Pathology Informatics:Past, Present, and Future

Mike Hogarth, MD, FACP UCDHS Medical Dir. of Clinical RegistriesProfessor and Vice Chair, Pathology and Lab MedicineProfessor, Internal Medicinemahogarth@ucdavis.edu

Overview

• What is “informatics”?• What is “medical informatics”?• A history of medical informatics• History of UCDHS informatics (in pathology)• What is “pathology informatics”?• UCDHS pathology informatics – what do we do?• Thoughts on pathology informatics and the future of

healthcare -- ?what does the future hold?

What is “Informatics”

It is the science of “information”....

What is “medical informatics”?

"The study, invention and implementation of structures and algorithms to improve communication, understanding and management of medical information." --- Homer Warmer

"Medical information science is the science of using system-analytic tools . . . to develop procedures (algorithms) for management, process control, decision making and scientific analysis of medical knowledge.” --- Ted Shortliffe

Informatics does not always require computers – Nightingale was a pioneer in medical data analytics

Notes on matters affecting the health, efficiency and hospital administration of the British army – Florence Nightingale (1858)-- demonstrated that sanitation was a significant cause of the 42.7% hospital mortality rate in Barrack Hospital, Scutari, Istanbul

Crimean War 1853-1856

Florence Nightingale

1858

Nightingale pioneered the use of data and statistics to improve health

• Developed a Model Hospital Statistical Form• 1858 – Became Fellow of the Royal Statistical Society• 1874 – Honorary Member, American Statistical

Association• 1860 – Sent letter to Intl. Statistical Congress president

advocating for uniform collection of hospital statistics so outcomes could be compared – the first model for the systematic collection of hospital data using a uniform classification of diseases (ICD)

Really, what is medical informatics...?

• A multi-disciplinary field that is focused on the science of information

• Examples of what you might see in the field• Medical decision making models• Clinical decision support• Information organization and flow• Algorithms• User interface design and usability (error causing?)• Medical image processing• Modeling of medical observations and data• Ontology and terminology systems• Methods for evaluating healthcare information systems• Development and design of clinical information systems

Informatics draws from many fields

What medical informatics is NOT...

• It is not “information technology” • It uses information technology as a tool... much like a pathologist

might use a microscope... A pathologist is not a “microscopist” but a diagnostician!

• It is not “computers in medicine”• It studies various aspects of information in healthcare, but it is

not simply the implementation of computerization of the process• Some excellent informatics has been done *without* computers!

• It is not “healthcare programming”• We often build systems to implement models of information

management but informatics is not about the building of these systems..

• Informatics uses software design/development to achieve its goals (and study its benefits/detrimental effects of such systems)

Medical Informatics is not a new field...

Robert Ledley – a pioneer in using computers in medicine

Robert Ledley -Physicist and DDS-Pioneered the use of digital computers in biology and medicine-Developed system to automate analysis of chromosomes (FIDAC)-Led the development of the Automatic Computerized Transverse Axial (ACTA) scanner...the CT scan!-National Medal of Technology

The direct application of computing to medical practice is also not new...

• Dr. Morris Collen hired by Dr. Sidney Garfield (Kaiser Permanente)

• 1952 – Became Medical Director, Kaiser, Oakland• 1961 – Heard presentation on automating clinical data

capture and processing• mid 1960’s - Implemented computerized “multi-phasic”

testing (health screening)• Kaiser was one of the first to computerize medical data

Medical informatics is not just for young healthcare professionals...

Computerized medical records are also not new...

• 1965 – El Camino Hospital (Mt. View, CA) and Lockheed collaborate on the “Technicon Systems” electronic medical record system

• 1972 – Technicon Medical Information System goes “live” in El Camino hospital

• Physician order entry• Clinical documentation

directly from health provider• Results reporting

Bill Creelman of Technicon performing training onSystem with nursing staff.

UCDHS and Medical Informatics

• 1973 – Sacramento Medical Center is bought from Sac county by UC Davis Medical School

• 1976 - Dick Walters, PhD – Faculty in Computer Science Dept. also joins faculty in Family Practice

• 1985 - Dr. Walters elected to ACMI

• co-developer of MUMPS, a programming language in clinical systems

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1130476/

1976

UC Davis Informatics Milestones

• 1985 - Dr. Cardiff (Chair, DOPLM) and Dr. Walters create the “Center for Medical Informatics”

• 1999 – Health Informatics master’s program

• 1987 – 1st “web-cast” informatics symposium featuring Dr. Don Lindberg

• 2000 – UCD DOPLM develops hybrid tele-pathology system

Medical Informatics evolves in the US

AMIA Definition of Biomedical Informatics and related fields

Medical Informatics evolves in the US

AMIA Definition of Biomedical Informatics and related fields

Pathology Informatics-- Association of Pathology Informatics (API)

• 2000 – founded with the goal of defining pathology informatics as a clinical subspecialty within pathology• Develops standards for managing pathology-related

information• Promotes education in pathology informatics

• “Pathology informatics involves collecting, examining, reporting, and storing large complex sets of data derived from tests performed in clinical laboratories, anatomic pathology laboratories, or research laboratories in order to improve patient care and enhance our understanding of disease-related processes”

UCDHS Pathology Informatics

• 2009 – Pathology Informatics formally established in DOPLM

• Mission – to apply information science to solve challenges in the discipline of pathology

So what is “pathology informatics” here?• The application of information science to support the scope of

pathology practice (or research)• What does it entail?

• Laboratory Information Systems• Managing clinical information systems supporting anatomic pathology, clinical

pathology, transfusion medicine, and molecular diagnostics• Laboratory automation

• Digital Pathology Imaging Systems• Image capture methods, diagnostic fidelity • Whole-slide scanning systems, tele-pathology systems, Image archives/path-

PACS

• Data mining (of pathology information)• Natural language processing of surgical pathology reports

• Decision support• Provide CDSS for diagnostic testing by health providers

• Analytics and Registries • to support performance/quality improvement

UCDHS Pathology Informatics: 2014-2015

• Information Management• Implement, operate/manage systems that support UCDHS anatomic pathology,

clinical pathology, transfusion medicine• Integration of LIS data with EHR• Integration of LIS data with external referral labs (ie, ARUP)• Whole slide scanning systems (in collab with health IT)

• Education• PGY Pathology informatics rotation• Health informatics certificate for pathology fellows• Health informatics master’s program (leadership, teaching courses)• Master’s of Public Health (public health informatics)

• Grants/Contracts -- ~$25M in grants/contracts since 2005• California Electronic Death Registration System (2005)• Maryland EDRS (2014)• MediCal “Big Data” analytics and EHRs (2014)• TRANSCEND Clinical Trial Information System (supporting I-SPY2 since 2009)• pSCANNER – PCORI Clinical Data Research Network (2014)• UC-ReX (founding member, 2009)• Athena Breast Health Network (2008)• Oversight of UCDHS clinical registries (2011)• UC Health Quality Improvement analytics (2014)

UCDHS Pathology Informatics

http://www.ucdmc.ucdavis.edu/pathinformatics

Pathology Informatics Staff

What does the future hold?

• Trends in healthcare1. The pursuit of the Triple Aim

Increasing focus on quality/cost (value)• DSRIP (Delivery System

Reform Incentive Payments) program

• Accountable Care Organizations (ACOs)

1. Tailored diagnostics and therapeutics

2. Wearable devices 3. “Big Data” and “Data

Science” 4. “Open Data” movement

(health.data.gov)

“The Triple Aim”

21st Century US Healthcare

The Learning Healthcare System

Sarah M. Greene, Robert J. Reid, Eric B. Larson; Implementing the Learning Health System: From Concept to Action. Annals of Internal Medicine. 2012 Aug;157(3):207-210.

TMR Transfusion Registry

Transfusion registry leverages data from the Laboratory Information System (LIS), clinical data from UC Davis Health System EHR, and administrative (coded) data

Registries a new way

A Tethered Meta-Registry

-“Meta-Registry” – All data for all registries is in one repository

-“Tethered” – routine, automated data extraction from source systems

-One data set – algorithms “tag” patients as being in one or more registries

-Automated dashboards and reports

A Tethered Meta-Registry

-“Meta-Registry” – All data for all registries is in one repository

-“Tethered” – routine, automated data extraction from source systems

-One data set – algorithms “tag” patients as being in one or more registries

-Automated dashboards and reports

Did you know? “80% of data elements in institutional registries are common across

all of them”

Did you know? “80% of data elements in institutional registries are common across

all of them”

Tethered Meta Registry Data Flow

Sepsis Registry

Mobility (ICU)

Registry

Diabetes Registry

Source Data“Tether”

EMR Reporting Database

Administrative Data

Laboratory Information

System

TMR Patient

TMR Encounters

TMR Flowsheets

TMR Procedures/Labs

TMR Medications

2.2 Million

25 Million

100 Million

57 MillionCancerRegistry

Database

TMR Cancer Diagnosis

Transfusion Registry

Cancer Registry

A glimpse into the possible future...

http://www.businessweek.com/articles/2014-07-03/hospitals-are-mining-patients-credit-card-data-to-predict-who-will-get-sick#r%3Dread

Pathology Informatics and future trends

• “Team Medicine” / Integrated care• Will require tight data integration between EHR and LIS functions• Consolidation of LIS as a core EHR component

• Computerized clinical decision support • Will require structured data from pathologists• Structured reporting (synoptic reporting) using XML CAP “electronic checklists”

(eCC XML)• We are currently collaborating with ASCO and CAP on improving structured data

capture in cancer care

• Population health management • Will require clinical data analytics and registries• Combining data from multiple sources for predictive analytics.• Creation/management of data sets (registries) to support performance

improvement within pathology, as well as externally• Analytics platform to characterize care

• Patient-centered care • Will require new ways of “reporting” information

• Patient-directed reports?• Mobile/mhealth

Questions...

Slide deck download – http://www.hogarth.org