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  • Long, (most would say too long), eventful history from the initial, academic conception to the current pervasiveness of PACS and Digital Radiology.
  • Technology Enablers + Economic drivers Need for better workflow
    - DICOM 3.0 as a major milestone
  • Pathology is poised for leap-frogging
  • Reproducing the analog workflow (a 1930’s workflow, really) has been the first goal.
    This objective took a long time to achieve, but once accomplished, the focus shifted on integrating the now digital Radiology into the rest of the healthcare Enterprise.
    The current drivers of progress now come from outside of the department and are forcing the further evolution of the practice of Radiology.
  • Fig 1. Pathology Workflow: Present and Future. Solid lines represent transfer of physical information (ie. Slides, gross specimens) while dashed lines represent transfer of digital information. Red lines depict a hypothetical workflow in the future where whole slide imaging (WSI) modalities are utilized for diagnosis. In our example, the anatomic pathology laboratory information system (APLIS) vendor and imaging vendors are independent. It is likely that both physical slide based workflow and digitized slide workflow will co-exist where upon initial adoption of WSI technology only a minority of selected cases are being digitized. As experience using WSI technology and user interfaces is gained and as WSI technology matures it is expected that larger numbers of cases will be diverted into the WSI workflow (red lines). One important issue that must be addressed is how metadata (ie. patient demographic info, block/slide info) is assigned to digitized WSI images. This can be accomplished through the APLIS but requires unique identifiers for each digitized slide. In our example, these identifies are generated by the APLIS itself and passed with the appropriate metadata to an annotation engine where metadata is linked to the newly digitized image and then sent to a picture archival and storage system (PACS). Manual data entry must be minimized whenever possible if WSI technology is to be incorporated into and ultimately replace existing physical slide based workflow.
  • The clinical application (i.e.: the abstract concept of the workstation) is rapidly evolving under the environmental pressures.
    Demands of higher productivity in the face of ever-increasing volumes of image-data and tighter and tighter integration
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    1. 1. Joe Biegel VP, Product Management McKesson Medical Imaging Group October 23, 2007 Evolution of PACS as a Model to Predict Adoption of Digital Pathology
    2. 2. A Brief History of PACS 1970’s1970’s 1980’s1980’s 1990’s1990’s 2000’s2000’s Original concepts: Dr. T. Iinuma, “Image processing in clinical medicine – considerations of a system”, Bull., Tokyo Women Med. 44, 152 (in Japanese). 1974 Dr. Samuel J. Dwyer III describes PACS ideas at a Seminar at the University of Iowa. Dr. Judith M. Prewitt introduces the term PACS. Cardiovascular radiologist Dr. Andre Duerinckx describes the far reaching future benefits of PACS for a hospital. 1981 1st International Conference on the PACS, Newport Beach, California. 1982 US Army teleradiology project starts. 1983 Siemens/Philips start developing PACS concepts. EuroPACS starts annual meetings. 1984 US National Cancer Institute funds UCLA group under Professor Bernie Huang. 1985 Berlin BERKOM project started. 1986 PRIMIS created at VUB Brussels – to study applications of digital imaging. 1987 NATO conference in France includes topic on Imaging Networks. SCAR celebrates 10th annual meeting. 1990 US – Baltimore Veterans Hospital PACS. UK – Hammersmith and Conquest PACS projects. 1992 Roger Baumann and Gunther Gell identify 23 large PACS worldwide with over 100 PACS projects. 1995 Baumann and Gell follow up survey – 177 large PACS identified worldwide. 2000 Multiple regional and national projects initiated. Worldwide mass adoption begins in earnest 2002
    3. 3. PACS Market Evolution 1990 20001985 Standards Technology Enablers Market Solutions Offered ACR-NEMA ACR-NEMA 2.0 IHE DICOM + HL7 DICOM 3.0 Research Pioneers Early Adopters Replacement Mass Adoption Single Modality Applications Departmental PACS Enterprise RIS/PACS Multi-Modality Viewing Apps Departmental RIS/PACS HSM Systems NAS / SAN Storage H/W $  Hi-Res Displays Affordable UNIX workstations Optical Storage Media 9-track tapes Mainframe Computers Voice Recognition Optical Storage Jukeboxes TCP/IP adoption
    4. 4. The Evolution of Imaging IT Market Segments 1990 20101985 2000 Radiology PACS Market Research Pioneers Early Adopters Replacement Mass Adoption Cardiology PACS Market Research Pioneers Replacement Early Adopters Mass Adoption Optical Imaging Research Pioneers Early Adopters Mass Adoption Replacement
    5. 5. Historical Radiologist Workflow Early Perceived Value Radiologist Workflow with RIS/PACS Rad bar codes requisition into dictation system 1 Clerks/Tech match up films to be read with patient’s master jacket Films with masters are delivered to Radiologist Is there previous in master Rad hangs films on view box Rad hangs previous for review Rad enters MRN into RIS, finds patient, reviews results No Rad bar codes requisition into dictation system Rad dictates patient name, order, and accession number in dictation system, and dictates report Rad places films back into daily folder and signs bag Rad places signed daily with patient master jacket aside for pickup by clerical staff. 1 Rad opens unread worklist on PACS in dictate mode and opens first exam to be read Rad clicks on clinical history icon to review patient’s reports and results from HIS/RIS Dictation automatically initiated. Order information from the RIS automatically sent to dictation system. Relevant prior studies automatically display Rad dictates report, and clicks next study Patient and order level information sent from PACS to RIS with no patient search required Next study is loaded. Dictation is initiated, and previous exam is marked dictated in PACS 1 1
    6. 6. Pathology progress, as compared to Radiology  The evolution of Digital Imaging in Radiology offers significant lessons for Pathology  Parallels with a later start, … but likely faster progress ─ Radiology in 1995 vs. Path in 2005 ─ Radiology today vs. Path in 2010  Moore’s law helps  No need to repeat the same pitfalls Source: Bruce Beckwith, MD – 2005 DICOM International Conference – Budapest, Hungary
    7. 7. Radiology c. 1995 -vs- Pathology c. 2005 RadiologyRadiology PathologyPathology Analog image capture Analog image capture or no image capture Single modality to multi –modality focus Single modality DICOM standards- early formation of IHE Emerging standards Separate workflows – RIS, Reporting, Separate workflows – APLIS, Reporting Radiology focused Images hard to interpret for non pathologists Storage needs seem overwhelming Extreme storage needs Digital Imaging is more expensive than analog Digital Imaging costs money “Island” workflow Unstructured, collaborations, distribution Most of spending is still on film Modest budgets
    8. 8. Radiology Now -vs- Pathology in 2010 RadiologyRadiology PathologyPathology Digital Acquisition is standard Digital acquisition growing Automatic meta-data capture Streamlined image capture with metadata CAD assists Radiologist’s interpretation CAD interpretable portions Many patient requests Large transactions per study Large and constantly growing storage needs Large storage needs, but cost barrier decreasing Digital imaging saves money, and is required to make money Digital pathology adds value and is required to make money Large budgets Budgets expand into IT space Radiology outside the dept. of Radiology walls Remote pathology, protocols, strong links to clinical practice.
    9. 9. Driving adoption is key  Automating the current workflow is only the first step ─ Both physical slide based workflow and digitized slide workflow will co-exist for a long time ─ Metadata (ie. patient demographic info, block/slide info) needs to be assigned to digitized WSI images ─ Manual data entry must be minimized whenever possible if WSI technology is to be incorporated into and ultimately replace existing physical slide based workflow  Economic drivers of digital pathology are evolving ─ Factors from outside the department will dominate ─ Standard of care, costs & reimbursement are the keys  Solution requirements will also evolve
    10. 10. 01010101010 101010101010110 1010101010101010101 Pathology Workflow Present & Future Source: Sourav Ray MD, et al: CAP, 2006 Metadata Annotation Engine Histology Laboratory Physical Slides Slide Storage PACS 10101010101 101010111011 10110101010101010 101010101 0101010101010101010010101010101010101010101101010101010101010101010101010101 10110010101010101010101010101 101010101010101010 10110010101010101010101 101010101010101010 101010101 10101010101 101010110100101010101010101010 10101101 10110010101010101 101010110100101010101010101010101010 10101010101010101010101010101010 10101010101010101010 Gross Specimen Pathologist Orders: Recuts, Levels, IHC/Special Stains, Ancillary Studies WSI unique ID # for each WSI slide H&E Data, IHC Data, Flags, Comments WSI or not WSI? Block Data, Gross Description, Gross Images Cassettes/Blocks 3rd Party Whole Slide Imaging (WSI) Apparatus Load with WSI Unique Slide ID# Patient Block Slide Data attached to WSI Unique ID# Digitized Whole Slide Images (WSI) attached to WSI Unique ID# Annotated Whole Slide Images (WSI) Region of Interest (ROI) jpeg images (Direct Operation 3rd Party Imaging Apparatus) Request WSI Images Via WSI unique ID# Request ROI Images WSI Images as requested per case Order s Patient/Case/ Block Data, Prior Reports, Images (ROI) and WSI) APLIS Remote Operation 3rd Party Imaging Apparatus (TWAIN) Region of Interest (ROI) jpeg Images Physical Slide Analog Optical Image
    11. 11. Future Pathology Workflow  The vision of automating the current workflow is a noble goal, but it is only the first step ─ The true value of Digital Pathology will have to be defined in terms of faster, improved Patient Care  Going Digital will change the practice of Pathology and will lead to a new, yet undefined workflows ─ Standards, IHE will help: necessary but insufficient to drive wide-scale adoption
    12. 12. DICOM in Pathology  Visible Light Supplement 15 ─ Included support for gross images, microscopic images, x,y.z position, lab accession numbers  Working Group 26 ─ Evolving to include whole slide imaging  Growing number of imaging products targeting pathology are DICOM compliant  US Veteran’s Administration: ─ Pathology imaging vendors must be DICOM compliant
    13. 13. IHE-J in Pathology – Workflow/Data Structure Order Sample Macro Image Slide Block Sample Sample Slide Slide Study Series Image Block Source: Tofukuji * Okuno – 2005 IHE –Japan Pathology WG
    14. 14. Diagnostic Imaging Cockpit = ‘vision’ under pressure Diagnostic Imaging CockpitDiagnostic Imaging Cockpit Departmental PACS diagnostic tools Collateral content 3D, Fusion, CAD Orthopaedic extensions Enterprise Worklist Departmental management & reporting tools EMR Integration Voice Recognition Structured Reporting: eg OB, ER discrepancy & critical results reporting
    15. 15. A B A B Worklist & Case History Gross / Low Res. Image Analysis Digital Slides Report This is an example text bocks for the gross image shown above. This text is so small that it is unlikey that anyone can read it. Can you? I really doubt it. This is an example text bocks for the gross image shown above. This text is so small that it is unlikey that anyone can read it. Can you? I really doubt it. Source: Aperio Technologies The Pathology “Cockpit” – current focus
    16. 16. Pathology  Next stage Pathology CockpitPathology Cockpit Advanced diagnostic tools 3D, Fusion, CAD Muti-spectral imaging Test sub-routines (histology, etc.) Enterprise Worklist Departmental management & reporting tools EMR Integration Voice Recognition Structured Reporting Critical findings / ER ?? Departmental Productivity Reporting
    17. 17. Synergies with Diagnostic Imaging  Leverage image management infrastructure ─ Cost and expertise synergies will speed adoption  Routine access will likely create clinical use cases which will drive the adoption ─ The extent to which these use cases impact outcomes will impact market acceleration  Access needs vary ─ Pathologists want access to diagnostic image data ─ Radiologists have interest in access to summary data and no interest in WSI access
    18. 18. Value Points = Business Control Points  Modality = Data Acquisition  Storage = Physical Storage Devices (H/W)  Image Access Points = Clinical Application(s)  Workflow = Order  $  Data = Data-mining  CAD – address the volume – may be more formative than in Radiology  Financial benefit needs to become more clear
    19. 19. Organic evolution is a slow, painful process with many side-tracks  Integration and interoperability with other systems is key to adoption ─ Isolated systems, IT-silos are short-lived, with limited clinical benefits  Don’t repeat the evolutionary sidetracks from the history of other clinical disciplines…  Use PACS as a starting point and build on it !!
    20. 20. Summary  Pathologists need PACS now ─ value is immediate ─ Pathologists should have PACS access now – the patient record needs to contain relevant imaging data  If you want to accelerate the adoption-curve of digital pathology: ─ ‘Hook’ your digital Pathology plans to your PACS  It is likely that early workflows will leverage other specialties, BUT these will inevitably be transient solutions with the “real” Digital Pathology workflow to follow ─ Pathology dept specific workflow solutions are needed and must have digital path imaging as part of the workflow now.
    21. 21. Questions?Questions?

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