Joe BiegelVP, Product Management

McKesson Medical Imaging GroupOctober 23, 2007

Evolution of PACS as a Model to Predict Adoption of

Digital Pathology

A Brief History of PACS

1970’s1970’s 1980’s1980’s 1990’s1990’s 2000’s2000’s

Original concepts: Dr. T. Iinuma, “Image processing in clinical medicine – considerations of a system”, Bull., Tokyo Women Med. 44, 152 (in Japanese).

1974

Dr. Samuel J. Dwyer III describes PACS ideas at a Seminar at the University of Iowa. Dr. Judith M. Prewitt introduces the term PACS. Cardiovascular radiologist Dr. Andre Duerinckx describes the far reaching future benefits of PACS for a hospital.

1981

1st International Conference on the PACS, Newport Beach, California.

1982

US Army teleradiology project starts.

1983

Siemens/Philips start developing PACS concepts. EuroPACS starts annual meetings.

1984

US National Cancer Institute funds UCLA group under Professor Bernie Huang.

1985

Berlin BERKOM project started.

1986

PRIMIS created at VUB Brussels – to study applications of digital imaging.

1987

NATO conference in France includes topic on Imaging Networks. SCAR celebrates 10th annual meeting.

1990

US – Baltimore Veterans Hospital PACS.

UK – Hammersmith and Conquest PACS projects.

1992

Roger Baumann and Gunther Gell identify 23 large PACS worldwide with over 100 PACS projects.

1995

Baumann and Gell follow up survey – 177 large PACS identified worldwide.

2000

Multiple regional and national projects initiated. Worldwide mass adoption begins in earnest

2002

PACS Market Evolution

1990 20001985

Standards

TechnologyEnablers

Market

SolutionsOffered

ACR-NEMA

ACR-NEMA 2.0

IHE

DICOM + HL7

DICOM 3.0

Research PioneersEarly Adopters

Replacement

Mass Adoption

Single Modality Applications Departmental PACS Enterprise RIS/PACS

Multi-Modality Viewing Apps Departmental RIS/PACS

HSM Systems

NAS / SAN

Storage H/W $

Hi-Res Displays

Affordable UNIX workstations

Optical Storage Media

9-track tapes

Mainframe Computers Voice Recognition

Optical Storage Jukeboxes

TCP/IP adoption

The Evolution of Imaging IT Market Segments

1990 20101985 2000

RadiologyPACS

Market

Research PioneersEarly Adopters

Replacement

Mass Adoption

CardiologyPACS

Market

Research Pioneers

Replacement

Early Adopters

Mass Adoption

OpticalImaging

Research PioneersEarly Adopters

Mass Adoption

Replacement

Historical Radiologist Workflow

Early Perceived Value

Radiologist Workflow with RIS/PACS

Rad bar codes requisition into

dictation system

1Clerks/Tech match up films to be read

with patient’s master jacket

Films with masters are delivered to Radiologist

Is there previous in

master

Rad hangs films on view box

Rad hangs previous for review

Rad enters MRN into RIS,

finds patient, reviews results

No

Rad bar codes requisition into

dictation system

Rad dictates patient name, order, and accession

number in dictation system, and dictates report

Rad places films back into daily folder and

signs bag

Rad places signed daily with patient

master jacket aside for pickup by clerical staff.

1

Rad opens unread worklist on PACS in

dictate mode and opens first exam to be read

Rad clicks on clinical history icon to review patient’s reports and results from HIS/RIS

Dictation automatically initiated. Order information from the RIS automatically sent to dictation system.

Relevant prior studies automatically

display

Rad dictates report, and clicks next study

Patient and order level information sent from PACS

to RIS with no patient search required

Next study is loaded. Dictation is initiated, and

previous exam is marked dictated in PACS

1

1

Pathology progress, as compared to Radiology

The evolution of Digital Imaging in Radiology offers significant lessons for Pathology

Parallels with a later start, … but likely faster progress─ Radiology in 1995 vs. Path in 2005

─ Radiology today vs. Path in 2010

Moore’s law helps No need to repeat the same pitfalls

Source: Bruce Beckwith, MD – 2005 DICOM International Conference – Budapest, Hungary

Radiology c. 1995 -vs- Pathology c. 2005

RadiologyRadiology PathologyPathology

Analog image capture Analog image capture or no image capture

Single modality to multi –modality focus Single modality

DICOM standards- early formation of IHE Emerging standards

Separate workflows – RIS, Reporting, Separate workflows – APLIS, Reporting

Radiology focused Images hard to interpret for non pathologists

Storage needs seem overwhelming Extreme storage needs

Digital Imaging is more expensive than analog

Digital Imaging costs money

“Island” workflow Unstructured, collaborations, distribution

Most of spending is still on film Modest budgets

Radiology Now -vs- Pathology in 2010

RadiologyRadiology PathologyPathology

Digital Acquisition is standard Digital acquisition growing

Automatic meta-data capture Streamlined image capture with metadata

CAD assists Radiologist’s interpretation CAD interpretable portions

Many patient requests Large transactions per study

Large and constantly growing storage needs

Large storage needs, but cost barrier decreasing

Digital imaging saves money, and is required to make money

Digital pathology adds value and is required to make money

Large budgets Budgets expand into IT space

Radiology outside the dept. of Radiology walls

Remote pathology, protocols, strong links to clinical practice.

Driving adoption is key

Automating the current workflow is only the first step─ Both physical slide based workflow and digitized slide workflow will

co-exist for a long time

─ Metadata (ie. patient demographic info, block/slide info) needs to be assigned to digitized WSI images

─ Manual data entry must be minimized whenever possible if WSI technology is to be incorporated into and ultimately replace existing physical slide based workflow

Economic drivers of digital pathology are evolving─ Factors from outside the department will dominate

─ Standard of care, costs & reimbursement are the keys

Solution requirements will also evolve

01010101010

1010

1010

1010

110

1010101010101010101

Pathology WorkflowPresent & Future

Source: Sourav Ray MD, et al: CAP, 2006

Metadata Annotation

Engine

Histology Laboratory

Physical Slides

Slide Storage

PACS10101010101

101010111011

10110101010101010

101010101

0101010101010101010010101010101010101010101101010101010101010101010101010101

10110010101010101010101010101

101010101010101010

10110010101010101010101101010101010101010

101010101

10101010101

101010110100101010101010101010

10101101

10110010101010101101010110100101010101010101010101010

10101010101010101010101010101010

10101010101010101010

Gross Specimen Pathologist Orders: Recuts,

Levels, IHC/Special Stains, Ancillary Studies

WSI unique ID # for each WSI slideH&E Data, IHC Data,

Flags, CommentsWSI or not WSI?

Block Data, Gross Description,

Gross Images

Cassettes/Blocks

3rd Party Whole Slide Imaging (WSI) Apparatus

Load with WSI Unique Slide ID#

Patient Block Slide Data attached to WSI Unique ID#

Digitized Whole Slide Images (WSI) attached to WSI Unique ID#

Annotated Whole Slide

Images (WSI)

Region of Interest (ROI) jpeg images (Direct Operation 3rd Party Imaging

Apparatus)

Request WSI Images Via WSI unique ID#

Request ROI Images

WSI Images as requested per case

Orders

Patient/Case/Block Data, Prior Reports,

Images (ROI) and WSI)

APLIS Remote Operation 3rd Party Imaging

Apparatus (TWAIN)

Region of Interest (ROI) jpeg Images

Physical Slide

Analog Optical Image

Future Pathology Workflow

The vision of automating the current workflow is a noble goal, but it is only the first step─ The true value of Digital Pathology will have to be

defined in terms of faster, improved Patient Care

Going Digital will change the practice of Pathology and will lead to a new, yet undefined workflows─ Standards, IHE will help: necessary but insufficient to

drive wide-scale adoption

DICOM in Pathology

Visible Light Supplement 15─ Included support for gross images, microscopic

images, x,y.z position, lab accession numbers

Working Group 26─ Evolving to include whole slide imaging

Growing number of imaging products targeting pathology are DICOM compliant

US Veteran’s Administration:─ Pathology imaging vendors must be DICOM

compliant

IHE-J in Pathology – Workflow/Data Structure

OrderSample

Macro Image

Slide

Block

Sample

Sample

Slide

Slide

Study Series Image

Block

Source: Tofukuji * Okuno – 2005 IHE –Japan Pathology WG

Diagnostic Imaging Cockpit = ‘vision’ under pressure

Diagnostic Imaging CockpitDiagnostic Imaging Cockpit

Departmental PACS diagnostic tools

Collateral content

3D, Fusion, CAD

Orthopaedic extensions

Enterprise Worklist

Departmental management &

reporting tools

EMR Integration

Voice Recognition

Structured Reporting: eg OB,

ER discrepancy & critical results

reporting

A

B A

B

Worklist & Case History

Gross / Low Res.Image Analysis

Digital Slides Report

This is an example text bocks for the gross image shown above. This text is so small that it is unlikey that anyone can read it. Can you? I really doubt it.

This is an example text bocks for the gross image shown above. This text is so small that it is unlikey that anyone can read it. Can you? I really doubt it.

Source: Aperio Technologies

The Pathology “Cockpit” – current focus

Pathology Next stage

Pathology CockpitPathology Cockpit

Advanced diagnostic tools

3D, Fusion, CAD

Muti-spectral imaging

Test sub-routines (histology, etc.)

Enterprise Worklist

Departmental management &

reporting tools

EMR Integration

Voice Recognition

Structured Reporting

Critical findings / ER ??

Departmental Productivity Reporting

Synergies with Diagnostic Imaging

Leverage image management infrastructure

─ Cost and expertise synergies will speed adoption

Routine access will likely create clinical use cases which will drive the adoption

─ The extent to which these use cases impact outcomes will impact market acceleration

Access needs vary─ Pathologists want access to

diagnostic image data─ Radiologists have interest in

access to summary data and no interest in WSI access

Value Points = Business Control Points

Modality = Data Acquisition Storage = Physical Storage Devices (H/W) Image Access Points = Clinical Application(s) Workflow = Order $ Data = Data-mining CAD – address the volume – may be more

formative than in Radiology Financial benefit needs to become more clear

Organic evolution is a slow, painful process with many side-tracks

Integration and interoperability with other systems is key to adoption

─ Isolated systems, IT-silos are short-lived, with limited clinical benefits

Don’t repeat the evolutionary sidetracks from the history of other clinical disciplines…

Use PACS as a starting point and build on it !!

Summary

Pathologists need PACS now─ value is immediate─ Pathologists should have PACS access now – the patient record

needs to contain relevant imaging data

If you want to accelerate the adoption-curve of digital pathology:

─ ‘Hook’ your digital Pathology plans to your PACS

It is likely that early workflows will leverage other specialties, BUT these will inevitably be transient solutions with the “real” Digital Pathology workflow to follow

─ Pathology dept specific workflow solutions are needed and must have digital path imaging as part of the workflow now.

Questions?Questions?