louis wilson , the first pathologist of the mayo clinic group practice in rochester , minnesota , described a reproducible method for rapid histologic evaluation of surgical specimens .
this methodology involves rapid freezing of fresh tissue on a specially designed microtome down to temperatures below those used in modern cryostat microtomes , allowing evaluation of a wider variety of tissue types while minimizing freezing artifacts .
the frozen section technique allows for intraoperative diagnosis and evaluation of tumor margin status , leading to improved patient outcomes . in 2014 , approximately 20,000 frozen section intraoperative consultations were performed at mayo clinic in rochester ( i.e. , 7080 frozen section cases per weekday ) using this technique , with the interpretation of more than 150,000 histologic blocks and 100,000 frozen section slides . to enable rapid diagnoses with such high case volumes , pathologic , radiologic , surgical , and clinical information
is gathered and synthesized for each case before the day of surgery by surgical pathology residents and fellows . on the day of surgery ,
the information is then disseminated to the frozen section laboratory team during a trainee - led morning report .
morning report involves a synoptic discussion of the day 's patients and requires concise and accurate transmission of large volumes of case information to a diverse audience in a limited time frame .
case information is then applied in real time by laboratory staff to guide gross dissection and microscopic diagnosis .
before the work described herein , aspects of the case review process were carried out in an idiosyncratic and manual fashion .
review of pending surgical pathology cases was a largely paper - based process that required extensive transcription of information from the electronic health record ( ehr ) .
transmission of the gathered information then occurred through a fast - paced verbal morning report in which all participants transcribed relevant case information onto their own printed copies of the day 's surgical list .
although this challenging task was quite functional and well handled by trainees and staff , it was somewhat laborious and bore an inherent risk for errors to occur in either collection , transmission , or recording of clinical information . to help address perceived inefficiencies in the list review process and to eliminate , where possible , the potential for errors in the communication of case information , a process improvement effort was undertaken .
herein , we describe that improvement effort , the software application that resulted from it , and the use of that application to facilitate improved communication of case review information and enable real - time case tracking during surgical pathology consultation .
a lean process improvement strategy was utilized to identify areas of waste in the surgical pathology list review process . a workflow process map [ figure 1 ] was developed to capture the essential inputs and outputs required to complete the list review process and then utilize the gathered information for surgical pathology diagnoses .
specific areas for process improvement were identified by interviewing stakeholders ( residents , fellows , pathology assistants , and staff pathologists ) , with a focus on tasks perceived as inefficient or unproductive , and by independently observing and mapping the current processes .
presurgical case preparation was identified as an area of significant potential inefficiency , with residents and fellows reporting that case review using the ehr involved several repetitive activities .
abstraction of information from the ehr for pathological diagnosis can be a complex and time consuming ; in our practice , the average reported time to complete the list review and case annotation ( ~125 total cases with ~35 frozen section cases ) was 4 hours per person per day ( with single fellow and/or resident participating ) .
significant time was consumed in shifting attention between a printed list of surgical patients ( used by residents and fellows to identify potential cases for review ) and the pathology , radiology , and clinical note sections within the ehr . once cases were identified , pertinent details then had to be abstracted from the ehr by manual transcription to either a printed surgical patient list or separate note sheet . in the absence of an established mechanism for collating the list review work product before morning report , residents and fellows independently reviewing the list ( typically accomplished at night and/or from home ) sometimes duplicated case review work . process flow diagram for ( a ) presurgical case review , ( b ) morning report , and ( c ) real - time case review .
an accessory process for surgical listing information recipients who participate in specimen grossing is shown in tan .
information flows between processes are designated by red arrows other areas identified for improvement by stakeholders were clarity and completeness of morning report ( during which information from the case review is disseminated to the frozen section laboratory team ) and situational case awareness during the intraoperative case review .
interestingly , the physical size of the existing printed surgical list was identified as a potential logistical issue in case review .
although only 3040 surgical cases in a day ( out of 75175 ) might require a frozen section consultation , the electronic listing system in place was only capable of printing a surgical list including all cases ( typically 3040 pages in length ) .
stakeholders reported that a nontrivial amount of time was used to simply search through the printed list to locate a specific listing ( and associated case notes ) when tissue from a new case would arrive in the laboratory .
after mapping the case review process in its entirety , three major subprocesses were identified [ figure 1 ] in the creation and application of the surgical list for frozen section pathology : ( 1 ) generation of the pathology notes for the surgical list ; ( 2 ) communication of those findings to the laboratory staff ; and ( 3 ) utilization of those notes to aid in the diagnostic process .
furthermore , the utilization of pathology notes by other staff ( junior residents and pathology assistants ) to perform the gross dissection of frozen section specimens was identified as an important accessory process [ figure 1 ] . to increase efficiency and reduce the possibility for errors in the gathering , recording , communicating , and application of case information , it was determined that a software application should be developed .
modification of an existing surgical and procedure scheduling ( sps ) software application was identified as the best approach for meeting the needs of the surgical pathology practice .
the sps application is custom software developed in - house and primarily used by the mayo clinic department of surgery to create and manage the institutional surgical schedule .
a  listing  in the application contains patient demographics , procedure type , procedure indication , diagnosis ( if available ) , medication orders , patient assessments , required equipment or supply notes , and pharmacy and anesthesia requests . the sps application was designed to accommodate
 modules  with additional functionality from other departments , such as anesthesia or pharmacy , to facilitate total care of surgical patients . taking advantage of this architecture , development of a pathology - specific module ( pm ) for the sps application was undertaken using an agile software development process .
sps - pm requirements [ table 1 ] were defined from the process map [ figure 1 ] and then further refined with stakeholder feedback on specific areas of waste or inefficiency . over a 2-month period , several development cycles ( sprints )
were undertaken during which key functionality was added to the sps - pm , tested by a resident serving as an end - user technical representative , and then formally integrated into the sps - pm module .
once core functionality was present , the sps - pm was launched to end users for an initial 2-month evaluation period .
the software was designed for ease of use , with a user interface paradigm consistent with typical office productivity software .
an initial basic demonstration of functionality , but no specific end - user training , was provided to a cohort of residents on the frozen section service . in turn
residents and fellows then served as information sources and advocates for adoption by the frozen section staff including staff pathologists , pathology assistants , and technicians .
the attending head of the frozen section working group was the physician champion for the project , and one of the residents directly involved in the development of the software acted as a superuser to provide real - time support for issues and also to serve as a recipient for evaluation feedback . during the initial evaluation period ,
ongoing user feedback was used to improve sps - pm stability and to identify several additional key features ( case searching and an operating room visual overview ) to be added . after the review period
, the sps - pm application was moved into a production environment , and additional presentations were given to key stakeholder groups ( attending physicians and physician assistants ) to demonstrate features and functionality .
pathology module feature requirements associated with case review , communication of review information , and real - time intraoperative case management the sps is a. net c # windows presentation foundation application that runs on the microsoft windows operating system , version 7 or greater .
it was developed using the csla.net ( http://cslanet.com/ ) and model - view - viewmodel ( mvvm ) light ( https://mvvmlight.codeplex.com/ ) frameworks , using a mvvm ( https://msdn.microsoft.com/en-us/library/hh848246.aspx ) design pattern to separate application logic from the presentation layer .
listing information was maintained in sybase and ms structured query language ( sql ) databases accessible through standard sql queries .
additional clinical information was retrieved from the mayo clinic electronic medical record ( ge healthcare , wauwatosa , wi , usa ) through web service application programing interface requests .
access to protected health information through these systems is implemented through client authentication within a monitored hipaa - compliant environment .
after 3 months of use , staff pathologists , residents , and fellows were surveyed to assess the sps - pms impact on practice workflow .
study survey data were captured and managed using the research electronic data capture ( redcap ) system ( vanderbilt university , nashville , tn , usa ) .
fifty - five physicians , fellows , and residents involved in the frozen section pathology processes were surveyed .
there were 21 respondents ( 34 non - respondents ) , of which five had not used the sps - pm application and sixteen had used the application .
the sixteen respondents included five staff pathologists , eleven trainees ( residents or fellows ) .
a lean process improvement strategy was utilized to identify areas of waste in the surgical pathology list review process . a workflow process map [ figure 1 ] was developed to capture the essential inputs and outputs required to complete the list review process and then utilize the gathered information for surgical pathology diagnoses .
specific areas for process improvement were identified by interviewing stakeholders ( residents , fellows , pathology assistants , and staff pathologists ) , with a focus on tasks perceived as inefficient or unproductive , and by independently observing and mapping the current processes .
presurgical case preparation was identified as an area of significant potential inefficiency , with residents and fellows reporting that case review using the ehr involved several repetitive activities .
abstraction of information from the ehr for pathological diagnosis can be a complex and time consuming ; in our practice , the average reported time to complete the list review and case annotation ( ~125 total cases with ~35 frozen section cases ) was 4 hours per person per day ( with single fellow and/or resident participating ) .
significant time was consumed in shifting attention between a printed list of surgical patients ( used by residents and fellows to identify potential cases for review ) and the pathology , radiology , and clinical note sections within the ehr . once cases were identified , pertinent details then had to be abstracted from the ehr by manual transcription to either a printed surgical patient list or separate note sheet . in the absence of an established mechanism for collating the list review work product before morning report , residents and fellows independently reviewing the list ( typically accomplished at night and/or from home ) sometimes duplicated case review work . process flow diagram for ( a ) presurgical case review , ( b ) morning report , and ( c ) real - time case review .
an accessory process for surgical listing information recipients who participate in specimen grossing is shown in tan .
information flows between processes are designated by red arrows other areas identified for improvement by stakeholders were clarity and completeness of morning report ( during which information from the case review is disseminated to the frozen section laboratory team ) and situational case awareness during the intraoperative case review .
interestingly , the physical size of the existing printed surgical list was identified as a potential logistical issue in case review .
although only 3040 surgical cases in a day ( out of 75175 ) might require a frozen section consultation , the electronic listing system in place was only capable of printing a surgical list including all cases ( typically 3040 pages in length ) .
stakeholders reported that a nontrivial amount of time was used to simply search through the printed list to locate a specific listing ( and associated case notes ) when tissue from a new case would arrive in the laboratory .
after mapping the case review process in its entirety , three major subprocesses were identified [ figure 1 ] in the creation and application of the surgical list for frozen section pathology : ( 1 ) generation of the pathology notes for the surgical list ; ( 2 ) communication of those findings to the laboratory staff ; and ( 3 ) utilization of those notes to aid in the diagnostic process .
furthermore , the utilization of pathology notes by other staff ( junior residents and pathology assistants ) to perform the gross dissection of frozen section specimens was identified as an important accessory process [ figure 1 ] .
to increase efficiency and reduce the possibility for errors in the gathering , recording , communicating , and application of case information , it was determined that a software application should be developed .
modification of an existing surgical and procedure scheduling ( sps ) software application was identified as the best approach for meeting the needs of the surgical pathology practice .
the sps application is custom software developed in - house and primarily used by the mayo clinic department of surgery to create and manage the institutional surgical schedule .
listing  in the application contains patient demographics , procedure type , procedure indication , diagnosis ( if available ) , medication orders , patient assessments , required equipment or supply notes , and pharmacy and anesthesia requests .
the sps application was designed to accommodate  modules  with additional functionality from other departments , such as anesthesia or pharmacy , to facilitate total care of surgical patients .
taking advantage of this architecture , development of a pathology - specific module ( pm ) for the sps application was undertaken using an agile software development process .
sps - pm requirements [ table 1 ] were defined from the process map [ figure 1 ] and then further refined with stakeholder feedback on specific areas of waste or inefficiency . over a 2-month period , several development cycles ( sprints )
were undertaken during which key functionality was added to the sps - pm , tested by a resident serving as an end - user technical representative , and then formally integrated into the sps - pm module .
once core functionality was present , the sps - pm was launched to end users for an initial 2-month evaluation period .
the software was designed for ease of use , with a user interface paradigm consistent with typical office productivity software .
an initial basic demonstration of functionality , but no specific end - user training , was provided to a cohort of residents on the frozen section service . in turn
residents and fellows then served as information sources and advocates for adoption by the frozen section staff including staff pathologists , pathology assistants , and technicians .
the attending head of the frozen section working group was the physician champion for the project , and one of the residents directly involved in the development of the software acted as a superuser to provide real - time support for issues and also to serve as a recipient for evaluation feedback . during the initial evaluation period , ongoing user feedback was used to improve sps - pm stability and to identify several additional key features ( case searching and an operating room visual overview ) to be added .
after the review period , the sps - pm application was moved into a production environment , and additional presentations were given to key stakeholder groups ( attending physicians and physician assistants ) to demonstrate features and functionality .
pathology module feature requirements associated with case review , communication of review information , and real - time intraoperative case management
the sps is a. net c # windows presentation foundation application that runs on the microsoft windows operating system , version 7 or greater .
it was developed using the csla.net ( http://cslanet.com/ ) and model - view - viewmodel ( mvvm ) light ( https://mvvmlight.codeplex.com/ ) frameworks , using a mvvm ( https://msdn.microsoft.com/en-us/library/hh848246.aspx ) design pattern to separate application logic from the presentation layer .
listing information was maintained in sybase and ms structured query language ( sql ) databases accessible through standard sql queries .
additional clinical information was retrieved from the mayo clinic electronic medical record ( ge healthcare , wauwatosa , wi , usa ) through web service application programing interface requests .
access to protected health information through these systems is implemented through client authentication within a monitored hipaa - compliant environment .
after 3 months of use , staff pathologists , residents , and fellows were surveyed to assess the sps - pms impact on practice workflow .
study survey data were captured and managed using the research electronic data capture ( redcap ) system ( vanderbilt university , nashville , tn , usa ) .
fifty - five physicians , fellows , and residents involved in the frozen section pathology processes were surveyed .
there were 21 respondents ( 34 non - respondents ) , of which five had not used the sps - pm application and sixteen had used the application .
the sixteen respondents included five staff pathologists , eleven trainees ( residents or fellows ) .
the sps - pm application was designed for three specific tasks within the list review process : ( 1 ) preconsultation case review , ( 2 ) communication of review information to frozen section laboratory staff , and ( 3 ) real - time intraoperative case management .
the preconsultation case review functionality was intended to provide all pathology - relevant information on a surgical listing , while eliminating nonrelevant information ( e.g. anesthesia or nursing notes ) that slowed or obscured the review process .
the listing information is presented to the user within a scrollable list [ figure 2 ] that allows all cases for a given day and surgical site to be viewed and annotated . by default ,
the list is organized by surgical specialty , but it can be organized by patient name , operating room , or status ( preoperative , in surgery , or postoperative ) by the user .
pathology notes are shown in bold lettering at the bottom of each listing , with author identified by initials .
options allow for showing cases that have been excluded and also filtering of cases by status in the operating room each sps - pm case listing includes the patient 's unique medical record number , which serves a direct link to that patient 's record within the ehr .
an annotation function then allows pathology - specific notes to be added to listing information by text entry or copy - paste from the medical record .
in contrast to other listing notes , pathology notes are visible only to users within the department of pathology .
the sps - pm annotation screen is accessed by double - clicking on a patient 's surgical listing [ figure 3 ] .
in addition to providing for entry of case notes , the system prefetches case - associated radiology , pathology , and operative reports from the ehr and presents them within a sortable field for review .
once added and saved , pathology notes are visible within the main surgical listing view [ figure 2 ] .
user initials appended to the end of the notes allow for identification of the note author .
cases without a requirement for intraoperative pathology consultation can be excluded in this annotation screen to hide them from the active case list .
these excluded cases , however , do remain in the system and are retrievable at any time . potentially , infectious cases can be designated as  hood required ,  which adds emphasis text to a surgical listing as a visible reminder that tissue should be processed in a biohazard safety cabinet . to facilitate morning report and real - time case tracking ,
two print views were created : a standard print view that prints in a format similar to the old printed surgical list minus excluded cases , and a  condensed  list view allowing the entire surgical list to be printed on as few sheets as possible [ figure 4 ] .
a note textbox can be used to enter typed or copied text . in the lower right ,
prefetched pathology , radiology , and operative note information can be seen and selected for review .
this screen also allows a case to be excluded from the active set of listings or defined as requiring a biosafety hood print - friendly case listing view .
the operating rooms included within a given column are listed for easy reference at the bottom of that column several application features were designed to facilitate intraoperative case management .
cases are automatically designated as pending ( orange ) , active ( green ; time of incision noted ) , or complete ( blue ; time of closure noted ) .
assessment of case status and serves as a filterable field whereby users can select only pending cases , active cases , or not yet completed cases .
the list can also be organized by surgical specialty , patient name , or operating room number to facilitate different workflows within the frozen section laboratory .
text search functionality is available for rapid filtering based on text matching to any portion of the surgical listing including the pathology notes . before the development of the sps - pm application ,
a different software tool was used to provide situational awareness in the frozen section laboratory . that tool provided a map - like overview of the operating rooms and was much prized for its ability to provide a quick overview of workload status .
based on user feedback , a similar feature was added to the sps - pm application [ figure 5 ] .
this feature consists of a pseudogeographic overview of the operating rooms at either hospital , with coloration and text providing essential real - time case information .
the overview screen can be refreshed manually at any time , and automatically refreshes at 2 minute intervals may be enabled with a toggle button . to facilitate diagnostic workflow when using this view , a  specimen jar 
pathology - specific notes in this view can be accessed by hovering over the specimen jar icon as a tooltip or by double - clicking on the operating room to reveal a modal dialog box [ figure 6 ] .
operating room map view . a pseudotopological map representing the operating room layout at mayo clinic in rochester  saint mary 's campus .
case status in each operating room is color coded : entry ( orange ) , incision ( green ) , and closure ( blue ) . a  specimen jar 
icon in the upper left indicates cases with associated pathology notes operating room map view pathology notes detail .
icon reveals a case 's associated pathology notes adoption of sps - pm by residents and fellows was nearly instantaneous upon its introduction into clinical use .
a redcap survey of perceptions of the sps - pm application was sent to 21 staff , fellows , and residents ; there were 16 respondents ( five staff pathologists and eleven trainees ) .
the survey asked questions about three areas of practice : preconsultation case preparation , morning report , and real - time case awareness .
nearly all trainees ( 10/11 ; 91% ) reported that the application both improved abstracting information from the ehr and the time required to complete case preparation .
time saved by the application was a mean of 1.4 h / day ( range of 04 h ; one trainee reported no time savings ) .
the sps - pm application also improved identification of potentially infectious cases ( 7/11 ; 64% ) . for morning report and surgical day performance ,
respondents indicated the application improved the speed ( 11/16 ; 69% ) , clarity ( 13/16 ; 81% ) , and accuracy ( 10/16 ; 63% ) of morning presurgical case review .
the survey was conducted before the addition of the operating room map overview feature ; even so , a majority surveyed reported case review at the time of diagnosis ( 14/16 ; 88% ) and situational awareness of multiple ongoing cases ( 13/16 ; 81% ) was improved by the sps - pm .
the sps - pm application was designed for three specific tasks within the list review process : ( 1 ) preconsultation case review , ( 2 ) communication of review information to frozen section laboratory staff , and ( 3 ) real - time intraoperative case management .
the preconsultation case review functionality was intended to provide all pathology - relevant information on a surgical listing , while eliminating nonrelevant information ( e.g. anesthesia or nursing notes ) that slowed or obscured the review process .
the listing information is presented to the user within a scrollable list [ figure 2 ] that allows all cases for a given day and surgical site to be viewed and annotated . by default ,
the list is organized by surgical specialty , but it can be organized by patient name , operating room , or status ( preoperative , in surgery , or postoperative ) by the user .
pathology notes are shown in bold lettering at the bottom of each listing , with author identified by initials .
options allow for showing cases that have been excluded and also filtering of cases by status in the operating room each sps - pm case listing includes the patient 's unique medical record number , which serves a direct link to that patient 's record within the ehr .
an annotation function then allows pathology - specific notes to be added to listing information by text entry or copy - paste from the medical record .
in contrast to other listing notes , pathology notes are visible only to users within the department of pathology .
the sps - pm annotation screen is accessed by double - clicking on a patient 's surgical listing [ figure 3 ] .
in addition to providing for entry of case notes , the system prefetches case - associated radiology , pathology , and operative reports from the ehr and presents them within a sortable field for review .
once added and saved , pathology notes are visible within the main surgical listing view [ figure 2 ] .
user initials appended to the end of the notes allow for identification of the note author .
cases without a requirement for intraoperative pathology consultation can be excluded in this annotation screen to hide them from the active case list .
these excluded cases , however , do remain in the system and are retrievable at any time . potentially , infectious cases can be designated as  hood required ,  which adds emphasis text to a surgical listing as a visible reminder that tissue should be processed in a biohazard safety cabinet . to facilitate morning report and real - time case tracking ,
two print views were created : a standard print view that prints in a format similar to the old printed surgical list minus excluded cases , and a  condensed  list view allowing the entire surgical list to be printed on as few sheets as possible [ figure 4 ] .
a note textbox can be used to enter typed or copied text . in the lower right ,
prefetched pathology , radiology , and operative note information can be seen and selected for review .
this screen also allows a case to be excluded from the active set of listings or defined as requiring a biosafety hood print - friendly case listing view .
the operating rooms included within a given column are listed for easy reference at the bottom of that column several application features were designed to facilitate intraoperative case management .
cases are automatically designated as pending ( orange ) , active ( green ; time of incision noted ) , or complete ( blue ; time of closure noted ) .
assessment of case status and serves as a filterable field whereby users can select only pending cases , active cases , or not yet completed cases .
the list can also be organized by surgical specialty , patient name , or operating room number to facilitate different workflows within the frozen section laboratory .
text search functionality is available for rapid filtering based on text matching to any portion of the surgical listing including the pathology notes . before the development of the sps - pm application ,
a different software tool was used to provide situational awareness in the frozen section laboratory . that tool provided a map - like overview of the operating rooms and was much prized for its ability to provide a quick overview of workload status .
based on user feedback , a similar feature was added to the sps - pm application [ figure 5 ] .
this feature consists of a pseudogeographic overview of the operating rooms at either hospital , with coloration and text providing essential real - time case information .
the overview screen can be refreshed manually at any time , and automatically refreshes at 2 minute intervals may be enabled with a toggle button . to facilitate diagnostic workflow when using this view , a  specimen jar 
pathology - specific notes in this view can be accessed by hovering over the specimen jar icon as a tooltip or by double - clicking on the operating room to reveal a modal dialog box [ figure 6 ] .
operating room map view . a pseudotopological map representing the operating room layout at mayo clinic in rochester  saint mary 's campus .
case status in each operating room is color coded : entry ( orange ) , incision ( green ) , and closure ( blue ) . a  specimen jar 
icon in the upper left indicates cases with associated pathology notes operating room map view pathology notes detail .
adoption of sps - pm by residents and fellows was nearly instantaneous upon its introduction into clinical use .
a redcap survey of perceptions of the sps - pm application was sent to 21 staff , fellows , and residents ; there were 16 respondents ( five staff pathologists and eleven trainees ) .
the survey asked questions about three areas of practice : preconsultation case preparation , morning report , and real - time case awareness .
nearly all trainees ( 10/11 ; 91% ) reported that the application both improved abstracting information from the ehr and the time required to complete case preparation .
time saved by the application was a mean of 1.4 h / day ( range of 04 h ; one trainee reported no time savings ) .
the sps - pm application also improved identification of potentially infectious cases ( 7/11 ; 64% ) . for morning report and surgical day performance ,
respondents indicated the application improved the speed ( 11/16 ; 69% ) , clarity ( 13/16 ; 81% ) , and accuracy ( 10/16 ; 63% ) of morning presurgical case review .
the survey was conducted before the addition of the operating room map overview feature ; even so , a majority surveyed reported case review at the time of diagnosis ( 14/16 ; 88% ) and situational awareness of multiple ongoing cases ( 13/16 ; 81% ) was improved by the sps - pm .
review of clinical information , prior pathology , and imaging are an essential component of pathological diagnosis in all settings .
the frozen section practice at mayo clinic in rochester is unique in that its rapid turn - around time and large case volumes require that a large number of individuals take part in rendering an intraoperative consultation .
as all team members require working knowledge of the relevant case information , gathering and dissemination of that information take on a vital significance . while the time - tested method of manual record abstraction from the ehr followed by verbal communication of the information to the laboratory staff was effective , it was also inefficient .
development of the sps - pm application allowed many of those inefficiencies to be addressed , resulting in expected improvements in both trainee 's time required and effort expended .
one immediate benefit of moving the surgical list review process to an electronic platform was the transferability of completed case annotations when a surgical date would change . before implementation of the sps - pm
, trainees would usually be required to wait until the next day 's surgical schedule was finalized at 19:00 h before embarking on the several hour processes of running the list .
three factors drove this behavior : ( 1 ) a requirement that the list be discussed at morning report in the correct final order ( no list changes in operating room assignments or case order ) , ( 2 ) a desire to avoid reviewing cases that might be cancelled or postponed , ( 3 ) a need to ensure all cases requiring frozen section diagnosis were identified and researched ( i.e. , no omission of late add - on cases ) .
the sps - pm application has largely nullified these concerns . if the order of cases is changed or a patient 's surgery moved , the surgical list is automatically reordered with all associated pathology notes ; therefore , there was no risk of lost effort in reviewing a case .
indeed , the persistence of case notes has enabled trainees to begin the list review process several days in advance of the surgical date ( as soon as a listing is made ) , thereby easing the caseload for review on the evening before the surgical day . finally , because the case list can be quickly scanned in real time with associated notes , seemingly  last minute 
in addition , there were several unintended but beneficial outcomes associated with the sps - pm application .
although not a planned feature , the visibility of notes in a central repository allowed for better coordination between trainees reviewing the same list , largely eliminating the problem of duplicate case review .
furthermore , the addition of text searching within the surgical list led to organ system - specific subspecialty groups ( e.g. , hematopathology and neuropathology ) preemptively screening the day 's cases to identify those likely to require intraoperative subspecialty consultation or special handling at frozen section .
finally , the recent integration of research protocol information into the sps - pm has allowed for expedited research collections , replacing the previously performed daily manual list abstraction work performed by pathology assistants and technicians .
the sps - pm application was rapidly adopted into the frozen section pathology laboratory practice at mayo clinic .
the survey results suggest user acceptance was , at least in part , due to the perception that the application significantly improved essential aspects of case review workflow .
while it is unlikely that a software application for frozen section case review would be necessary at all institutions practicing frozen section pathology , the user - centered development process and rapid prototyping design process may be useful approaches for process improvement initiatives in many settings .
in addition , this work provides a practical example of how software applications can assist pathology workflows by enabling extraction ( from the ehr ) and presentation of diagnostically relevant patient information .
 background : the frozen section pathology practice at mayo clinic in rochester performs ~20,000 intraoperative consultations a year ( ~7080/weekday ) . to prepare for intraoperative consultations , surgical pathology fellows and residents review the case history , previous pathology , and relevant imaging the day before surgery . 
 before the work described herein , review of pending surgical pathology cases was a paper - based process requiring handwritten transcription from the electronic health record , a laborious and potentially error prone process.methods:to facilitate more efficient case review , a modular extension of an existing surgical listing software application ( surgical and procedure scheduling [ sps ] ) was developed . 
 the module ( sps - pathology - specific module [ pm ] ) added pathology - specific functionality including recording case notes , prefetching of radiology , pathology , and operative reports from the medical record , flagging infectious cases , and real - time tracking of cases in the operating room . 
 after implementation , users were surveyed about its impact on the surgical pathology practice.results:there were 16 survey respondents ( five staff pathologists and eleven residents or fellows ) . all trainees ( 11/11 ) responded that the application improved an aspect of surgical list review including abstraction from medical records ( 10/11 ) , identification of possibly infectious cases ( 7/11 ) , and speed of list preparation ( 10/11 ) . 
 the average reported time savings in list preparation was 1.4 h / day . 
 respondents indicated the application improved the speed ( 11/16 ) , clarity ( 13/16 ) , and accuracy ( 10/16 ) of morning report . during the workday , respondents reported the application improved real - time case review ( 14/16 ) and situational awareness of ongoing cases ( 13/16).conclusions : a majority of respondents found the sps - pm improved all preparatory and logistical aspects of the mayo clinic frozen section surgical pathology practice . 
 in addition , use of the sps - pm saved an average of 1.4 h / day for residents and fellows engaged in preparatory case review . 
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Process analysis
Development process
Technical background
Survey
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Application features
User perceptions
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Financial support and sponsorship
Conflicts of interest