Integrated Diagnostics: TheIntegrated Diagnostics: The
Perspective of a PathologistPerspective of a Pathologist
Bruce A. F...
- Overhead 2 -
Lecture OutlineLecture Outline
 Defining current role of specialized diagnosticians in theDefining current...
- Overhead 3 -
The Genesis of an Idea forThe Genesis of an Idea for
Revamping the Diagnostic ProcessRevamping the Diagnost...
- Overhead 4 -
Ten Reasons for Merging Pathology,Ten Reasons for Merging Pathology,
Lab Medicine, and RadiologyLab Medicin...
- Overhead 5 -
Ten Reasons for Merging Pathology,Ten Reasons for Merging Pathology,
Lab Medicine, and Radiology (cont.)Lab...
- Overhead 6 -
Arriving at a Diagnosis for a Patient:Arriving at a Diagnosis for a Patient:
A Collaborative ExerciseA Coll...
- Overhead 7 -
How Do Specialized DiagnosticiansHow Do Specialized Diagnosticians
Communicate with Clinicians?Communicate ...
- Overhead 8 -
Diagnoses Versus ImpressionsDiagnoses Versus Impressions
Versus Numerical/Narrative DataVersus Numerical/Na...
- Overhead 9 -
The Integration Challenge AcrossThe Integration Challenge Across
the Array of Diagnostic Studiesthe Array o...
- Overhead 10 -
Inefficiencies/Errors Associated withInefficiencies/Errors Associated with
Lack of Integrated DiagnosticsL...
- Overhead 11 -
What is Integrated Diagnostics?What is Integrated Diagnostics?
 Integrated-Dx: collaborative efforts by d...
- Overhead 12 -
Multidisciplinary Teams inMultidisciplinary Teams in
Therapeutics & DiagnosticsTherapeutics & Diagnostics
...
- Overhead 13 -
How to Best Pursue Integrated Dx;How to Best Pursue Integrated Dx;
Need for Successful Pilot ProjectsNeed ...
- Overhead 14 -
Accountable Care Organizations andAccountable Care Organizations and
the Pursuit of Cheaper-Better-Fastert...
- Overhead 15 -
Relevance of Digital Pathology toRelevance of Digital Pathology to
Integrated DiagnosticsIntegrated Diagno...
- Overhead 16 -
Example of Optimized IntegratedExample of Optimized Integrated
Work-Flow in a Breast CenterWork-Flow in a ...
- Overhead 17 -
Specialized Dashboard/Console forSpecialized Dashboard/Console for
Support of Integrated DiagnosticsSuppor...
- Overhead 18 -
More Details About the IntegratedMore Details About the Integrated
Diagnostic ReportDiagnostic Report
 Cu...
- Overhead 19 -
The Future Pursuit of the IntegratedThe Future Pursuit of the Integrated
Diagnostic Center (IDC)Diagnostic...
- Overhead 20 -
Wrap-up of Major Take-Home PointsWrap-up of Major Take-Home Points
 Call for modification of “silo-ed” dx...
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Integrated Diagnostics: The Perspective of a Pathologist

  1. 1. Integrated Diagnostics: TheIntegrated Diagnostics: The Perspective of a PathologistPerspective of a Pathologist Bruce A. Friedman, M.D.Bruce A. Friedman, M.D. Emeritus Professor of PathologyEmeritus Professor of Pathology University of Michigan Medical SchoolUniversity of Michigan Medical School Ann Arbor, MIAnn Arbor, MI Email:Email: friedman@labinfotech.comfriedman@labinfotech.com Blog:Blog: www.labsoftnews.comwww.labsoftnews.com Twitter: @labsoftnewsTwitter: @labsoftnews
  2. 2. - Overhead 2 - Lecture OutlineLecture Outline  Defining current role of specialized diagnosticians in theDefining current role of specialized diagnosticians in the healthcare enterprise; relationship with clinicianshealthcare enterprise; relationship with clinicians  The integration challenge across the wide array ofThe integration challenge across the wide array of diagnostic studies; errors caused by lack of integrationdiagnostic studies; errors caused by lack of integration  Defining integrated diagnostics; what gains can beDefining integrated diagnostics; what gains can be achieved by closer collaboration in the dx enterprise?achieved by closer collaboration in the dx enterprise?  Healthcare reimbursement as major driver for integratedHealthcare reimbursement as major driver for integrated diagnostics; “cheaper, faster, better” as new goal?diagnostics; “cheaper, faster, better” as new goal?  Deploying the integrated dx report; taking advantage ofDeploying the integrated dx report; taking advantage of a multidisciplinary team in dx; similar to rx teamsa multidisciplinary team in dx; similar to rx teams
  3. 3. - Overhead 3 - The Genesis of an Idea forThe Genesis of an Idea for Revamping the Diagnostic ProcessRevamping the Diagnostic Process  On 10/23/2006, I posted a blog note onOn 10/23/2006, I posted a blog note on Lab Soft NewsLab Soft News:: Ten Reasons to Merge Pathology & RadiologyTen Reasons to Merge Pathology & Radiology  Idea struck me as reasonable in an era of increasingIdea struck me as reasonable in an era of increasing specialization and “silo-ization”; return to “big picture”specialization and “silo-ization”; return to “big picture”  Clearly, this is a change that will not take placeClearly, this is a change that will not take place overnight, if ever; too much resistance to changeovernight, if ever; too much resistance to change  Also, current environment evolved for a reason; most ofAlso, current environment evolved for a reason; most of the incumbents have large stake in the current systemthe incumbents have large stake in the current system  Following are the ten reasons as originally published inFollowing are the ten reasons as originally published in Lab Soft NewsLab Soft News but with some editing for brevity/claritybut with some editing for brevity/clarity
  4. 4. - Overhead 4 - Ten Reasons for Merging Pathology,Ten Reasons for Merging Pathology, Lab Medicine, and RadiologyLab Medicine, and Radiology 1.1. Substantial overlap between current missions of theSubstantial overlap between current missions of the diagnostic specialties (pathology, radiology, lab med)diagnostic specialties (pathology, radiology, lab med) 2.2. Enhanced clinical and research value if the LIS, RIS,Enhanced clinical and research value if the LIS, RIS, and PACS databases were merged/analyzedand PACS databases were merged/analyzed 3.3. Integrated [diagnostic] reports would achieve higherIntegrated [diagnostic] reports would achieve higher levels of quality; pursuit of the “super-diagnosis” for pts.levels of quality; pursuit of the “super-diagnosis” for pts. 4.4. Merger of medical imaging, molecular imaging, andMerger of medical imaging, molecular imaging, and molecular dx is already taking place at rapid pacemolecular dx is already taking place at rapid pace 5.5. Science & research agendas of molecular imaging &Science & research agendas of molecular imaging & molecular dx already demonstrate extensive overlapmolecular dx already demonstrate extensive overlap
  5. 5. - Overhead 5 - Ten Reasons for Merging Pathology,Ten Reasons for Merging Pathology, Lab Medicine, and Radiology (cont.)Lab Medicine, and Radiology (cont.) 6.6. Dx medicine would form the basis for a cohesive,Dx medicine would form the basis for a cohesive, cohesive, and competitive new medical specialtycohesive, and competitive new medical specialty 7.7. Dx medicine would benefit from a critical mass ofDx medicine would benefit from a critical mass of trainees who would carve out a professional identitytrainees who would carve out a professional identity 8.8. Core dx technologies would benefit from infusion of theCore dx technologies would benefit from infusion of the new science & technology currently used in imagingnew science & technology currently used in imaging 9.9. Pathology & lab medicine need a new influx of capitalPathology & lab medicine need a new influx of capital investment in the form of corporate R&D fundsinvestment in the form of corporate R&D funds 10.10. Radiology, pathology, & lab medicine are similarlyRadiology, pathology, & lab medicine are similarly dependent on IT, molecular dx, & imaging technologydependent on IT, molecular dx, & imaging technology
  6. 6. - Overhead 6 - Arriving at a Diagnosis for a Patient:Arriving at a Diagnosis for a Patient: A Collaborative ExerciseA Collaborative Exercise  DiagnosisDiagnosis: identifying a disease on basis of signs,: identifying a disease on basis of signs, symptoms, and results of various diagnostic proceduressymptoms, and results of various diagnostic procedures  In modern medicine, clinicians order various dx tests &In modern medicine, clinicians order various dx tests & procedures as means to arrive at a correct diagnosisprocedures as means to arrive at a correct diagnosis  Clinicians interact directly with patients; specializedClinicians interact directly with patients; specialized diagnosticians act as consultants in this dx processdiagnosticians act as consultants in this dx process  Because clinicians control dx ordering, it falls to them toBecause clinicians control dx ordering, it falls to them to integrateintegrate the results/reports into the final diagnosisthe results/reports into the final diagnosis  IntegrationIntegration becoming more difficult because ofbecoming more difficult because of increasing sophistication of tests/procedures offeredincreasing sophistication of tests/procedures offered
  7. 7. - Overhead 7 - How Do Specialized DiagnosticiansHow Do Specialized Diagnosticians Communicate with Clinicians?Communicate with Clinicians?  In theory and in past, diagnosticians were available toIn theory and in past, diagnosticians were available to clinicians for face-to-face discussions about patientsclinicians for face-to-face discussions about patients  Because of workload & physical separation,Because of workload & physical separation, communication accomplished via LIS/RIS/EMR reportscommunication accomplished via LIS/RIS/EMR reports  Radiology totally converted to digital; these images nowRadiology totally converted to digital; these images now available on-line for review by clinicians via the PACSavailable on-line for review by clinicians via the PACS  Only minority of clinicians (e.g., ortho/neuro surgeons)Only minority of clinicians (e.g., ortho/neuro surgeons) attempt to routinely interpret their own ordered studiesattempt to routinely interpret their own ordered studies  One group of clinicians, cardiologists, has maintainedOne group of clinicians, cardiologists, has maintained some degree of control over their own dx studiessome degree of control over their own dx studies
  8. 8. - Overhead 8 - Diagnoses Versus ImpressionsDiagnoses Versus Impressions Versus Numerical/Narrative DataVersus Numerical/Narrative Data  Surgical pathologists, render dx’s; when tissue surgicallySurgical pathologists, render dx’s; when tissue surgically removed, falls to them to be serve as final arbiterremoved, falls to them to be serve as final arbiter  Radiologists renders impressions, dx’s, conclusions;Radiologists renders impressions, dx’s, conclusions; answer questions posed by the clinicians in their ordersanswer questions posed by the clinicians in their orders  Because radiology can be less precise than surgicalBecause radiology can be less precise than surgical pathology, a differential diagnosis is often includedpathology, a differential diagnosis is often included  A suggestion often included in radiology report about theA suggestion often included in radiology report about the next imaging study to narrow the differential diagnosisnext imaging study to narrow the differential diagnosis  In clinical pathology & molecular dx, report frequentlyIn clinical pathology & molecular dx, report frequently provides numerical results with occasional analysisprovides numerical results with occasional analysis
  9. 9. - Overhead 9 - The Integration Challenge AcrossThe Integration Challenge Across the Array of Diagnostic Studiesthe Array of Diagnostic Studies  Little integration across CP & AP; also little integrationLittle integration across CP & AP; also little integration across the various radiology imaging modalitiesacross the various radiology imaging modalities  Surgical pathology, various clinical labs, imagingSurgical pathology, various clinical labs, imaging modalities (e.g., CT, MRI) each generate their own reportsmodalities (e.g., CT, MRI) each generate their own reports  It falls to the clinicians to integrate each of these individualIt falls to the clinicians to integrate each of these individual reports released across time to arrive at the correct dxreports released across time to arrive at the correct dx  Hard to fault this approach historically because cliniciansHard to fault this approach historically because clinicians has the best knowledge of the progression of dx workuphas the best knowledge of the progression of dx workup  Due to complexity of modern medicine, diagnosticiansDue to complexity of modern medicine, diagnosticians need to provide more integrated reporting to cliniciansneed to provide more integrated reporting to clinicians
  10. 10. - Overhead 10 - Inefficiencies/Errors Associated withInefficiencies/Errors Associated with Lack of Integrated DiagnosticsLack of Integrated Diagnostics  By working inside their silos, diagnosticians turning aBy working inside their silos, diagnosticians turning a blind eye to inefficiencies/errors promoted by systemblind eye to inefficiencies/errors promoted by system – Different vocabularies have evolved in rad/ pathDifferent vocabularies have evolved in rad/ path over time to describe same pathologic changesover time to describe same pathologic changes – Surgical pathology dx’s could be focused/ improvedSurgical pathology dx’s could be focused/ improved with parallel ordering/interp. of molecular dx studieswith parallel ordering/interp. of molecular dx studies – Scheduling of dx studies often turfed to clinicians;Scheduling of dx studies often turfed to clinicians; dx services could use scheduling algorithmsdx services could use scheduling algorithms – Diagnosticians best qualified to eliminate down-timeDiagnosticians best qualified to eliminate down-time & waste form their own internal processes/systems& waste form their own internal processes/systems
  11. 11. - Overhead 11 - What is Integrated Diagnostics?What is Integrated Diagnostics?  Integrated-Dx: collaborative efforts by dx services toIntegrated-Dx: collaborative efforts by dx services to present clinicians with final, integrated dx for patientspresent clinicians with final, integrated dx for patients  In the short-run, efforts will focus on low-lying fruit;In the short-run, efforts will focus on low-lying fruit; wring out waste & facilitate generation of common dx’swring out waste & facilitate generation of common dx’s  In the long-run, I envision merging of current dxIn the long-run, I envision merging of current dx specialties into new discipline – Diagnostic Medicinespecialties into new discipline – Diagnostic Medicine  Early efforts will be laborious because initiative isEarly efforts will be laborious because initiative is novel; existing specialties will resist radical changenovel; existing specialties will resist radical change  These efforts will result in computer-managedThese efforts will result in computer-managed diagnostic algorithms to optimize tests & proceduresdiagnostic algorithms to optimize tests & procedures
  12. 12. - Overhead 12 - Multidisciplinary Teams inMultidisciplinary Teams in Therapeutics & DiagnosticsTherapeutics & Diagnostics  Highest quality care being delivered in cancer centersHighest quality care being delivered in cancer centers staffed by multidisciplinary [clinical] teams (MDTs)staffed by multidisciplinary [clinical] teams (MDTs)  MDTs generate optimal treatment recommendations butMDTs generate optimal treatment recommendations but inhibit natural instincts of individual physician specialistsinhibit natural instincts of individual physician specialists  Also need to decouple clinical decision-making fromAlso need to decouple clinical decision-making from reimbursement stream where procedures yield incomereimbursement stream where procedures yield income  Multidisciplinary [diagnostic] teams achieve same end;Multidisciplinary [diagnostic] teams achieve same end; integration of “silo diagnoses” into a “super” diagnosisintegration of “silo diagnoses” into a “super” diagnosis  Because of volume of diagnostic tests/procedures; suchBecause of volume of diagnostic tests/procedures; such teams can only work effectively on virtual basis (see later)teams can only work effectively on virtual basis (see later)
  13. 13. - Overhead 13 - How to Best Pursue Integrated Dx;How to Best Pursue Integrated Dx; Need for Successful Pilot ProjectsNeed for Successful Pilot Projects  Pessimistic that pathology/radiology would pursuePessimistic that pathology/radiology would pursue integrated diagnostics independently & spontaneouslyintegrated diagnostics independently & spontaneously  Current silos evolved on basis of greater productivity &Current silos evolved on basis of greater productivity & specialty ethos of silos; incumbents will fight to keepspecialty ethos of silos; incumbents will fight to keep  Error reduction studies via integration could provideError reduction studies via integration could provide incentives, but will never be performed on large-scaleincentives, but will never be performed on large-scale  Only significant driver will be integrated-dx pilotOnly significant driver will be integrated-dx pilot studies that produce “cheaper-faster-better” resultsstudies that produce “cheaper-faster-better” results  Logical place for such pilot studies will be in existingLogical place for such pilot studies will be in existing radiology-managed, screening-driven breast clinicsradiology-managed, screening-driven breast clinics
  14. 14. - Overhead 14 - Accountable Care Organizations andAccountable Care Organizations and the Pursuit of Cheaper-Better-Fasterthe Pursuit of Cheaper-Better-Faster  An ACO is a clinically integrated group of providers who improveAn ACO is a clinically integrated group of providers who improve the health of a defined population and share resulting savings.the health of a defined population and share resulting savings.  PPACA (2010): A group of providers of services and suppliersPPACA (2010): A group of providers of services and suppliers meeting criteria specified by [HHS] may work together tomeeting criteria specified by [HHS] may work together to manage and coordinate care for Medicare fee-for-servicemanage and coordinate care for Medicare fee-for-service beneficiaries.beneficiaries.  Comparative effectiveness research (CER) is the conduct andComparative effectiveness research (CER) is the conduct and synthesis of research comparing the benefits and harms ofsynthesis of research comparing the benefits and harms of different interventions and strategies to prevent, diagnose, treatdifferent interventions and strategies to prevent, diagnose, treat and monitor health conditions in “real world” settings. Theand monitor health conditions in “real world” settings. The purpose of this research is to improve health outcomes …[andpurpose of this research is to improve health outcomes …[and determine] which interventions are most effective for whichdetermine] which interventions are most effective for which patients under specific circumstances.patients under specific circumstances.
  15. 15. - Overhead 15 - Relevance of Digital Pathology toRelevance of Digital Pathology to Integrated DiagnosticsIntegrated Diagnostics  Recall that the goal of integrated dx is cheaper, faster,Recall that the goal of integrated dx is cheaper, faster, better and the need to wring out waste from systemsbetter and the need to wring out waste from systems  Digital pathology facilitates tissue diagnoses; portabilityDigital pathology facilitates tissue diagnoses; portability of whole-slide-images creates new optionsof whole-slide-images creates new options  Hospital pathologists can “read images” anywhere; WSIHospital pathologists can “read images” anywhere; WSI also enables e-consultations for small groupsalso enables e-consultations for small groups  Digital pathology has also ushered in era ofDigital pathology has also ushered in era of algorithms for analyzing IHC/FISH stained breast tumorsalgorithms for analyzing IHC/FISH stained breast tumors  Digital pathology major step in conversion of surgicalDigital pathology major step in conversion of surgical pathology to more of a quantitative medical specialtypathology to more of a quantitative medical specialty
  16. 16. - Overhead 16 - Example of Optimized IntegratedExample of Optimized Integrated Work-Flow in a Breast CenterWork-Flow in a Breast Center  Patients with new breast masses discovered atPatients with new breast masses discovered at screening & referred patients moved to dx sidescreening & referred patients moved to dx side  Additional imaging studies & FNA or core biopsy whenAdditional imaging studies & FNA or core biopsy when indicated; tissues specimens transferred to histo labindicated; tissues specimens transferred to histo lab  Tissue samples processed/embedded; glass slidesTissue samples processed/embedded; glass slides scanned with WSI to path PACS; pathologists alertedscanned with WSI to path PACS; pathologists alerted  Case interpreted by pathologist; relevant serum/tissueCase interpreted by pathologist; relevant serum/tissue biomarkers ordered on basis of approved protocolbiomarkers ordered on basis of approved protocol  ““Virtual” conferencing by panel of diagnosticians toVirtual” conferencing by panel of diagnosticians to assign “super” dx on basis of specialized dx’sassign “super” dx on basis of specialized dx’s
  17. 17. - Overhead 17 - Specialized Dashboard/Console forSpecialized Dashboard/Console for Support of Integrated DiagnosticsSupport of Integrated Diagnostics  Unlikely in the near-term that we will see integratedUnlikely in the near-term that we will see integrated diagnostic systems (LIS+RIS+PACS); little demanddiagnostic systems (LIS+RIS+PACS); little demand  As substitute and to support integrated dx,As substitute and to support integrated dx, development of web-based dx dashboards/consolesdevelopment of web-based dx dashboards/consoles – Interfaced to legacy LIS, RIS, PACSs, EMRInterfaced to legacy LIS, RIS, PACSs, EMR – Will display all relevant diagnostic images and dataWill display all relevant diagnostic images and data including all relevant IP/OP clinical dataincluding all relevant IP/OP clinical data – Critical integrative tool for pathologists/radiologists whoCritical integrative tool for pathologists/radiologists who will participate in the virtual dx “panels”will participate in the virtual dx “panels” – Some of these devices are already on market; more toSome of these devices are already on market; more to follow event absent interest in integrated diagnosticsfollow event absent interest in integrated diagnostics
  18. 18. - Overhead 18 - More Details About the IntegratedMore Details About the Integrated Diagnostic ReportDiagnostic Report  Current process is to release imaging studies, surgicalCurrent process is to release imaging studies, surgical path reports, molecular dx sequentially, each with dx’spath reports, molecular dx sequentially, each with dx’s  Proposal: convene “virtual” panels of diagnosticians toProposal: convene “virtual” panels of diagnosticians to review individual dx’s & generate “super” diagnosisreview individual dx’s & generate “super” diagnosis  Analogous to MDTs in Cancer Centers that discussAnalogous to MDTs in Cancer Centers that discuss cases & recommend integrated therapeutic regimenscases & recommend integrated therapeutic regimens  Each member of “virtual” panel would simultaneouslyEach member of “virtual” panel would simultaneously review case using dx console for access to all datareview case using dx console for access to all data  Connectivity using video conferencing would be time-Connectivity using video conferencing would be time- saver; necessary because of the volume of casessaver; necessary because of the volume of cases
  19. 19. - Overhead 19 - The Future Pursuit of the IntegratedThe Future Pursuit of the Integrated Diagnostic Center (IDC)Diagnostic Center (IDC)  I envision that early integrated diagnostic initiatives willI envision that early integrated diagnostic initiatives will eventually morph into both physical/virtual IDCseventually morph into both physical/virtual IDCs  PCPs/internists/surgeons would refer patients withPCPs/internists/surgeons would refer patients with undiagnosed masses; pts. would exit with diagnosesundiagnosed masses; pts. would exit with diagnoses  During diagnostic process, all ordering & patientDuring diagnostic process, all ordering & patient management would be managed by diagnosticiansmanagement would be managed by diagnosticians  Oncologists are in the therapeutic & not diagnosticOncologists are in the therapeutic & not diagnostic “business”; only want referrals of diagnosed patients“business”; only want referrals of diagnosed patients  Other types of organ masses after breast that would beOther types of organ masses after breast that would be suitable for referral: lung, thyroid, kidney, liversuitable for referral: lung, thyroid, kidney, liver
  20. 20. - Overhead 20 - Wrap-up of Major Take-Home PointsWrap-up of Major Take-Home Points  Call for modification of “silo-ed” dx processes;Call for modification of “silo-ed” dx processes; collaboration of pathology, radiology, lab medicinecollaboration of pathology, radiology, lab medicine  Integrated diagnostics analogous to emergence of multi-Integrated diagnostics analogous to emergence of multi- disciplinary therapeutic teams in cancer centersdisciplinary therapeutic teams in cancer centers  Goal would be “cheaper, faster, better” diagnoses; digitalGoal would be “cheaper, faster, better” diagnoses; digital pathology key TAT element from pathology sidepathology key TAT element from pathology side  ““Virtual” panels, using specialized diagnostic dashboardsVirtual” panels, using specialized diagnostic dashboards would generate “super” dx’s from myriad dx reportswould generate “super” dx’s from myriad dx reports  Current breast clinics, used mainly for screening, wouldCurrent breast clinics, used mainly for screening, would be valuable/logical sites for pilot projects to test TATbe valuable/logical sites for pilot projects to test TAT  Success will not come easily with entrenched interests;Success will not come easily with entrenched interests; drive toward ACOs could serve as stimulus for changedrive toward ACOs could serve as stimulus for change
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