Informatics and anatomic pathology: meeting challenges and charting the future

Improving American Healthcare Through "Clinical Lab 2.0": A Project Santa Fe Report

Project Santa Fe was established both to provide thought leadership and to help develop the evidence base for the valuation of clinical laboratory services in the next era of American healthcare. The participants in Project Santa Fe represent major regional health systems that can operationalize laboratory-driven innovations and test their valuation in diverse regional marketplaces in the United States. We provide recommendations from the inaugural March 2016 meeting of Project Santa Fe. Specifically, in the transition from volume-based to value-based health care, clinical laboratories are called upon to provide programmatic leadership in reducing total cost of care through optimization of time-to-diagnosis and time-to-effective therapeutics, optimization of care coordination, and programmatic support of wellness care, screening, and monitoring. This call to action is more than working with industry stakeholders on the basis of our expertise; it is providing leadership in creating the programs that accomplish these objectives. In so doing, clinical laboratories can be effectors in identifying patients at risk for escalation in care, closing gaps in care, and optimizing outcomes of health care innovation. We also hope that, through such activities, the evidence base will be created for the new value propositions of integrated laboratory networks. In the very simplest sense, this effort to create “Clinical Lab 2.0” will establish the impact of laboratory diagnostics on the full 100% spend in American healthcare, not just the 2.5% spend attributed to in vitro diagnostics. In so doing, our aim is to empower regional and local laboratories to thrive under new models of payment in the next era of American health care delivery.

Pathology Informatics Essentials for Residents: A Flexible Informatics Curriculum Linked to Accreditation Council for Graduate Medical Education Milestones (a secondary publication)

CONTEXT

Recognition of the importance of informatics to the practice of pathology has surged. Training residents in pathology informatics has been a daunting task for most residency programs in the United States because faculty often lacks experience and training resources. Nevertheless, developing resident competence in informatics is essential for the future of pathology as a specialty.

OBJECTIVE

To develop and deliver a pathology informatics curriculum and instructional framework that guides pathology residency programs in training residents in critical pathology informatics knowledge and skills, and meets Accreditation Council for Graduate Medical Education Informatics Milestones.

DESIGN

The College of American Pathologists, Association of Pathology Chairs, and Association for Pathology Informatics formed a partnership and expert work group to identify critical pathology informatics training outcomes and to create a highly adaptable curriculum and instructional approach, supported by a multiyear change management strategy.

RESULTS

Pathology Informatics Essentials for Residents (PIER) is a rigorous approach for educating all pathology residents in important pathology informatics knowledge and skills. PIER includes an instructional resource guide and toolkit for incorporating informatics training into residency programs that vary in needs, size, settings, and resources. PIER is available at http://www.apcprods.org/PIER (accessed April 6, 2016).

CONCLUSIONS

PIER is an important contribution to informatics training in pathology residency programs. PIER introduces pathology trainees to broadly useful informatics concepts and tools that are relevant to practice. PIER provides residency program directors with a means to implement a standardized informatics training curriculum, to adapt the approach to local program needs, and to evaluate resident performance and progress over time.

Pathology Informatics Essentials for Residents: A Flexible Informatics Curriculum Linked to Accreditation Council for Graduate Medical Education Milestones

CONTEXT

-Recognition of the importance of informatics to the practice of pathology has surged. Training residents in pathology informatics has been a daunting task for most residency programs in the United States because faculty often lacks experience and training resources. Nevertheless, developing resident competence in informatics is essential for the future of pathology as a specialty.

OBJECTIVE

-To develop and deliver a pathology informatics curriculum and instructional framework that guides pathology residency programs in training residents in critical pathology informatics knowledge and skills, and meets Accreditation Council for Graduate Medical Education Informatics Milestones.

DESIGN

-The College of American Pathologists, Association of Pathology Chairs, and Association for Pathology Informatics formed a partnership and expert work group to identify critical pathology informatics training outcomes and to create a highly adaptable curriculum and instructional approach, supported by a multiyear change management strategy.

RESULTS

-Pathology Informatics Essentials for Residents (PIER) is a rigorous approach for educating all pathology residents in important pathology informatics knowledge and skills. PIER includes an instructional resource guide and toolkit for incorporating informatics training into residency programs that vary in needs, size, settings, and resources. PIER is available at http://www.apcprods.org/PIER (accessed April 6, 2016).

CONCLUSIONS

-PIER is an important contribution to informatics training in pathology residency programs. PIER introduces pathology trainees to broadly useful informatics concepts and tools that are relevant to practice. PIER provides residency program directors with a means to implement a standardized informatics training curriculum, to adapt the approach to local program needs, and to evaluate resident performance and progress over time.

Pathology Informatics Essentials for Residents: A flexible informatics curriculum linked to Accreditation Council for Graduate Medical Education milestones

Context:

Recognition of the importance of informatics to the practice of pathology has surged. Training residents in pathology informatics have been a daunting task for most residency programs in the United States because faculty often lacks experience and training resources. Nevertheless, developing resident competence in informatics is essential for the future of pathology as a specialty.

Objective:

The objective of the study is to develop and deliver a pathology informatics curriculum and instructional framework that guides pathology residency programs in training residents in critical pathology informatics knowledge and skills and meets Accreditation Council for Graduate Medical Education Informatics Milestones.

Design:

The College of American Pathologists, Association of Pathology Chairs, and Association for Pathology Informatics formed a partnership and expert work group to identify critical pathology informatics training outcomes and to create a highly adaptable curriculum and instructional approach, supported by a multiyear change management strategy.

Results:

Pathology Informatics Essentials for Residents (PIER) is a rigorous approach for educating all pathology residents in important pathology informatics knowledge and skills. PIER includes an instructional resource guide and toolkit for incorporating informatics training into residency programs that vary in needs, size, settings, and resources. PIER is available at http://www.apcprods.org/PIER (accessed April 6, 2016).

Conclusions:

PIER is an important contribution to informatics training in pathology residency programs. PIER introduces pathology trainees to broadly useful informatics concepts and tools that are relevant to practice. PIER provides residency program directors with a means to implement a standardized informatics training curriculum, to adapt the approach to local program needs, and to evaluate resident performance and progress over time.

Customizing Laboratory Information Systems: Closing the Functionality Gap

Highly customizable laboratory information systems help to address great variations in laboratory workflows, typical in Pathology. Often, however, built-in customization tools are not sufficient to add all of the desired functionality and improve systems interoperability. Emerging technologies and advances in medicine often create a void in functionality that we call a functionality gap. These gaps have distinct characteristics—a persuasive need to change the way a pathology group operates, the general availability of technology to address the missing functionality, the absence of this technology from your laboratory information system, and inability of built-in customization tools to address it. We emphasize the pervasive nature of these gaps, the role of pathology informatics in closing them, and suggest methods on how to achieve that. We found that a large number of the papers in the Journal of Pathology Informatics are concerned with these functionality gaps, and an even larger proportion of electronic posters and abstracts presented at the Pathology Informatics Summit conference each year deal directly with these unmet needs in pathology practice. A rapid, continuous, and sustainable approach to closing these gaps is critical for Pathology to provide the highest quality of care, adopt new technologies, and meet regulatory and financial challenges. The key element of successfully addressing functionality gaps is gap ownership—the ability to control the entire pathology information infrastructure with access to complementary systems and components. In addition, software developers with detailed domain expertise, equipped with right tools and methodology can effectively address these needs as they emerge.

Pathologists as Stewards of Laboratory Information

Just as electronic health records are transforming the practice of medicine and health care information management, practicing in the era of the electronic health record offers opportunities, if not imperatives, for pathologists to take on new and “transformative” professional and leadership roles for the organizations they serve. Experience indicates that clinicians will perceive pathologists and laboratories as responsible for all aspects of laboratory testing and information management, including order entry and results reporting, even though such functions may fall beyond the control of the laboratory. As described and expanded upon in the previous 4 articles of this series, the use of electronic health records dictates changes in how clinicians interact with laboratory information. In this environment, pathologists are uniquely positioned to act as the stewards for laboratory information in electronic health records and throughout health care organizations.

Pathology training in informatics: evolving to meet a growing need

CONTEXT

The mechanics of the practice of medicine in general and of pathology in particular is evolving rapidly with the rise in the use of electronic information systems for managing the care of individual patients, including the ordering and reporting of laboratory tests, maintaining the health of served populations, and documenting the full range of health care activities. Pathologists currently in practice and those in training need to acquire additional skills in informatics to be prepared to maintain a central role in patient care.

OBJECTIVE

To summarize the evolving landscape of pathology informatics, with particular attention to the preparation of pathologists for this discipline and to the possible influence of the new subspecialty certification in clinical informatics.

DATA SOURCES

Most of the information discussed is drawn from the authors' direct experience with informatics, resident and fellow education, and the organizations supporting these activities in pathology.

CONCLUSIONS

The increasing reliance of medical practice on electronic health records and other clinical information systems is creating a greater need for physicians skilled in the use and management of these tools. The establishment of clinical informatics as a formal subspecialty in medicine will likely help secure a role for physicians within information management structures at health care institutions. Pathologists must actively engage in informatics to assure that our specialty is appropriately recognized and represented in this growing discipline.

Automated whole slide imaging

BACKGROUND

Automated high-speed, high-resolution whole slide image (WSI) technology is being rapidly adopted in pathology owing to increased speed of computing, rapid networking, and high image quality and potential to reduce the overall turnaround time required for slide assessment. Method/objectives: This review presents the structure, functioning and performance of some of the WSI systems available in the market and highlights a few validation studies that have been performed to assess the overall utility of WSI systems.

CONCLUSION

The automated WSI is a robotic microscope that digitizes the entire slide field by field and uses software to merge or stitch individual fields into a composite image. Commercially available systems provide many improved functions that are useful for editing the digital images and improving the image quality.

A decade of experience in the development and implementation of tissue banking informatics tools for intra and inter-institutional translational research

Context:

Tissue banking informatics deals with standardized annotation, collection and storage of biospecimens that can further be shared by researchers. Over the last decade, the Department of Biomedical Informatics (DBMI) at the University of Pittsburgh has developed various tissue banking informatics tools to expedite translational medicine research. In this review, we describe the technical approach and capabilities of these models.

Design:

Clinical annotation of biospecimens requires data retrieval from various clinical information systems and the de-identification of the data by an honest broker. Based upon these requirements, DBMI, with its collaborators, has developed both Oracle-based organ-specific data marts and a more generic, model-driven architecture for biorepositories. The organ-specific models are developed utilizing Oracle 9.2.0.1 server tools and software applications and the model-driven architecture is implemented in a J2EE framework.

Result:

The organ-specific biorepositories implemented by DBMI include the Cooperative Prostate Cancer Tissue Resource (http://www.cpctr.info/), Pennsylvania Cancer Alliance Bioinformatics Consortium (http://pcabc.upmc.edu/main.cfm), EDRN Colorectal and Pancreatic Neoplasm Database (http://edrn.nci.nih.gov/) and Specialized Programs of Research Excellence (SPORE) Head and Neck Neoplasm Database (http://spores.nci.nih.gov/current/hn/index.htm). The model-based architecture is represented by the National Mesothelioma Virtual Bank (http://mesotissue.org/). These biorepositories provide thousands of well annotated biospecimens for the researchers that are searchable through query interfaces available via the Internet.

Conclusion:

These systems, developed and supported by our institute, serve to form a common platform for cancer research to accelerate progress in clinical and translational research. In addition, they provide a tangible infrastructure and resource for exposing research resources and biospecimen services in collaboration with the clinical anatomic pathology laboratory information system (APLIS) and the cancer registry information systems.

What hematopathology tells us about the future of pathology informatics

The field of hematopathology has been a leader in the application of new technologies for both diagnostics and therapy. The ready accessibility of blood cells for examination, the ability to quantify important indices, and the relative responsiveness of otherwise fatal hematologic diseases to chemotherapy have all contributed to rapid advances in the field. Hematopathology provides many insights into the challenges that pathology informatics will face in addressing the needs of a growing and aging population in the era of personalized medicine.

Medical laboratory informatics

Laboratory informatics is the application of computers and information systems to information management in the pathology laboratory. Effective information management is crucial to the success of pathologists and laboratorians. Informatics has become one of the key pillars of pathology, and the requirement for skilled informaticists in the laboratory has quickly grown. This article provides a wide-ranging review of pertinent aspects of laboratory informatics, and deals with important technical and management processes. Topics covered include personal computing, networks, databases, fundamentals and advanced functions of the laboratory information system, interfaces and standards, digital imaging, coding, hospital information systems and electronic medical records.

Adequacy of pathology resident training for employment: a survey report from the Future of Pathology Task Group

CONTEXT

The recent change in accreditation requirements for anatomic pathology and clinical pathology residency training from 5 to 4 years and the rapid advances in technologies for pathology services have sparked a renewed debate over the adequacy of pathology residency training. In particular, perceived deficiencies in training have been declared from a variety of sources, both in the form of recent editorial opinions and from surveys of community hospital pathologist employers in 1998, 2003, and 2005 by Dr Richard Horowitz.

OBJECTIVE

To obtain more comprehensive data on the perceptions of strengths and weaknesses in pathology residency training.

DESIGN

The College of American Pathologists conducted a survey of potential pathology employers (senior College of American Pathologists members, members designated as head of group, and members of the Association of Directors of Anatomic and Surgical Pathology). Also surveyed were recent graduates of pathology residency programs, who were identified as being junior members of the College of American Pathologists, were recent recipients of certification from the American Board of Pathology, or were contacted through their directors of pathology residency programs.

RESULTS

There were 559 employer respondents, of whom 384 were responsible for hiring and/or supervising new pathologists. There were 247 recent graduates of pathology residency training programs who responded. From the employers' standpoint, the majority expressed overall satisfaction with recent graduates, but almost one third of employers indicated that new hires had a major deficiency in a critical area. Specific areas of deficiency were clinical laboratory management and judgment in ordering special stains and studies. In addition, one half of employers agreed that more guidance and support for newly trained pathologists is needed now than was required 10 years ago. Academic employers generally were more satisfied than private sector employers. Newly trained pathologists did not appear to be inappropriately overconfident in their abilities. In addition, their perceptions of those specific areas in which they are most and least prepared are very similar to the ratings provided by employers. On average, newly trained pathologists' ratings of their own preparedness are highest for specific aspects of general pathology and anatomic pathology, and lowest for specific aspects of clinical pathology and administration. In selecting new pathologists, employers perceived medical knowledge and interpersonal skills as the most important discriminating applicant characteristics. When new employees were asked why they thought they were offered their position, the discriminating qualifications cited most often were academic background and training, as well as completion of a fellowship and subspecialty training.

CONCLUSIONS

It is our hope that the results of this survey can be used as input for further discussions and recommendations for training of pathology residents so as to further advance the ability of pathologists to provide quality patient care upon their graduation from training.

Evidence-based interpretation of liver biopsies

'Evidence based medicine' is a paradigm introduced in the 1990s in which collection of clinical data in a reproducible and unbiased way is intended to guide clinical decision-making. This paradigm has been promulgated across the spectrum of medicine, but with more limited critical analysis in the realm of pathology. The 'evidence base' in support of our practices in Anatomic Pathology is a critical issue, given the key role that such diagnoses play in patient management decisions. The question is, 'On what basis are diagnostic opinions rendered in Anatomic Pathology?' The operative question becomes, 'What is the published literature that supports our anatomic pathology interpretations?' This second question was applied to the published literature in Hepatopathology, by identifying the 'citation classics' of this discipline. Specifically, the top 150 most-cited liver pathology articles were analyzed for: authorship; journal of publication; type of publication; and year of publication. Results are as follows. First, it is indeed true that the preeminent hepatopathologists of the age are the most cited authors in the 'top 150'. Second, the most cited articles in hepatopathology are not published in the pathology literature, but are instead published in much higher impact clinical journals. Third, the pathology of viral hepatitis is demonstrated to be extraordinarily well-grounded in 'evidence based medicine'. Much of the remainder of the hepatopathology literature falls into a 'narrative based' paradigm, which is the rigorous reporting of case experience without statistical clinical outcomes validation. Finally, the years of publication reflect, on the one hand, a vigorous recent literature in the pharmaceutical treatment of viral hepatitis, and on the other, a broadly distributed set of 'narrative' articles from the 1960s, 1970s, 1980s, and 1990s. In conclusion, the discipline of hepatopathology appears to be well-grounded in 'evidence based medicine' in the realm of viral hepatitis. The remainder of our discipline rests predominantly upon the time-honored identification of disease process through the publication of narrative case series.

Pathology and patient safety: the critical role of pathology informatics in error reduction and quality initiatives

Understanding the role of pathology informatics in patient safety entails an introduction to terminology and projects that have represented efforts to date in this area. The authors provide a short alphabetized introduction to several "buzzwords" and terms related to tools and processes that are used by health care research experts and workers involved in patient safety initiatives. The authors also include short descriptions of key health care research and patient safety projects that are relevant to pathology. They aim to highlight the areas where pathology informatics in all of its flavors (production systems provided by vendors as well as research and development efforts) can play a role in promoting patient safety.

Informatics training in pathology residency programs: proposed learning objectives and skill sets for the new millennium

CONTEXT

To be successful in tomorrow's health care environment, to make the most appropriate decisions for their laboratories, to optimize training and continuing medical education opportunities, and to advance pathology as a professional specialty, pathologists must possess basic informatics knowledge and proficiency. Traditional areas of anatomic and clinical pathology residency training employ learning objectives, knowledge expectations, and skill sets, but such items have not been as well developed or widely implemented for pathology informatics training.

OBJECTIVE

We present a proposal that defines a standard and specific set of learning (knowledge) objectives and skill set (proficiency) expectations for resident training in pathology informatics.

DESIGN

The proposal includes a comprehensive and detailed set of knowledge applications and proficiencies that will assist residency programs in developing basic pathology informatics training for residents. The content of the proposal is based on and compiled from existing successful pathology informatics training programs. Learning objectives include those related to general and enterprise computing as well as objectives related specifically to pathology informatics. Skill set expectations include the ability to use software that facilitates and adds value to the work of pathologists, including the use of a laboratory information system and of productivity software and other tools. Other topics include guidelines for evaluating residents' informatics competency, suggestions regarding curriculum structure and implementation, and recommendations for residents' computing infrastructure.

CONCLUSION

This proposal provides a foundation for building effective and standard curricula for residency training in pathology informatics. These curricula will be able to meet increasing expectations and needs for pathologists to contribute to clinical information management.

Training in pathology informatics: implementation at the University of Pittsburgh

CONTEXT

Pathology informatics is generally recognized as an important component of pathology training, but the scope, form, and goals of informatics training vary substantially between pathology residency programs. The Training and Education Committee of the Association for Pathology Informatics (API TEC) has developed a standard set of knowledge and skills objectives that are recommended for inclusion in pathology informatics training and may serve to standardize and formalize training programs in this area.

OBJECTIVE

The University of Pittsburgh (Pittsburgh, Pa) core rotation in pathology informatics includes most of these goals and is offered as an implementation model for pathology informatics training.

DESIGN

The core rotation in pathology informatics is a 3-week, full-time rotation including didactic sessions and hands-on laboratories. Topics include general desktop computing and the Internet, but the primary focus of the rotation is vocabulary and concepts related to enterprise and pathology information systems, pathology practice, and research. The total contact time is 63 hours, and a total of 19 faculty and staff contribute. Pretests and posttests are given at the start and end of the rotation. Performance and course evaluation data were collected for 3 years (a total of 21 residents).

RESULTS

The rotation implements 84% of the knowledge objectives and 94% of the skills objectives recommended by the API TEC. Residents scored an average of about 20% on the pretest and about 70% on the posttest for an average increase during the course of 50%. Posttest scores did not correlate with pretest scores or self-assessed computer skill level. The size of the pretest/posttest difference correlated negatively with the pretest scores and self-assessed computing skill level.

CONCLUSIONS

Pretest scores were generally low regardless of whether residents were familiar with desktop computing and productivity applications, indicating that even residents who are computer "savvy" have limited knowledge of pathology informatics topics. Posttest scores showed that all residents' knowledge increased substantially during the course and that residents who were computing novices were not disadvantaged. In fact, novices tended to have higher pretest/posttest differences, indicating that the rotation effectively supported initially less knowledgeable residents in "catching up" to their peers and achieving an appropriate competency level. This rotation provides a formal training model that implements the API TEC recommendations with demonstrated success.

Informatics training in pathology residency programs

Information management is crucial in pathology, and previous reports have stressed the needfor improved informatics training in pathology residency programs. We surveyed 150 US programs to assess informatics training with respect to types of training, proficiency expectations, and computing infrastructure. Seventy-two programs (48.0%) responded. Of the respondents, 67 (93%) reported offering informatics training; of these, 52 (78%) required it. Most programs integrated informatics into another rotation, usually management. In 37 programs (55%), the amount of informatics training has increased during the last 3 to 5 years. The most common instructional methods were hands-on training and self-study; 61 programs (91%) used multiple methods. In all but 2 programs, computers were designated for residents; 9 programs offered individual computers to residents. All programs provided productivity software. These data suggest progress in informatics training but that considerable room for improvement exists. Our data also document for the first time detailed computing resources available to residents.

Digital storage of glass slides for quality assurance in histopathology and cytopathology

Proficiency testing programmes for measuring screening skills in pathology are mainly conducted using conventional glass microscope slides. However, the availability of robotic microscopes allows an entire conventional slide to be digitized. Our experiments have shown that, using a widely available robotized microscope and a PC, the image of a single field may be acquired in 2 s on average, including stage movements, autofocus and storage. Digitizing an entire slide, a fully automated procedure, takes up to 8 h. If the image of each field is compressed at an appropriate quality level (a compression ratio of, say, 35:1) it requires about 40 kByte to be stored, resulting in a total storage requirement of about 600 MByte per slide. Thus one CD-ROM can be used to store one virtual slide, as well as a self-installing program to provide a microscope simulator facility. This allows pathologists to examine the virtual case from their computer in a similar manner to looking at a glass slide on a conventional microscope. This permits a new, computer-based approach to proficiency testing in histopathology and cytopathology. Use of virtual slides should encourage the diffusion of national quality assurance programmes, which at present suffer from certain organizational and logistical limitations.