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I am in the process of accomplishing one of my new years resolutions to become Black Belt certified in Lean Six Sigma. I am two thirds of the way done. I became certified as a Six Sigma Green Belt in April and Lean certified in June; both with a focus in healthcare. I am currently in the process of taking my black belt course and working on a project for certification. These days Lean Six Sigma methods are constantly running through my head and I have applied several methods to my consulting work.
The power of Post-It's and moveable whiteboards!
One of my favorite tools are Post-its and take anywhere, disposable white boards. I use them on-site with clients and I also use them in my office, ALL over my office. So in an ongoing effort to immerse myself more in Lean Six Sigma for the lab I turned to one the leaders of Lean Six Sigma in pathology, Henry Ford Hospital.
Dr. Mark Tuthill, Division Head of Pathology Informatics, was kind enough to give me a tour and WOW was I impressed. Yes.. it was a big WOW! My last blog post was about creating WOWs instead of waiting for them to happen. This is exactly what Henry Ford’s department for Pathology and Laboratory Medicine has done and continues to do, because striving to improve is never complete! You know from the moment you enter the department you have walked into a remarkable place. Placards are prominently displayed with powerful messages including:
Every Life Deserves World-Class Laboratory Service”
Lean Six Sigma is a management philosophy and their department is lead by prominent pathologist Dr. Richard Zarbo, who clearly embraces the power of Lean Six Sigma. The entire department is involved and committed to continuous improvement; a fact that would make their founder, and the father of Lean, Henry Ford proud.
Here are some of my take-aways from my visit.
Gross Room: Process Flow Chart
Defect Tracking
Can you guess their next step for their digital future? Digital Pathology! With the foundation described above, a Lean Six Sigma culture, and a management team with vision I have no doubt that they will be successful. Thank you Henry Ford Hospital for your level of excellence, you truly are a gold standard.
There have been situations in my career when I wish I knew less and when I wish I knew more about pathology and laboratory medicine. Typically both of those emotions arise when a personal situation collides with my professional world.
A very close friend of mine just had a miscarriage when she was 13 weeks pregnant. During this sad and emotional time she was faced with a tough decision. Did she want to have the fetal tissue tested after her D&C for chromosomal abnormalities? Her OB said the fetal tissue would be sent to pathology either way but further testing could possibly answer the question as to “why” she miscarried. The word “pathology” stuck with my friend and since she knows what I do she called me for advice and for my opinion on whether she should have the testing done.
I was deeply concerned and sad for my friend. Although I wanted to help her I knew there was no way I could (or should) answer this for her- it had to be her decision. But one thing that was obvious was my friend needed more information and a medical professional she could talk to.
I believe that medical professional should of been a geneticist, pathologist, or someone affiliated with the lab. Lab tests are often just ordered, or if presented to the patients as an option, the ordering physician typically do not know enough of the facts on the test to answer questions beyond generalities. In the case of my friend I think the answers to the following questions may of helped her:
I am going to guess her OB would not have known the answer to these questions, but someone in the lab would or should! The day before my friends D&C she received a telephone call from her OB and an Anesthesiologist to prepare her for the procedure. What if someone from the lab had called too to go over the pathology and testing options? Would that have helped? I’m guessing so!
We need to transform the model of care in the lab to include a proactive approach to diagnosis and testing rather than just reactive. From a business perspective I’m guessing the lab would prefer patients to order cytogenetic testing. To increase orders for the right lab tests and to decrease the blind useless ordering of other tests, labs and their physicians must step up!
In the end my friend decided against the cytogenetic testing. Her lack of understanding of the tests and fear of a gigantic bill when insurance denied the claim caused her to decline the testing. Yet the tissue was still sent to pathology. So somewhere in some lab there are glass slides with fetal tissue from my friends baby. Will she ever know the pathologists findings? Probably not, but she should.
It’s true, anyone can benefit from knowing more! Knowledge is power, even in the confusing world of healthcare. I have talked about this before in my post Go Above And Beyond The Dx: Participatory Medicine. I firmly believe that the blind faith patients have in their doctors and the healthcare system is a major problem. Doctors “practice” medicine; they are not perfect. Everyone has the right to ask questions or search the internet for more information. But what if a doctor proactively came to you and explained how they achieved their diagnosis and why they support a certain treatment option? What if they could show you pictures (maybe whole slide images on an iPad) to support their findings?
Well that is exactly what Dr. Jennifer Hunt, Pathologist and Dr. Lori Wirth an Oncologist at MGH are trying to do and document in a new study. The study will track the value of a pathologist providing patient consultations. I just finished reading about it in the November Issue of CAP Today, “Face Value- pathologists one on one with patients.” The article discusses the vision and preliminary experiences of the study. There are several statements I love in this article, but my favorite comes from Dr. Hunt who answers the question Is this for everyone?
The “yes” argument is that any patient can become more knowledgeable about his or her health care. It’s not about the patient being smart; it’s not knowing nothing or knowing everything about your disease. It’s the idea that anyone could benefit from knowing more, and working more closely with their clinician- which includes their pathologist.”
Bravo! This is exactly the type of transformation we need and a wonderful example of Participatory Medicine.
As for me, I have chosen to act on this belief by volunteering for a patient advocacy program at a local hospital in Denver called the Reconnect Leadership Project. I have just finished my training as a Reconnect Leader and will start working with patients next week. The goal of our program is to reduce readmission rates to the hospital and empower patients to take charge of their health. Patient engagement is another thing (in addition to digital pathology) that I am very passionate about.
Once again, I applaud the work of Dr. Hunt and Dr. Wirth. I cannot wait to see the results of this study!
Patients do not understand the importance of a pathologist in the diagnosis of their disease. They also have no idea about digital pathology. But that could all change with a simple, powerful marketing campaign by GE’s Healthymagination. Can you imagine it? I can, and I have been for years. A Healthymagination commercial would bring attention, good attention to the practice of pathology.
Although no commercial has aired, it has been a busy week for GE in the world of pathology. On October 22nd GE announced the purchase of Clarient in a $587 million deal to accelerate GE Healthcare’s ability to predict and diagnose diseases; and yesterday GE healthcare’s joint venture with UPMC, Omnyx, announced the start of clinical trials for their digital pathology solutions. Although Omnyx was not involved in the purchase of Clarient, it makes sense that they will come together to further GE Healthcare’s $6 billion healthymagination initiative to improve cost, quality, and access in healthcare; or in our world- pathology.
In addition, GE and Omnyx executives spent the past few days promoting their innovation and advancements at two conferences in San Diego, CA- Pathology Visions and TEDMED. At TEDMED Mike Barber, GE’s VP of Healthymagination, gave an 18 minute power presentation which included digital pathology. Mr. Barber was quoted,
I don’t say this lightly – while digitization may seem like a relatively simple change in today’s tricked-out techno world, it’s a revolutionary step in pathology that may lead to the transformation of the practice, and the evolution of our understanding of cell biology.”
Digital pathology is no longer a new topic in pathology. However, it needs to become a new topic in healthcare and with patients. So while we wait for a Healthymagination commercial let’s start to spread the word of our amazing future to anyone who will listen.
I was walking through the grocery store yesterday and saw the cover of Denver’s 5280 magazine, Top Docs for 2010. I thought to myself… I wonder if there are any pathologists listed? If there are, I’ll buy it and can find out what makes these pathologists “Top Docs.” Sure enough, there were three pathologists! Happy to see this, I checked out with my chicken,vegetables, egg noodles (I was making homemade chicken noodle soup for dinner) and the 5280 magazine.
After my yummy dinner, I settled down to read the article. Quickly I realized this article was not going to be what I had hoped for; it was just a list. A list that is created by physicians who vote on each other, not who are voted on by their patients. Sadly, I now knew why pathologists were listed. It would be rare for patients to have interaction with their pathologist; however physicians would (I hope!) have had some interaction. Yet this still brings me to the bigger question, what really makes a Top Doc or in our case a Top Pathologist?
In Denver, the top three pathologists are:
Although I am not sure why these docs won, I am curious to understand what you think makes a great pathologist?
As for the Top Doc lists, these should be created by surveying physicians and area residents; furthermore, they should have a description of what makes these “Top Docs” special and/or unique. There wasn’t even a profile for the doctor on the cover, a diagnostic radiologist. What made him soo special to be on the cover? Could it be his good looks? Understanding”why” a doctor was chosen is the reason people buy this or other similar Top Doc city magazines.
If you are physician, and have taken one of these surveys for your city I would appreciate your comments and impression of the process and outcome. Do you feel this fairly markets “Top Docs” to area residents or is just a bunch of show to sell magazines? As for me, I lost my blind faith in healthcare and doctors a long time ago; I need facts! So unless the survey process changes and/or provides more “why” information, I will not buy this issue again.
After my article last month, Advance offered me the opportunity to write a web article to compliment their vendor roundtable article. Below is the article.
Imagine your digital future. You walk into your office, and on the desk is a computer; your microscope is covered and untouched; on the shelves are books and journals, and nothing is on the floor. Paper and glass do not cover every inch of your office. Gone are the numerous external hard drives filled with countless images. All that remains is you, your knowledge and a computer.
This computer is your diagnostic workstation, customized to you and providing you with resources to improve diagnostic outcomes, advise on treatments and monitor patient response to those treatments. Digital pathology will enable and frame our digital future. However, forging this vision has not been easy, and realization of the vision is a constant work in progress.
History In the 1990s, the first robotic microscope was controlled over the Internet by Ronald S. Weinstein, MD,1 and the first slide scanner was invented to measure preinvasive cancer by James W. Bacus, MD, and his son Jim V. Bacus Jr.2 At about the same time, Dirk G. Soenksen, founder of Aperio, was imagining a world where microscopists looked at computer monitors rather than microscopes.3 These four inventors established the foundation for our digital future. As visionaries and advocates, they have brought digital pathology to life.
Resistant to Change
Ask around and the consensus is that digital pathology is our future. However, the timeline of when our future becomes a reality is widely debated. The digital pathology industry, pathology organizations and consumer crusaders have worked hard over the past 15 years to educate the market on the benefits of digital pathology, yet they are often met with a fierce resistance to change. The resistance is often driven by fear–not of change but of being changed.
No one pathologist, department or company can be forced to adopt and learn something new. Therefore, we must continue to educate and create an understanding of the tangible advantages, which instills a desire to change. Change is hard, but if we overestimate the importance of pathology’s capabilities today, we will underestimate the significance of what the field could become tomorrow.
Tangible Advantages
Digital pathology can reduce subjectivity, increase diagnostic confidence and ensure diagnoses are reproducible–all important advantages, especially when incidences of misdiagnosis have been publicized lately and the practice of pathology and laboratory medicine scrutinized. It is well-known that risk for human error in slide preparation and patient identification is greatly reduced when the histology process is bar coded.
A 2009 publication in the American Journal of Clinical Pathology about the Henry Ford Health System surgical pathology lab highlights a 62% reduction in the overall misidentification case rate.3 Add digital pathology to the picture, and you will enable scanning of glass slides, software (instead of technicians) correlating patient data and whole slide images, and electronic delivery of patient information and slides to the pathologist. Risk of error will continue to drop while powerful tools will support the pathologist throughout the diagnostic process.
Have a difficult case? No problem. The pathologist can simply assign the case or send an e-mail request to a specialized pathologist for a second opinion. This digital consultation process, often described as telepathology, is more secure and eliminates the risk of patient slides being lost or damaged, decreases the turnaround time to hours rather than days and reduces subjectivity while controlling costs. Still want more diagnostic support? Search the digital pathology slide database to review relevant clinical slides, quickly retrieve historical patient data, perform image analysis to obtain quantitative support, or easily set up a tumor board with physicians to illustrate the patient case and create a forum to discuss the next step or design a treatment plan.
All the tangible advantages described above can be done today and are being done, although the process is not perfect. Yet to achieve perfection you must find imperfections and then take time to transform those imperfections for the better.
Transformation
Government demands and consumer expectations are growing for transparency in medicine, improvements in patient safety and identification, electronic medical records and more personalized treatment plans. At the same time, the perception of laboratory medicine and pathology needs to improve, especially given its essential and significant role in patient care.
Digital pathology supports this healthcare evolution and enables the digital transformation of pathology and laboratory medicine. Our transformation is not easy. The process is not perfect, but the benefits are powerful and will outweigh the fears. Do not resist the transformation, embrace it.
Click here read the vendor roundtable print article and web article.
For over 10 years, the digital pathology industry has been riddled with vendors speaking their own language or languages (aka file format). Today a major milestone in interoperability was achieved with the final approval of Supplement 145; a DICOM universal format for whole slide images. Although vendors will never give up their native tongue, this new supplement creates a universal language everyone can understand in digital pathology, even those outside of our industry.
WG-26, lead by Bruce Beckwith, MD, has worked hard for several years to create supplement 145. Harry Solomon of GE Healthcare contributed a lot of help over the past year to move this to ballot and beyond. Harry put forward the following comments in an email to WG-26 today:
I’d like to add my thanks to the members of DICOM WG-26 for the significant body of pathology domain knowledge that has been added to the DICOM Standard, both in this new Supplement 145, and in Supplement 122 in 2008. That knowledge is now available to further improve interoperability in a field that was early to health informatics standards with the Systematized Nomenclature of Pathology, now known as the Systematized Nomenclature of Medicine (SNOMED), and is now poised for a significant leap with digital pathology. Here are some statistics on that domain knowledge base: One major new DICOM Information Object Definition (Whole Slide Imaging) with new concepts to manage the huge WSI data set A major revision of a DICOM Information Entity (Specimen) with a rigorous information model 56 new data elements added to the DICOM Standard in 14 new or revised modules 7 new or revised DICOM structured data templates and 18 new defined value sets 80 new coded terminology concepts added to SNOMED, and 36 added to DICOM 40 pages of explanatory information about pathology workflow and imaging
I’d like to add my thanks to the members of DICOM WG-26 for the significant body of pathology domain knowledge that has been added to the DICOM Standard, both in this new Supplement 145, and in Supplement 122 in 2008. That knowledge is now available to further improve interoperability in a field that was early to health informatics standards with the Systematized Nomenclature of Pathology, now known as the Systematized Nomenclature of Medicine (SNOMED), and is now poised for a significant leap with digital pathology.
Here are some statistics on that domain knowledge base:
Overall, this is another major step forward in the clinical use of digital pathology. Thank you to everyone who worked hard to make this a reality! The final document will be available within the next week.
Below is an article I wrote for ADVANCE for Laboratory Professionals, Perspectives In Pathology.
By Amanda Lowe
Digital pathology is often described as the scanning of a glass slide into a whole slide image; yet, it is much more. It is so much more, in fact, that pathologists and laboratory professionals find themselves puzzled with how it will affect their future. As technology progresses, we must start to understand how to put the pieces of it together—from acquisition to integration to data management and interpretation.
Acquisition
Acquisition of a whole slide image from a glass slide is done on a slide scanner, which creates the image necessary for interpretation. Important elements of slide preparation and patient information can make the acquisition process simple or complex.
Slide preparation is a crucial and often overlooked element of digital pathology. Pathologists can handle slide artifacts such as folds and air bubbles under a microscope; slide scanners are not always as forgiving. Also, staining has to be perfected, not only for scanning but for accurate interpretation and use with image analysis software. Poor staining can result in tissue not being scanned, inaccurate image analysis data—and in the worst case—a wrong diagnosis.
Traditionally, when glass slides are prepared, they are manually matched with the patient paperwork (including patient history, requisition and gross review), then delivered to the pathologist. With digital pathology, the process looks different. You now have whole slide images that need to be reconciled to the digital patient paperwork, then delivered to the pathologist. The only way to do this is with a laboratory information system (LIS), electronic medical record (EMR) integration, and bar codes. Bar codes will reduce human error, save time on the constant need for verification and re-checks, and improve quality assurance by tracking all specimens throughout the histology process.
Integration
The LIS and often the EMR need to share information with the digital pathology software to create a pathology picture archiving and communication system (PACS) that consolidates all patient paperwork, gross images and whole slide images for interpretation. This is the most important but also the most difficult piece for labs to handle. The process can be costly and require collaboration of two or more vendors, which can be a frustrating and hard process to manage. However, it can be accomplished with a plan, a budget and someone to manage the project.
Data Management
Many hospitals do not have adequate IT resources or the expertise to handle their already stressed storage demands. Yet these whole slide images have to be stored somewhere. Unfortunately, most IT departments do not understand the fundamentals of digital pathology. Pathology leaders and their lab personnel must improve communication with their IT departments and take an active role in educating IT on the realistic needs of the department now and over the next five years. Hospitals have to prepare for the increase in lab data and pathology images that will soon be their future.
To estimate your whole slide image storage needs, divide the number of surgical slides your lab generates per year by 3,500 to get an estimate of terabytes needed annually; 3,500 is the average number of whole slide images per one terabyte.
Healthcare providers are required to save medical records for a specified time; for most, this is a minimum of seven years. Security is not optional, and HIPAA mandates backup and disaster recovery plans for patient records, including all medical images. The specialty of pathology will not be an exception to the rule.
Interpretation
One goal of digital pathology is to enhance the sign-out process for pathologists. Pathologists should be able to sit down at a computer monitor to sign out digital cases retrieved from a pathology PACS system. Easy access to archived cases for disease progression or comparison, rapid case sharing and consultations, data mining for decision support and image analysis will all help improve the diagnostic process.
Powered by the rapid and endless growing portfolio of image analysis algorithms, pathology will transition from a qualitative to a quantitative discipline. Digital pathology partnered with image analysis will create the infrastructure necessary so pathologists can confidently determine the severity of a disease and predict responses to a target therapy.
Digital pathology streamlines laboratory workflow, enhances the sign-out process, and can improve diagnostic outcomes and treatment responses for patients while at the same time forge a new foundation for the use of pathology data to drive translational research and higher standards of care.
One week from today on August 10th at 12 PM EST / 9 AM PST, the second webinar in a new series titled “Pathology 2.0″ will be presented by Keith Kaplan, MD.
Topic Overview
This webinar is designed to enhance your knowledge of Pathology 2.0. Dr. Kaplan will Increase your knowledge of 2.0 tools and technologies, teach you how 2.0 will apply to the daily practice of surgical pathology, and give you an understanding of the long-term implications of 2.0 for our practices. In addition, you’ll learn how to improve your services and showcase your specialty while providing information to patients that was once locked away. To learn more about Pathology 2.0 read an article from CAP Today “Manifest destiny—Pathology 2.0 is here,and it’s clear. Time to climb aboard.”
About Keith J Kaplan, MD
Dr. Kaplan is a surgical pathologist and chief information officer for Carolinas Pathology Group and Celligent Diagnostics. He was formerly associate professor of pathology at Mayo Clinic College of Medicine where he served as Biospecimens Director for the North Central Cancer Treatment Group (NCCTG). He received his MD degree from Northwestern University Feinberg School of Medicine followed by residency training in anatomic and clinical pathology at Walter Reed Army Medical Center. While at Walter Reed, in conjunction with the Armed Forces Institute of Pathology he founded and directed the Army Telepathology Program connecting 25 hospitals worldwide for consultation via telepathology. He has authored over 60 peer-reviewed scientific articles book chapters, editorials and scientific abstracts. His subspecialty interests include gastrointestinal and hepatic pathology, cytopathology and pathology informatics and has presented at national and international meetings on those topics. Dr. Kaplan’s research interests involve gastrointestinal and hepatobiliary pathology, hyperspectral imaging, image analysis and the use of Web 2.0 tools in pathology. He is active in many medical societies including the College of American Pathologists where he has chaired or served on several committees, serves as a reviewer for many scientific journals, serves on the editorial board for Human Pathology and blogs daily at www.tissuepathology.com.
REGISTER TODAY
This webinar is provided by www.thedigitalpathologywiki.com and it’s sponsors.
It is time; time to change how you give a diagnosis.
Participatory Medicine, defined by the Society for Participatory Medicine, is a cooperative model of health care that encourages and expects active involvement by all connected parties (patients, caregivers, healthcare professionals, etc.) as integral to the full continuum of care. The patient role has evolved, therefore the role of a pathologist must evolve too. Pathologists must start to go above and beyond the diagnosis and become a key advisor to physicians and patients on the prevention of disease, therapeutic treatments, and the progression of disease within patients.
I have written a post before about my dad, a resident of Colorado, who had a liver transplant in August 2009 at Cleveland Clinic (CC). As soon as he returned home to Colorado, he had to have bi-weekly blood draws for review by his clinical care team at CC. The initial plan was for my dad’s family medicine office to do the blood draw with kits that were shipped from the Cleveland Clinic’s lab, and package them up in a pre-paid envelope (also provided by CC ) and ship them back to CC’s lab for analysis. The turnaround time would be about 36-48 hours for the result, plus the cost and risk of shipping the blood to CC.
After trying this out and realizing it was a logistical nightmare, my parents decided to have all the blood work done by the University of Colorado lab, which would post the results within 8 hours to their hepatology patient care system. My parents could then simply access the results securely online, print and fax them to Cleveland Clinic. This new process brought the turnaround time to 8-12 hours; saving 24-36 hours over the original method. Overall, a great example of participatory medicine!
In Pathology, the use of a participatory model is a greater challenge since pathologists rarely interact with the growing numbers of patients they diagnosis everyday. However transformation to a new model of care must be accepted, and the College of American Pathologists (CAP) has two programs “Transforming Pathologists” and ”Every Number Is A Life” where the evolving role of pathologists and value of pathology are being advocated for. CAP says on the transformation website,
…As health care changes quickly and on all fronts, Pathologists must step up and embrace transformation, pursue new roles in the workplace, and re-position themselves as the center of the clinical care team. This is an urgent call to action and we must take action now. If Pathologists are to survive, we must adapt….Pathologists must have an understanding of their changing role – they must NOT be defined by the tools they use. We have a bright future as researchers/innovators, test providers, interpreters, clinical data integrators, clinical consultants, business developers and practice leaders.
However, pathologists often do not know where to begin. Try these steps:
Proponents of the participatory model of care believe that adoption can increase patient satisfaction, save time, reduce costs, improve care, and lower liability risks for physicians. Although change is difficult, pathologists must seize the opportunity they have been given! It is time, time to go above and beyond the diagnosis.
In the middle of difficulty lies opportunity. ~Albert Einstein
In the middle of difficulty lies opportunity.
~Albert Einstein
Are you a patient who has a great story about a pathologist? Share your story today! Click here
Want to learn how to become an organ donor? Click here
A great read on participatory medicine by American Medical News- Participatory medicine: A high-tech alliance with patients
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