian PaquinSophia GyorySophia GyoryGarry ArcherGarry Archer

Wolfgang FreisWolfgang FreisEmma Walz-VaitkusEmma Walz-Vaitkus