# Presentation: 143346

## caBIG Imaging PanelcaBIG Annual Meeting, Tuesday, February 6th, 2007 

**Michael J. Becich, MD PhD – becich@pitt.edu **
**Chairman, Department of Biomedical Informatics**
**University of Pittsburgh Medical School**
**Professor of Biomedical Informatics, Pathology, **
**Information Sciences & Telecommunications**
**Department of Biomedical Informatics - http://dbmi.pitt.edu  **
**Advancing Practice Instruction and Innovation through Informatics (APIII) - **_**[http://apiii.upmc.edu](http://apiii.upmc.edu/)**__** – August September 6-8**_**th**** (Pittsburgh)**
**Association for Pathology Informatics **
**(API) - http://www.pathologyinformatics.org **

## Disclosures by MJB

**Corporate Support for API and APIII**
**750K projected for 2007 ****[Cerner, Misys, IBM, IMPAC - Tamtron, Cisco, Verizon, CAP Today, Amersham, Apollo, Applied Imaging, Apollo, Ardais, Bacus, Carl Zeiss, Data Access Technology, Defieniens, De-ID Corp, DMetrix, Excelleris Tech, General Data, GE Medical Systems/Triple G, MediSolutions Inc, MTuitive, Nikon, Nuance Communications, Olympus, Pathology Outlines.com, Trestle Holdings, Inc., SCC Soft, Sysmex, SNOMED, Stone Bond Tech, PSA, ThermoElectron, others]**
**Corporate Sponsored Research Agreements**
**2.8 M in 2007 ****[****Amgen, Cerner, Clarient, dbMotion, Google, IBM, IMPAC, Intel & Misys****]**
**Public Companies (****Consulant Equity - MJB****):**
**Clarient (NASDAQ:  CLRT) formerly Trestle Corporation (NASDAQ: TLHO), formerly InterScope Technologies, Inc. - http://www.trestlecorp.com (merged 3/05)**
**Provider of high speed/volume whole slide imaging/telepathology systems**
**Ultrarapid whole slide imaging: Gb data transfers, terabyte storage and robotics**
**Consultancy**
**Calgary Laboratory Service (CLS) (paid)**
**Misys – Strategic Planning Group and Physician Advisory Board (paid)**
**Pathology Education Consortium (PEC) with Bruce Friedman (volunteer)**
**Sponsors of Lab InfoTech Summit (spring companion meeting to APIII)**
**Provincial Laboratory Coordinating Office (PLCO) (paid)**
**Roswell Park Cancer Institute (RPCI) (paid)**
**ThermoElectron – Physician Advisory Board (paid)**

## Intro to Digital Imaging in Pathology

**Numerous situations where digital imaging and telepathology have provided useful solutions:**
**Digital Imaging**
**Gross room – documentation of resected specimens and requisitions**
**Microscopic signout – documentation of rare lesions, consults, etc...**
**Conference support – cheaper, faster, much more efficient**
**Telepathology**
**Dynamic telepathology – requires real time “live’ dedicated connection**
**Static telepathology – cheaper, asynchronous, sub-sampling issues**
**Web based – cheaper even yet, also asynchronous but doesn’t have to be**
**Whole Slide Imaging – Virtual Microscopes and Virtual Slides**
**Newest technology images entire slide – like radiology PACS**
**Allows glass slides to be dealt with like digital files and shared at multiple locations simultaneously – collaborative telemicroscopy**
**Dropping costs for network, storage and CPUs make this possible**
**Huge implications for the practice of pathology – major efficiency gains**

## Telepathology Timeline at Pittsburgh

**Telepathology Timeline at Pittsburgh**

## Telepathology Volumes at Pittsburgh (w/ Gross)

**Telepathology Volumes at Pittsburgh (w/ Gross)**

## Telepathology Volumes at Pittsburgh (w/o Gross)

**Telepathology Volumes at Pittsburgh (w/o Gross)**

## Pathology Centers Of Excellence at UPMC

_**UPMC Presbyterian**_
**ENT/Thyroid Pathology**
**Gastrointestinal Pathology**
**Hematopathology**
**Neuropathology**
**Thoracic/Mediastinal Pathology**
**Transplant Pathology**

_**UPMC Shadyside**_
**Breast Pathology**
**Dermatopathology**
**Genitourinary Pathology**
**Bone/Soft Tissue/Melanoma Pathology**

_**Magee-Womens Hospital, UPMC**_
**Breast Pathology**
**Gynecologic Cytopathology**
**Obstetric/Gynecologic Pathology**

## Whole Slide Imaging How will it work?

**Eventually all slides from a lab will undergo whole slide imaging**
**The slide images will be available via a storage area network (SAN) like in radiology today (on a common unit)**
**Multiple pathologists can view the case at the same time**
**Specialty cases (skin, prostate, GI, liver, hemepath, etc...) will be distributed with clinical information and to disease experts as top priority.**
**General cases (nevi, hernia sacs, lumbar discs, plastic surgery, degenerative bone, etc...) can be placed in “queue” for general community pathologists or as lower priority signout**
**Increase productivity dramatically**

**2nd Office**
** ****or Home**

**Histology Lab**
**Specimen**
**Processing**

**Primary **
**Office**

**On-Line**
**Archive**

## Whole Slide Imaging Commercially Available Systems

**http://ir.clarientinc.com**

**http://www.aperio.com**

**http://sales.hamamatsu.com**

**Whole Slide Imaging**** Commercially Available Systems**

## Enabling Technology

**Enabling Technology**

**Whole slide imaging (ultra fast digitization) will help to address several problems with pathology microscopy, including:**
**Difficulty sharing slides across distances**
**Access to experts, irrespective of patient location**
**Ability to share cases multiple peers simultaneously**
**Prioritization of case load**
**Reallocation of cases across a network (experts doing expert work and generalists doing general pathology)**
**Immediate access of archived images**
**Reduce or eliminate “slide” couriers/filers/consult issues**

## Metrics of Success

**Metrics of Success**

- Decreasing average turnaround time per case:
**Automatic queuing of cases to experts/generalists without requirement of location specific delivery**
**Instantaneous access to cases in a “lean” environment**
**Instantaneous access to view prior case material**
**Asynchronous sharing of difficult cases with experts**
- Improving the value of quality assurance (true QA)
- Reduction of costs related to sendouts (consults, 2nd opinion requests and quality assurance)
- Increasing the pathologist productivity (capacity)
- Reducing the costs for couriers & slide filing/retrieval
- Reducing the number of recuts (due to lost slides)
- Reducing the costs for “educational conferences”

## WSI in Quality & Patient SafetyDana Grzybicki & Steve Raab

## Pathology Imaging and the Electronic Medical Record

**Many integrated health systems have adopted enterprise wide imaging initiatives.**
**Model = PACS systems of Radiology**
**Drivers:**
**Reducing costs (filmless or slideless)**
**Increasing productivity at “point of care”**
**Improving and expediting patient care**
**Increasing customer service (doctors/patients are customers)**
**Educating peers and subordinates (not just residents/fellows)**
**What kind of institution is most appropriate for this in Pathology?**
**High volume laboratory (especially commercial labs)**
**Distributed regional network (academic/regional community network)**
**Veterinary pathology**
**Toxicology evaluation in Pharma and clinical trials**

## 3D Tissue Model

**Model creates geometric link between radiology and pathology images**

**A Visual Pathology Report to Facilitate Communication of Patient-Specific Pathology Information**

**K. Peperzak, D. Eibling, B. E. Chapman**

## API and the TMA XML Data Exchange Format

** ****<IMS_Case_Identifier>1033477551</IMS_Case_Identifier>**
** ****<Location_Code>N52</Location_Code>**
** ****<Race>Caucasian</Race>**
** ****<Year_of_Birth>1923</Year_of_Birth>**
** ****<Year_of_Diagnosis>1991</Year_of_Diagnosis>**
** ****<Year_of_Prostatectomy>1992</Year_of_Prostatectomy>**
**<Is_Residual_Carcinoma_Present>Yes</Is_Residual_Carcinoma_Present>**
** ****<Most_Prominent_Histologic_Type>adenocarcinoma NOS aka acinar</Most_Prominent_Histologic_Type>**
** ****<Gleason_Primary_Grade>4</Gleason_Primary_Grade>**
**<Gleason_Secondary_Grade>3</Gleason_Secondary_Grade>**
** ****<Gleason_Sum_Score>7</Gleason_Sum_Score>**
**<Number_of_Nodes_Examined>11</Number_of_Nodes_Examined>**
**<Number_of_Nodes_Positive>0</Number_of_Nodes_Positive>**
**<Distant_Mets__1_at_Time_of_Diagn>None</Distant_Mets__1_at_Time_of_Diagn>**
** ****<pT_Stage>pT3a</pT_Stage>**
** ****<pN_Stage>pN0</pN_Stage>**
** ****<pM_Stage>pM0</pM_Stage>**
** ****<Vital_Status>Alive</Vital_Status>**
** ****<Year_of_PSA_Recurrence></Year_of_PSA_Recurrence>**
**<PSA_Recurrence_Status>Unknown</PSA_Recurrence_Status>**
** ****<Recurrence_Free_Year></Recurrence_Free_Year>**
**</record>**

**API and the TMA ****XML Data Exchange Format**

**TMA slide set contains**
**Cancer tissue from radical prostatectomy specimens of 299 patients**
**Control non-neoplastic tissue from benign prostatic hyperplasia (BPH) **
**Control non-diseased tissue from organ donor prostates **
**Cores from prostate cancer cell lines**
**TMA XML Data Exchange Format**

**TMA XML Data Exchange Format for Core N52**

## Conclusions and Future Directions - Digital Imaging and Telepathology

**Pathology is now able to cost effectively take advantage of digital imaging technologies due to dropping costs for network & storage and faster, cheaper computing power at the desktop**
**Telepathology has had only limited success:**
**Due to subsampling issues (static)**
**Due to cost and lack of integration with LIS**
**Whole slide imaging (Virtual Slides/Microscopes)**
**Potentially provides a paradigm shift**
**Cost and integration drivers provided in ROI**
**Will change the way we practice (Radiology)**
**Provides a “platform” for digital diagnostics**

## Patel AA, Gilbertson JR, Parwani AV, Dhir R, Datta MW, Gupta R, Berman JJ, Becich MJ: More than a Tissue Bank – An Informatics Infrastructure for a Multi-Institute Biorepository: The CPCTR Model. BMC Cancer 2006, 6:120-132.
Becich, MJ, Patel AA, Juki DM.  The digital future of histopathology: where we are today and where we are heading.  The Bulletin of The Royal College of Pathologists July Issue 131(27-31) 2005.
Grzybicki DM, Turcsanyi B, Becich MJ, Gupta D, Gilbertson JR, Raab SS.  Database construction for improving patient safety by examining pathology errors.  Am J Clin Pathol. 2005 Oct;124(4):500-9. 
Patel AA, Kajdacsy-Ball A, Berman JJ, Bosland M, Datta MW, Dhir R, Gilbertson J, Melamed J, Orenstein J, Tai KF, Becich MJ. The development of common data elements for a multi-institute prostate cancer tissue bank: The Cooperative Prostate Cancer Tissue Resource (CPCTR) experience. BMC Cancer. 2005 Aug 21;5(1):108.
Becich MJ, Gilbertson JR, Gupta D, Grzybicki DM and Raab, SS.  Patient Safety and Healthcare Research:  The Critical Role of Path Informatics in Error Reduction and Quality Initiatives. Clin Lab Med. 2004 Dec;24(4):913-43.
Becich, M.J.  Patel A.A. and Jukic D.M.  A Diagnostic Virtual Microscope System for Whole Slide Robotic Imaging: The Value of Virtual Slides for the Practice of Pathology.  Gu, J. and Ogilvie, R.W., Eds., Virtual Microscopy and Virtual Slides in Teaching, Diagnosis and Research, Taylor & Francis, Boca Raton, 2005. In Press.
Melamed J, Datta MW, Becich MJ, Orenstein JM, Dhir R, Silver S, Fidelia-Lambert M, Kadjacsy-Balla A, Macias V, Patel A, Walden PD, Bosland MC, Berman JJ.  The cooperative prostate cancer tissue resource: a specimen and data resource for cancer researchers.  Clin Cancer Res. 2004 Jul 15;10(14):4614-21.
Lyons-Weiler J, Patel SV, Becich MJ, Godfrey T.  Tests for finding complex patterns of differential expression in cancers:  towards individualized medicine.  BMC Bioinformatics 2004, 5:110-116.
Yagi Y, Ahmed I, Gross W, Becich MJ, Demetris AJ, Wells A, Wiley CA, Michalopoulos GK, Yousem SA, Barnes B, Gilbertson JR.  Webcasting pathology department conferences in a geographically distributed medical center.  Hum Pathol. 2004 Jul;35(7):790-7. 
Crowley RS, Gadd CS, Naus G, Becich M, Lowe HJ. Defining the role of anatomic pathology images in the multimedia electronic medical record--a preliminary report. Proc AMIA Symp 2000:161-5. 
Landman A, Yagi Y, Gilbertson J, Dawson R, Marchevsky A, Becich MJ. Prototype web-based continuing medical education using FlashPix images. Proc AMIA Symp. 2000; 462-6.
Becich, M.J.. Information management: moving from test results to clinical information.  Clin Leadersh Manag Rev. 2000 Nov-Dec;14(6):296-300.
Becich, M.J. The role of the Pathologist as tissue refiner & data miner:The impact of functional genomics on the modern path laboratory & the critical role of Pathology Informatics & Bioinformatics Molec Diag. 5(4):287-299, 2000

**Patel AA, Gilbertson JR, Parwani AV, Dhir R, Datta MW, Gupta R, Berman JJ, **_**Becich MJ**_**: More than a Tissue Bank – An Informatics Infrastructure for a Multi-Institute Biorepository: The CPCTR Model. BMC Cancer 2006, 6:120-132.**
_**Becich, MJ**_**, Patel AA, Juki DM.  The digital future of histopathology: where we are today and where we are heading.  The Bulletin of The Royal College of Pathologists July Issue 131(27-31) 2005.**
**Grzybicki DM, Turcsanyi B, **_**Becich MJ**_**, Gupta D, Gilbertson JR, Raab SS.  Database construction for improving patient safety by examining pathology errors.  Am J Clin Pathol. 2005 Oct;124(4):500-9. **
**Patel AA, Kajdacsy-Ball A, Berman JJ, Bosland M, Datta MW, Dhir R, Gilbertson J, Melamed J, Orenstein J, Tai KF, **_**Becich MJ**_**. The development of common data elements for a multi-institute prostate cancer tissue bank: The Cooperative Prostate Cancer Tissue Resource (CPCTR) experience. BMC Cancer. 2005 Aug 21;5(1):108.**
_**Becich MJ**_**, Gilbertson JR, Gupta D, Grzybicki DM and Raab, SS.  Patient Safety and Healthcare Research:  The Critical Role of Path Informatics in Error Reduction and Quality Initiatives. Clin Lab Med. 2004 Dec;24(4):913-43.**
_**Becich, M.J**_**.  Patel A.A. and Jukic D.M.  A Diagnostic Virtual Microscope System for Whole Slide Robotic Imaging: The Value of Virtual Slides for the Practice of Pathology.  Gu, J. and Ogilvie, R.W., Eds., Virtual Microscopy and Virtual Slides in Teaching, Diagnosis and Research, Taylor & Francis, Boca Raton, 2005. In Press.**
**Melamed J, Datta MW, **_**Becich MJ**_**, Orenstein JM, Dhir R, Silver S, Fidelia-Lambert M, Kadjacsy-Balla A, Macias V, Patel A, Walden PD, Bosland MC, Berman JJ.  The cooperative prostate cancer tissue resource: a specimen and data resource for cancer researchers.  Clin Cancer Res. 2004 Jul 15;10(14):4614-21.**
**Lyons-Weiler J, Patel SV, **_**Becich MJ**_**, Godfrey T.  Tests for finding complex patterns of differential expression in cancers:  towards individualized medicine.  BMC Bioinformatics 2004, 5:110-116.**
**Yagi Y, Ahmed I, Gross W, **_**Becich MJ,**_** Demetris AJ, Wells A, Wiley CA, Michalopoulos GK, Yousem SA, Barnes B, Gilbertson JR.  Webcasting pathology department conferences in a geographically distributed medical center.  Hum Pathol. 2004 Jul;35(7):790-7. **
**Crowley RS, Gadd CS, Naus G, **_**Becich M**_**, Lowe HJ. Defining the role of anatomic pathology images in the multimedia electronic medical record--a preliminary report. Proc AMIA Symp 2000:161-5. **
**Landman A, Yagi Y, Gilbertson J, Dawson R, Marchevsky A, **_**Becich MJ.**_** Prototype web-based continuing medical education using FlashPix images. Proc AMIA Symp. 2000; 462-6.**
_**Becich, M.J..**_** Information management: moving from test results to clinical information.  Clin Leadersh Manag Rev. 2000 Nov-Dec;14(6):296-300.**
_**Becich, M.J**_**. The role of the Pathologist as tissue refiner & data miner:The impact of functional genomics on the modern path laboratory & the critical role of Pathology Informatics & Bioinformatics Molec Diag. 5(4):287-299, 2000**

**Recent Publications by Our Team – ****NOTE:  Please e-mail me at becich@pitt.edu  if you want PDFs**

## End of Talk – e-mail me at becich@pitt.edu if you have questions/clarifications not covered in the discussion. NOTE: Please e-mail me if you want PDFs of articles or presentation.

**Thank you for the invitation to participate in the caBIG Imaging Panel**

## Invitation to APIII 2007 September 9-12th, Pittsburgh PA

_**http://apiii.upmc.edu**_** **

**http://apiii.upmc.edu **

## Association for Pathology Informatics (API)http://www.pathologyinformatics.org 

- ...to advance the field of pathology informatics as an academic and a clinical subspecialty of pathology.