A.C.F. Makkus. MD

PAL Dordrecht, Dordrecht, The Netherlands

www.paldordrecht.nl

Clinical digital workflow

A.C.F. Makkus. MD

PAL Dordrecht, Dordrecht, The Netherlands

www.paldordrecht.nl

Clinical digital workflow

What is clinical workflow?

Receiving a sample and send out a report with findings what happens in our

laboratory in between is the workflow

We are a paperless laboratory

• everything is tracked using barcodes

• no paper, not even a request form

• Normally we use the slide as a reference to track

• Digital pathology means you do not have a slide, only images

• Tracking your cases becomes crucial

What I’m trying to convey to you?

• Take you on a tour of what happens to a tissue sample in our laboratory

• What impact digital pathology has on the workflow: The good, the bad and the

ugly

• I will skip the creation of the reports

• I will skip the reasoning for a diagnosis

• I will skip the intricacies of safe reporting

• No gory pictures

Why?

• Try to do a varying workload with the same people

• Time saving ($) for the pathologists and technicians• Measurements, cases immediately available when clinicians call

• Running around assigning cases and retrieving them

• Consultation/review/panels through digital slides

Opportunities forTime Saving

Laboratory chores

• Less Time Matching• Matching paperwork to case

• Matching new stains upon arrival

• Tracking receipt of ordered slides

• less Correcting: • Transporting case to correct pathologist

• Reducing duplicate slides ordered

• Picking up wrong slides / missing slides

• Retrieving prior cases

Administration chores

• Saving Time Transporting Cases: • Packing cases for consult

• Organizing Cases:

• Tracking cases ready for review

• Tracking cases for conferences

• Saving Time checking for Cases: • Checking if STAT cases have arrived

• Visibility of overdue cases

• Searching cases when receiving a call

Foundation

9 pathologists

1 trainee

2 hospitals

STZ hospital (full service)

GP’S in the area

Private practices

Output

~ 140,000 slides

~ 50,000 requested slides

~ 250 outside consultations

~ 400 outside revisions

~ 36,000 cases Histology

~ 105,000 blocks

500 Double Width slides

Scanning

600 GB/day – 155 TB/year

50 TB / year

230 GB / day

Storage

225 DAYS

85 DAYS

~ 200 SLIDES / DAY

ISO 15189 certified for histology, cytology, autopsy pathology and molecular pathology

Requests vs all Cases

Budget

Additional stains (30%)

Would need 3x scanners

3x the storage

3x the network load

We want Double width slides

Pathologists

The microscope is faster on routine cases

Poor initial acceptance

“let me look at it with my own microscope”

“Low hanging fruit”

Workflow

Would need Case Assignment by Laboratory management system

Need a system to distribute the cases, fairly according to (workload, tumor boards and

interest)

Visible needs• Scanner

• Viewer

• Invisible requirements

• Workflow• Assign cases to pathologists

• Keeping track of the cases…

• Interests, who’s in, equal workload

• Assign the requested slides to pathologist

• Trackable

• Integration with other systems• Seamless

• Case-mixup proof

• Acces anywhere

• Stable, uptime 99,99%

• Scalable

ORDERS

Pathology orders are electronically requested

o Patient ID and clinicians ID are automatically added

o The physician fills out relevant clinical history

o Markings are noted

o Mayor tumor types have a mandatory clinical data set to

be entered Eg Breast: tumor’s location, sentinel node, previuos

therapy

o Subsequently a barcode label is printed and affixed to the container

o Transportation to the laboratory

o Which is scanned in the lab en the specimen enters:

Clinical Digital Workflow begins

Specimen

Pathology specimens are electronically entered

o The barcode is scanned and all the associated

clinical information is retrieved from the hospital

and electronically transferred into the laboratory

information system (LIS)

o The LIS queries the national as well as local

database for the pathology history

o In pathology not the patient is the identifying

object but the specimen

STAGE 1 in the LIS

Grossing-cassettes

Cassettes with tissue ready to be processed

o Cassettes are printed and a barcode is printed on fortracking

o Cassettes are filled with patient material

o A report of the grossing is dictated into a speechrecognition system and (after recognition andredaction) added as a grossing report to the case

o Protocols are used for cut-up, making sure specimensare adequately sampled

o The LIS now knows how many cassettes constitute a case, the last printjob lets the LIS know it has entered

STAGE 2 in the LIS

Embedding

Cassettes ready to be blocks

o Based on the barcode on the cassette the grossing is retrieved

o The content of the cassette is compared to the grossingdescription

o The number of biopsies is checked

o Biopsies are ordered and orientated

o etc

o When the data is retrieved from the LIS, it’s at embedding

STAGE 3 in the LIS

Sectioning

The blocks are cut

o Based on the barcode on the cassette the grossing is retrieved

o Based on the barcode of the cassette the appropiate slides are printed

o With appropiate label and barcode also for the special stainers

o Slices of tissue are put on the slides

o The printing of the slides with unique numbers lets the LIS know how many slides and with what staining there should beand the stage

STAGE 4 in the LIS

Staining

The slides are stained

o Based on the barcode on the slide the stain is selected

o H&E

o Special stains like Fe, PAS, Grocott

o Immunohistochemistry

o Entry in the staining machine signals to the LIS that they

have entered

STAGE 5 in the LIS

Coverslipping

The slides are coverslipped

o When the slide leaves the coverslipper it’s barcode is

scanned

o Exiting the coverslipper signals to the LIS that they have

entered

STAGE 6 in the LIS

Scanning

The slides are scanned

o When the slide leaves the coverslipper they enter the

scanner

STAGE 7 in the LIS

PAPERLESS & GLASS SLIDES

= GREEN !

PAPERLESS & DIGITAL SLIDES

= CLUELESS

XML-COMMUNICATION

The slides barcode is scanned by the scanner

o When the slides barcode number (5943239) is scanned bythe scanner, this number is used to set-up communicationwith the LIS

o LIS responds: case, block, number, stain, profile among others

o Resulting in a slidename: T18-16301 C 03 Vimentin

o The scanners applies profile: Scanprofile_default

o This signals the LIS that the slide is at

But is the case complete?

STAGE 8 in the LIS

QUESTION BY CASECENTER

<?xml version="1.0" encoding="UTF-8"?>

<lmsinfo nummer="5943239"/>

REPLY BY LIS

<?xml version="1.0" encoding="utf-8"?>

<antwoord type="ack">T18-16301

<rubriek naam="scancode">5943239</rubriek><rubriek naam="staining">Vimentin</rubriek><rubriek naam="materialname">paraffine cassette</rubriek><rubriek naam="block">3</rubriek>

<rubriek naam="techniquename">Histochemisch</rubriek><rubriek naam="number">1</rubriek><rubriek naam="name">Scanprofiel_default</rubriek>…..</antwoord>

Full integration: LIS - Casecenter

Bi-Directional update of status change

o Achieved through XML

Creating LIS <<=

>>

CaseCenter

Opening LIS <<=

>>

CaseCenter

Closing LIS <<=

>>

CaseCenter

Deleting LIS <<=

>>

CaseCenter

Viewing LIS <<=

>>

CaseCenter

Lessons from P1000

Obsessed with getting the diagnosis out fast

o It’s fast… Images are beautiful

o The network and servers can easily support fully digital

o But…

if a case is being scanned when will it arrive???

Lessons from P1000

o Assign cases prior to scanning or after scanning.

o Which leads to cases without images they come later or substantial delay

if assigned after scanning.

o It is made worse by the capacity of the P1000

It must be done while they are still in the scanner

By the LIS!

What do you need from the LIS as a pathologist

Accurate information regarding:

o Case complete -> assign to pathologist

o Incomplete, for primary diagnosis -> wait...

o Additional requests case complete -> report

complete

o Additional requests case INcomplete -> report

with different colour

Lab

Pathologist

•Pathologists present

•Part-Time Factor•MDT Times•etc

Local Specialties

• Gynecolgy• Urology• Traning• etc

Distribution Software

Re-Assign

Day Listoverzicht

WorkOverview

Primary diagnosis

• Analogue

• Collect the slides after they leave the cover slipper

• Make sure the case is complete, if not wait for the remainder of the slides

• Assign the case to available pathologist, with regard to expertise

• Deliver the slide tray to the pathologist

• Digital

• The scanner scans the slides after they leave the cover slipper

• The XML signals that a slide is available

• The LIS checks whether the case is complete

If complete assign the case

If Incomplete wait…

• Have to have a means to find the cases that are not completely scanned after a certain time

• NB Done while the slide itself might be in the scanner

Requested additional slides

• Analogue

• Collect the slides after they leave the cover slipper

• Make sure the case is complete, if not wait for the remainder of the slides

• Assign the slides to the requesting pathologist, or his/her substitute

• Deliver the slide on a tray to the pathologist

• Digital

• The scanner scans the slides after they leave the cover slipper

• The XML signals that a slide is available

• The LIS checks whether the case is complete

• If complete assign the case, if Incomplete assign it with a different colour

Failover cluster Palga

National database

workstations

Servers:

• Storage

• Speechrecognition

• ImageServer

• Lab. Management System

• PALGA (authorized content, reports)

• Test Servers

• LMS, ImageServer, Palga, speech

Web based communication, xml:

<?xml version="1.0" encoding="utf-8"?>

<antwoord type="ack">T13-04000

<rubriek naam="scancode">746880</rubriek>

<rubriek naam="staining">PAS+</rubriek>

<rubriek naam="stainingnameextension"/>

<rubriek naam="materialname">cassette</rubriek>

<rubriek naam="techniquename">Histochemisch</rubriek>

<rubriek naam="sampledate_out">20130409143750</rubriek>

<rubriek naam=”specimen">1</rubriek>

<rubriek naam="block">1</rubriek>

<rubriek naam=”scanprofiel">scanprofiel_PAS+</rubriek>

<rubriek naam="paraffinenumber">1</rubriek>

</antwoord>

WORKFLOW

List of scanned images:

• Newly scanned cases (completed slidesets)

• Red when they are incomplete

• Signed out cases with new scanned images (eg Her2Neu)

• Cases disappear when digitally authorized or manually removed

Drop down list:

• All digitized slides

• Separate entries for each pathologist

Drop down list of images to be evaluated:

• Requested images

• Last week images

• Yesterdays image(sets)

Grossing

Tissue

Processing

Slide storage

Stainers, immuno

Scanner

Slide

storage

Scanner

Grossing

Tissue

Processing

Slide storage

Stainers, immuno

Scanner

time saved:

5 hours each day

@ 130.000 slides

Time saving:in line with other laboratories

Scan_profiles

• Continous loading possible no user/technician interaction

• Scan profiles are automatically selected based on stain or protocol

• 20x - 40x

• Lighter / darker presentation

• Scan entire slide if it is very fatty tissue

• For cytology: scan everything within the circle

Web based communication, xml:

<?xml version="1.0" encoding="utf-8"?>

<antwoord type="ack">T13-04000

<rubriek naam="scancode">746880</rubriek>

<rubriek naam="staining">PAS+</rubriek>

<rubriek naam="stainingnameextension"/>

<rubriek naam="materialname">cassette</rubriek>

<rubriek naam="techniquename">Histochemisch</rubriek>

<rubriek naam="sampledate_out">20130409143750</rubriek>

<rubriek naam=”specimen">1</rubriek>

<rubriek naam="block">1</rubriek>

<rubriek naam=”scanprofiel">Scanprofiel_PAS+</rubriek>

<rubriek naam="paraffinenumber">1</rubriek>

</antwoord>

Easy acces viewing

WORKFLOW

PATHOLOGYIMAGEEXCHANGE

PROJECT OF THE DUTCH PATHOLIGIST AND THE AUTOMATED PATHOLOGY

DATABASE TO WHICH ALL DUTCH LABS ARE CONNECTED SINCE 1980

Slide kindly provided by Dr. André Huisman, Medical PHIT

• Facilitate workflow of the exchange of Whole Slide Images (WSI), between pathology laboratories

• By Connecting current information systems like PALGA the solution is easily used/accepted

• Patient care is improved by easy and timely consultation / panelreview

• Future proof

• The solution has to be in compliance with dutch law

• Dicom is used for exchange of images, provided by 3DHistech

Goals project PIE

Slide kindly provided by Dr. André Huisman, Medical PHIT

• Process takes up to14 days (50% > 4 days)

• Patient has to wait for definitive result and treatment

• Stress, loss of productivity and quality of life

• Optimal mail logistics: process 2 days

• Low volume (250/400 cases) but high impact

Digitally: same day?

Logistics revisions and consultations

• Scan slides

• Upload to server

• Send message

• Log into server

• Assess

• Make report

• Send report to requesting pathologist

Done on the same day

Logistics revisions and consultations

Pathology Lab A

Pathology Lab

B

Players

suppliers• Sectra

• DTHS

• RAM Infotechnology

vendors• Sysmex (3DHistech)

• Hamamatsu

• 3DHistech (dicom converter)

• Philips

• Pilot Labs:• Manual upload: Pal (Dordrecht) &

ErasmusMC

• Automatic upload: Radboudumc & UMCU

• Pilot Panels: • Soft tissue Panel Noord NL (UMCG)

• ThymomA Panel (Maasstad/ErasmusMC)

• Heamatology Panel (Radboudumc)

• LANS oesophagus Panel (AMC)

Revisions consultations / panels

Pathology Lab A Pathology Lab B

Panel members

Answer

Panel diagnosisRequest

LoginUpload Images

Easy synoptic reporting

Easy creation of snapshots for long time storage with

the report

THANK YOU

QUESTIONS ?