The Daily Scan

KGH Pioneers New Telepathology Technology

From "Stories in the News", from Ketchikan, Alaska: KGH Pioneers New Telepathology Technology:

Imagine looking through a microscope in Bellingham, Washington, and viewing a slide in Ketchikan, Alaska, and you have the idea behind the new telepathology service that now links the two cities. The new service allows surgeons in the operating room at Ketchikan General Hospital real time consultation with pathologists at Northwest Pathology in Bellingham. The pathologist can change focus, illumination, magnification, and field of view at will as he or she uses an online interface to examine a frozen tissue slide prepared in Ketchikan.

Ketchikan General Hospital (KGH), in partnership with the PeaceHealth Laboratories and Northwest Pathology, is among the first hospitals in North America to use telepathology in an intraoperative setting. This technology has been used for research, academic instruction and general pathology consultations but KGH is pioneering this use of the technology, which is especially beneficial to smaller, rural critical access hospitals where technical experts may not be readily available.

The use of this technology will improve patient care and reduce travel costs. Here is how it works: a surgeon at KGH submits tissue for pathology review during a procedure. A histotechnologist at the Ketchikan lab will freeze the tissue, prepare the slide and scan it. In Bellingham, one of the pathologists will log into an online site to review the whole slide image and call the surgeon directly in the O.R. to discuss the results.

How cool is that?  The technology of digital pathology has such value in remote locations like Ketchikan, to bring the required expertise to each case when needed.

Not so fast? Concrete considerations for digital move...

CAP Today has an interesting article about the adoption of digital pathology: Not so fast? Concrete considerations for digital move... from Walter Hendricks, taken from his talk at last fall's APIII Conference.

My goal in this talk is to focus on the operational and workflow aspects that we and our vendor partners need to examine now that we’re starting to use images for clinical purposes. A number of things have to be accounted for in processes and procedures if digital pathology is to become anything close to a scalable workflow.

I’m going to define digital pathology as pathology practice based on digital representations of glass slides, and for this talk it’s mostly through whole-slide imaging. We all know it involves more than just scanning a slide and viewing it on a screen.

There’s a lot of talk about the merging of digital radiology and pathology and the similarities between the two. I appreciate and understand these discussions, but let’s take a small step back. Now and then I have encountered people outside of pathology who have said, ‘Look, it’s an image. You look at it, digitize it. Radiologists have done it. They’re out there making money doing this. Why can’t you?’ Well, guess what? Digital pathology is not digital radiology. And pathology isn’t radiology. Digitization is seamlessly integrated into radiology workflow and actually is the workflow. The images are created digitally, with no additional steps. They’re ready to go; they’re ready for interpretation.

We have that little inconvenience of, oh, by the way, actually having the tissue, having to look at the tissue before we have an image generated. We have to process the tissue, create a glass slide, stain it. All of the routine tissue procurement, gross exam, tissue processing, glass slide creation steps must still occur before digitization.

Therefore, digital pathology is extra work. It requires extra effort and time over and above all the steps that would have to take place anyway. Digital pathology means extra cost. We have to invest in image capture and digitization, transmission, displaying, viewing, and storage. In addition to the capital expense, there are labor and other expenses that come from having to incorporate digital pathology into any type of clinical workflow. These are all investments that have to be justified. The value proposition for digital pathology, then, hinges on benefits that outweigh the costs associated with the incremental work and required investments.

Please read the whole thing, it's a nice balanced overview of the pros and cons of adapting digital pathology into clinical workflow.

Where Do We Go from Here in Healthcare Reform?

Bruce Friedman asks, in the wake of Scott Brown being elected and the likely failure of this Congress to pass a healthcare reform bill, Where Do We Go from Here in Healthcare Reform?

There are four bad options facing congress; listed in parentheses are examples of how each option might be executed: (1) Heedless and Arrogant Approach: (ram the current policy through); (2) Weak and Feckless Approach: (try incremental reforms); (3) Dangerous and Demagogic Approach: (stripping the health bills of anything that might be unpopular and passing the rest regardless of the cost); and (4) Incoherent and Internecine Approach: (settling on no coherent policy but just blaming each other for cowardice and stupidity).

It seems that the incremental reforms approach of (2) is the only thing that can work; everything else runs afoul of one special interest group or another which is capable of derailing the the whole thing.

Clinical Laboratories in Ireland Will Soon Undergo Nationwide Restructuring

From the Dark Daily: Clinical Laboratories in Ireland Will Soon Undergo Nationwide Restructuring:

Pathology testing and clinical laboratories in Ireland will soon be involved in a major project to overhaul the entire system of laboratory medicine in this country of 4.5 million people. Today, your Dark Daily editor wraps up a week-long visit to medical laboratories in Dublin and the pending reorganization of clinical laboratories is a major topic among pathologists and clinical laboratory scientists.

Last year, Ireland’s Health Service Executive (HSE) issued a press release announcing the program to modernize the nation’s clinical laboratory service. The plan specifies that some pathology laboratories will be downsized or closed as regional laboratory testing networks are developed. Another major element in the plan is the creation of two or three “cold” laboratories—what North American laboratory professionals would recognize as a stand-alone clinical laboratory facility providing routine testing to general practice clinics—to serve this segment of the Irish healthcare system.

Huh, interesting...  it is possible to make global changes more easily in a smaller country with a single-payer system like Ireland than it is in the U.S., but the same sorts of changes are envisioned in some of President Obama's Health Care Bill provisions.  We'll be watching this with great interest.

Extraordinary Measures

TheScientist has posted a review of Extraodinary Measures, an interesting new movie about a rare disease and the process of drug discovery:

Rare diseases and drug discovery don't usually make for Hollywood blockbusters.  But today (January 22) a film about a genetic affliction that strikes fewer than 10,000 people worldwide hits movie screens, and it has some serious star power behind it.  Harrison Ford and Brendan Fraser head up the cast of Extraordinary Measures, a new movie that may lift Pompe disease from the shadows of obscurity into the spotlight, as the focal point of an inspirational story of paternal love and scientific innovation.

Extraordinary Measures tells the tale of businessman John Crowley (played by Fraser) who makes it his mission to promote the development of an enzyme therapy to treat his two youngest children, who are sick with Pompe.  Teaming up with University of Nebraska researcher Robert Stonehill (Ford), Crowley starts a small biotech company called Priozyme dedicated to his purpose.  (In reality, the researcher who helped Crowley was William Canfield of the University of the Oklahoma Health Sciences Center, and the company Crowley launched was called Novazyme.)

Wow, how interesting, as a Harrison Ford fan as well as someone interested in digital pathology, this seems like a must see.  And fortunately it seems that the movie mostly "gets it right"...

Do or Die: Clinical Laboratories Must Invest to Build Up LIS-EMR Interfaces with Physicians’ Offices

From the DarkDaily: Do or Die: Clinical Laboratories Must Invest to Build Up LIS-EMR Interfaces with Physicians’ Offices:

By dangling as much as $20 billion in front of physicians to encourage their adoption of electronic medical record (EMR) systems during the next few years, Congress has created a new and expensive challenge for the nation’s clinical laboratories. That challenge is the need for every pathology laboratory to establish a high-function interface from its LIS to the office-based physician’s EMR.

According to one expert, the government’s “carrot and stick” strategy to reward doctors financially for adopting EMR’s, will soon force independent medical laboratories and hospital laboratory outreach programs to play catch up with LIS-EMR interfaces to maintain access to physician referrals and the revenue that accompanies these laboratory test specimens.

It seems to me that the obstacle will be all the physician office systems, not the clinical labs' LIS.  Even if they have the capability - and it will take some time before they do - many physicians are not running the latest versions of their vendor's software, and configuration of an EMR will be time-consuming and costly for them, even if there is government assistance on offer.  Still, eventually it will happen, and the benefits for patients and physicians will be significant.

Kaiser Permanente, VA launch veterans health exchange

HealthImaging reports Kaiser Permanente, VA launch veterans health exchange:

The U.S. Department of Veterans Affairs (VA) and healthcare provider Kaiser Permanente recently launched a pilot medical data exchange program in San Diego enabling clinicians from VA and Kaiser Permanente to obtain views of a patient's health using EHR information through the National Health Information Network.

The pilot program connects Kaiser's HealthConnect and the VA’s EHR system, VistA. In November 2009, VA beneficiaries and Kaiser members in the San Diego area were invited to sign up for the pilot, with the understanding that their information would not be shared without their consent.

Cool.  The number of "public" EHR systems keeps growing; Federal Stimulus money is one reason, of course, but the desire by patients to have control over their medical information so they can take a more active role in directing their own care is another.

FDA Unveils First Phase of Transparency Initiative

The U.S. Food and Drug Administration today unveiled the first phase of its Transparency Initiative which is designed to explain agency operations, how it makes decisions, and the drug approval process.

During an online presentation, the chair of the FDA’s Transparency Task Force, Principal Deputy FDA Commissioner Joshua Sharfstein, described a Web-based curriculum called “FDA Basics,” aimed at helping the public better understand what the agency does. The curriculum is accessible via a link on the FDA Web site.

The curriculum includes:

• Questions and answers about the agency and the products it regulates
• Short videos that explain various agency activities
• Conversations with agency personnel about the work of their office

In addition, senior officials from FDA product centers and offices will answer questions on various topics during future online sessions. Each of these sessions will be announced on the FDA Web site.

In one of her first acts after assuming the office last spring, FDA Commissioner Margaret A. Hamburg, M.D. announced the formation of an internal task force to develop recommendations for enhancing the transparency of the FDA’s operations and decision-making processes.

As more digital pathology applications are targeted at clinical applications, the role of the FDA in regulating the vendors and products in the space becomes ever more important.  This additional transparency is a welcome step, seems like it will benefit everyone.  Ideally the FDA and vendors work together to ensure safe and effective products are brought to market.

What Does it Take to Qualify for the EHR Stimulus Funds?

An interesting hour-long video posted on the Medical Software Advice blog: What Does it Take to Qualify for the EHR Stimulus Funds?

We talk with hundreds of physician practices each month. Their biggest question: “What does the economic stimulus package mean for me?”

Practices understand that up to $45 billion is allocated to provide incentive for physicians to adopt EHRs. However, many questions remain about how and when providers will receive stimulus funds.

We teamed up with Justin Barnes, Chairman of the HIMSS Electronic Health Record Association and Vice President of Greenway Medical Technologies, to help answer these questions. The original presentation was delivered last week, however you can view the entire webinar. In this hour webinar, you’ll learn:

• How the stimulus money will be paid out
• What it takes to qualify for funding
• Which specialties qualify for funding
• How “meaningful use” is defined
• What constitutes a “qualified EHR”

It moves kind of slow, but it is pretty informative, you might want to check it out...

When clinicians lead

Hi everyone, this is Jared Schwartz.  I look forward to sharing my thoughts on The Daily Scan and from hearing yours; please feel free to post comments!

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An article in McKinsey Quarterly titled “When Clinicians Lead” argues there is a critical need for physicians to be actively involved in helping “lead the way” if we are to ever have real health care reform that results in better patient outcome and more efficient use of limited resources.  Having practiced medicine for many years and being actively involved in a variety of management and leadership roles, I can state this will be no easy task.  Leadership is something that can be learned through mentors or just personal drive, personality and education.  The problem is leadership as a core competency for success is not even on the list of topics taught throughout most physicians’ training.  I am not talking about leadership as in CEO, but everyday leadership through example that others will observe.  Treating all with respect, teamwork, more objectivity, mentoring, and demonstrating that you understand how important it is to use resources wisely is everyday leadership.  In my opinion this will have a greater impact on improving both the quality and efficiency of our medical care than all of the congressional committees’ and agencies’ ideas combined.  If medical schools and postgraduate programs do not lead the way in producing physician leaders, we as individuals and professional associations must do it ourselves.

Introducing my blog partner: Dr. Jared Schwartz

Hi all - back in November Aperio proudly announced that Dr. Jared Schwartz would be joining us as our Chief Medical Officer.  And he has indeed done so!  Having such an experienced and well-connected senior pathologist on our team has been amazing.

I have invited Dr. Schwartz to join me in posting to The Daily Scan!  So now in addition to links to things I find interesting, and my ramblings and chalk tips and such, you'll have the benefit of links to things he finds interesting, and his ramblings and such...

Please join me in welcoming Jared to the blogosphere!

CAP releases updated Electronic Cancer Checklists

The College of American Pathologists (CAP) have released new versions of the CAP electronic Cancer Checklists (CAP eCC), the XML version of the updated CAP Cancer Checklists.  The CAP eCC is a tool used to enhance and advance cancer reporting.

In addition to the XML version, designed for use by computer software to foster standardization and interoperability, the cancer protocols many be found in PDF form on the CAP website.

The amount of information pathologists provide in their reports on cancer specimens has increased in recent years, due to the expansion of scientific knowledge about cancer and continued advances in healthcare, such as molecular diagnostics and personalized medicine.

"A new cancer diagnosis profoundly affects a patient's life. A generation ago, a patient's cancer pathology diagnosis was often just a few lines long,” said John Madden, MD, PhD, FCAP, associate professor of pathology at Duke University Medical Center, Durham, N.C. and co-chair of the CAP’s Pathology Electronic Reporting Task Force. “With the current explosion of knowledge about cancer, the pathology diagnosis now often extends to multiple pages, and incorporates individualized information about literally dozens of critical tumor features, including the molecular and genetic characteristics of the patient's cancer, that play a major role in determining treatment success.”

The CAP Cancer Protocols and Checklists, developed by the CAP Cancer Committee, aid pathologists in cancer reporting and are recognized as a “gold standard” in cancer case summary reporting. The synoptic, or standardized, checklist format provides consistent and meaningful information that enable healthcare professionals to manage and study clinical data necessary to help improve patient care.

Among all the clinical uses to which these checklists can be put, they are invaluable in comparing diagnoses in clinical trials, by providing a standard and quantifiable way for a diagnosis to be recorded.

A Shopper’s Guide To Second Opinions

The Bulletin in Philadelphia published an interesting column from Herb Denenberg, A Shopper’s Guide To Second Opinions.

The second opinion is one of the great lifesavers in medicine. But it is underused for various reasons.

The need for second opinions can be better understood by considering the case of the pathologist’s report on a biopsy. One of the best discussions of this appears in a book I’ve discussed before, Patrick Malone’s The Life You Save: Nine Steps to Finding the Best Medical Care — and Avoiding the Worst.

Mr. Malone discusses the example of surgery to remove a cancer. The issue was whether the surgery was successful. To determine that, the pathologist will look at removed tissue and try to say whether the margins are clean, suggesting that the cancerous cells were removed. The pathologist may also have an opinion on how aggressive the cancer is.

Mr. Malone writes, “What laypeople don’t often know is that these opinions are fraught with possibility for disagreement and outright error, and that’s why getting a second opinion on biopsies  — and all other tests, for that matter — is one of the critical nine steps to taking charge of your health care.” Mr. Malone likens it to art critics attempting to decide if a Jackson Pollack painting is genuine. Art critics may debate with passion on that question and their opinions may be all over the lot. By like token, pathologists may also have a range of opinions and demonstrate far less certainty in reaching their conclusions than a casual observer might assume.

You've heard me say it many times, but the ease of getting second opinions with digital pathology is one of the key benefits this technology brings.

Happy New Decade!

Hi everyone!  Hope you all had a great Holiday and celebrated New Year's and the end of the decade in style.  Just wanted to wish you all a Happy New Decade!

For those of us who are fans of digital pathology, it should be pretty exciting, with many great products on the market, lots of applications, and steadily increasing adoption.  It is hard to imagine where we'll be at the end of this decade, but nearly everyone agrees digital pathology will make a huge difference in improving efficiency and accuracy, enabling new tests, and generally improving the quality of healthcare for patients, physicians, and payers.

Please stay tuned, and we'll watch it all happen together!

Stumbling Toward Personalized Medicine

TheScientist's editor Richard Gallagher wrote an interesting editorial in the December issue: Stumbling Toward Personalized Medicine.

Let’s remind ourselves of the three-part promise of personalized medicine. First, everyone’s genome will be sequenced cheaply and the sequence will be interpretable, and predictive. Second, the bulk of a person’s anticipated medical problems, discerned by analysis of the sequence, will be avoided by genetic, lifestyle or therapeutic means. And third, where a disease has to be treated, it will be done with medicines that are exquisitely tailored to both patient and ailment. No risk, no mess, no problem.

The reality (to date) has been dramatically different.

Of course these things never take hold as quickly or thoroughly as we'd like, but there has been progress; numerous companion diagnostics and screens have been developed, and genomic and cellular tests for a wide range of disease states are becoming available (and increasingly they make use of digital pathology, enabling accurate quantification).  The editorial does end on a more positive note:

So far we’ve stumbled forward a little on the road to personalized medicine, but it looks like the pace towards Nirvana is about to pick up.

Indeed!

CAP Today recap of FDA panel discussion on whole-slide imaging

CAT Today has a nice recap story on page one about the FDA panel discussion on whole-slide imaging.

Digital pathology recently took center stage in an FDA panel hearing on how best to regulate whole-slide digital imaging systems used for primary pathologic diagnosis. The Hematology and Pathology Devices Panel hearing on Oct. 22 and 23, in fact, tackled a number of issues the lab industry has been grappling with as digital imaging moves into the clinical realm.

The impetus for the panel meeting, surmises Yale pathologist and panel member John Sinard, MD, PhD, is that the FDA realized that the number of whole-slide digital imaging vendors, as well as pathology groups using the technology or looking into it, had reached a “critical mass.”

It's a nice balanced article which tees up many of the interesting issues which were discussed, and quotes many of the participants and Pathology thought leaders.  And me :)

Ventana to teens: Study, then come work for us

The Arizona Star has an interesting article about Ventana, who are located in Tucson, and who recently hosted a Young Scientist's Day: Ventana to teens: Study, then come work for us.

Students from Amphitheater, Canyon del Oro and Ironwood Ridge high schools in the Amphitheater Public Schools district, along with Marana and Mountain View high schools in the Marana Unified School District, attended the event. It took place at Ventana Medical Systems, 1910 E. Innovation Park Drive.

Among other things, Ventana develops and manufactures medical instruments used to diagnose cancer, such as automated devices to prepare tissue samples for microscopic analysis.

Students rotated through six hands-on activities in which they interacted with Ventana professionals. Chemistry, engineering, pathology and histology (study of tissue structure) were among the topics covered during Young Scientists Day.

How cool is that?  What a great way to get kids excited about science as a career, and maybe get some new employees in the bargain...

Webicina: PeRSSonalized Pathology

If you're looking for online resources about medicine, be sure to check out Webicina ("Practicing Medicine in the Web 2.0 Era"), and especially their listing of PeRSSonalized Pathology. 

I'm not sure how web technology will end up being used to treat patients, but it is already an invaluable way for physicians and patients to communicate and learn.

Needle biopsies safer and just about as good at diagnosing breast cancer

The LATimes has an interesting story: Needle biopsies safer and just about as good at diagnosing breast cancer, say authors of mammogram advice:

The federal government's Agency for Healthcare Research and Quality, apparently undaunted by the controversy it kicked up last month over mammograms, has waded back into the breast-cancer thicket with new advice on how best to distinguish benign breast lumps from possible malignancies. 

In a report released today, the arm of the Health and Human Services Department that is charged with comparing the effectiveness of competing medical interventions said that core-needle biopsies are just as good as the method long considered the "gold standard" of evaluating suspicious breast lesions: open surgical removal.

...

In addition to being roughly as accurate and less risky, core-needle biopsy is less costly than surgical removal and "generally is preferred by patients." And because about one in 10 women who have suspicious lumps in their breast biopsied proves to have breast cancer, the less invasive, less costly core-needle biopsy seems the better choice in most cases, the group concluded.

Huh, interesting.  An increasing number of Aperio customers are using digital pathology as a way to capture and view core needle biopsies.

"this is your cancer"

I liked this post from Keith Kaplan on pathtalk.org, "this is your cancer".  About once a year one of Keith's patients visits him and wants to see their slides.  They aren't necessarily pathologists so the images don't necessarily tell them anything specific.  And in most cases, they don't doubt the diagnosis.  Still there is something about seeing your cancer, seeing your enemy, that makes it real.  I am not a pathologist, but if I ever have cancer I would want to see mine.

I'm particularly interested in this because we've been studying the usefulness of digital pathology images for patient communications.  Of course most patients are not able to interpret slides, even less so than they are able to interpret X-rays.  But patients often like having their radiology images and sometimes carry them around with them on a disc.  You can imagine the same thing could happen in future with pathology images.  There is an attraction to the immediacy and sense of control this information gives you, even if you aren't able to interpret it yourself.

What do you think?  Will pathology images be useful to patients?