Political and Strategic Political and Strategic Aspects of Employing Aspects of Employing

Digital Pathology in Digital Pathology in Pathology DepartmentsPathology Departments

John D. Pfeifer, MD, PhDJohn D. Pfeifer, MD, PhDVice Chair for Clinical Affairs, Department of PathologyVice Chair for Clinical Affairs, Department of Pathology

Washington University School of MedicineWashington University School of Medicine

no conflicts of interest to declareno conflicts of interest to declare

objectives of this sessionobjectives of this session

• • Describe how a “value added” approach is being Describe how a “value added” approach is being used to integrate WSI into routine surgical used to integrate WSI into routine surgical pathology workflowspathology workflows

• • Describe the political issues that must be Describe the political issues that must be addressed when integrating WSI into routine addressed when integrating WSI into routine workflowsworkflows

• • Describe the financial issues that must be Describe the financial issues that must be considered when integrating WSI into routine considered when integrating WSI into routine workflows workflows

perspective for this talk:perspective for this talk: practice environmentpractice environment

Academic tertiary care medical centerAcademic tertiary care medical center

Academic departmentAcademic department

High volume of high complexity casesHigh volume of high complexity cases

Large number of surgical pathologistsLarge number of surgical pathologists

Large number of consult casesLarge number of consult cases

More than one signout area; more than More than one signout area; more than one frozen section areaone frozen section area

Large number of traineesLarge number of trainees

characteristics of a WSI system characteristics of a WSI system with clinical utilitywith clinical utility

Operational: easy to useOperational: easy to use

Low cost: direct costs (hardware and Low cost: direct costs (hardware and software) and indirect costs (support software) and indirect costs (support personnel)personnel)

Value addedValue added

our approach has been to focus on our approach has been to focus on the “value added” componentthe “value added” component

““value added” is defined broadly by operational value added” is defined broadly by operational measures (CTA)measures (CTA)

CostCost TimeTime AccuracyAccuracy

““value added” can apply tovalue added” can apply to Patient care Patient care Educational activitiesEducational activities ResearchResearch

things that are not “value added”things that are not “value added” Mere capability of being able to do itMere capability of being able to do it Novelty factorNovelty factor

digital signout digital signout is notis not “value “value added” in our patient care added” in our patient care

activitiesactivities

We are a high volume practiceWe are a high volume practice

We already have the glass slidesWe already have the glass slides

We have a subspecialty emphasis We have a subspecialty emphasis practice modelpractice model

we have this…we have this…

and this…and this…

WSI adds timeWSI adds time

20X scan 20X scan Enter histology and print label = 2 minutesEnter histology and print label = 2 minutesLabel slide with barcode = 1 minuteLabel slide with barcode = 1 minutePrep slide for scanning = 1 minutePrep slide for scanning = 1 minuteScan slide = 6 minutesScan slide = 6 minutesVerify slide information in CoPath = 4 minutesVerify slide information in CoPath = 4 minutesTotal = 14 minutes per slideTotal = 14 minutes per slide

  After the slides are scannedAfter the slides are scanned

Un-assign and delete bad scansUn-assign and delete bad scansOpen case in CoPath and Spectrum to assure Open case in CoPath and Spectrum to assure correct patient information has been transferred andcorrect patient information has been transferred andslides are associated with the correct caseslides are associated with the correct caseAssign/Resend slides that did not automatically crossAssign/Resend slides that did not automatically crossTotal = 4 minutes per caseTotal = 4 minutes per case

WSI costs moneyWSI costs money

Process 200,000 blocks per year (about 800 blocks per Process 200,000 blocks per year (about 800 blocks per day) and produce at least 380,000 slides per year (about day) and produce at least 380,000 slides per year (about 1,500 slides per day), not including consultation slides1,500 slides per day), not including consultation slides

In 2009 we scanned 9,454 slides (<3% of slides), for In 2009 we scanned 9,454 slides (<3% of slides), for which we needed one scanner (30% max utilization), which we needed one scanner (30% max utilization), one digital imaging technician (<30% utilization), and one one digital imaging technician (<30% utilization), and one IT support person (<30% utilization)IT support person (<30% utilization)

To scan all slides would add an additional initial direct To scan all slides would add an additional initial direct cost of +/- $2M (hardware and software), yearly direct cost of +/- $2M (hardware and software), yearly direct cost of +/- $10K (memory), and yearly indirect cost of cost of +/- $10K (memory), and yearly indirect cost of

+/- $650K (personnel)+/- $650K (personnel)

things that things that areare “value added” in “value added” in our patient care activitiesour patient care activities

Availability (don’t need to go to the slide file; don’t Availability (don’t need to go to the slide file; don’t need to request slides from outside institution need to request slides from outside institution again)again)Timeliness (get images in seconds)Timeliness (get images in seconds)Portability (can access images from anywhere in the Portability (can access images from anywhere in the medical center)medical center)Permanence (save image of slide that will be Permanence (save image of slide that will be destroyed during ancillary testing, or sent to an destroyed during ancillary testing, or sent to an outside institution)outside institution)Production of a substrate for digital image analysisProduction of a substrate for digital image analysis

““value added” applications we value added” applications we have identified in patient carehave identified in patient care

WSI of selected slides from cases sent WSI of selected slides from cases sent to us in consultationto us in consultation

Directly enhances patient care through the availability, Directly enhances patient care through the availability, portability, and permanence of the images for patient portability, and permanence of the images for patient care conferencescare conferences

Provides a QA functionProvides a QA function

WSI of slides that will be destroyed by WSI of slides that will be destroyed by ancillary testingancillary testingWSI of slides that will be sent outWSI of slides that will be sent outWSI of legal casesWSI of legal casesWSI of cases for digital image analysisWSI of cases for digital image analysis

to capture the “value added” in patient to capture the “value added” in patient care, we needed to develop an interface care, we needed to develop an interface between the imaging software and our between the imaging software and our

LIS because…LIS because…

Our surgical pathology faculty is Our surgical pathology faculty is comprised of 35 lone wolves, andcomprised of 35 lone wolves, and

The lone wolves are not all equally tech The lone wolves are not all equally tech savvy, andsavvy, and

It turns out that you can’t teach old It turns out that you can’t teach old lone wolves new trickslone wolves new tricks

more generally…more generally…

Multiple users with different interest and abilityMultiple users with different interest and ability Attendings (about 30)Attendings (about 30) Residents (about 40)Residents (about 40) Fellows (about 20, from ten different programs)Fellows (about 20, from ten different programs)

Multiple sitesMultiple sites OfficeOffice HomeHome RoadRoad

There is only one opportunity to make a first There is only one opportunity to make a first impressionimpression

our solution…our solution…

One Stop ShoppingOne Stop Shopping

costs for “One Stop Shopping” costs for “One Stop Shopping” functionalityfunctionality

TimeTime Architecture (9 months)Architecture (9 months) Implementation (2 months)Implementation (2 months)

MoneyMoney Aperio Interface ($15K)Aperio Interface ($15K) CoPath HL7 Interface ($12K)CoPath HL7 Interface ($12K) Advanced Bar Coding &Tracking (AB&T) Advanced Bar Coding &Tracking (AB&T)

module for CoPath ($45K)module for CoPath ($45K)

outcome of our “value added” outcome of our “value added” approach to WSI over the last approach to WSI over the last

three yearsthree yearsGrowthGrowth 2008: 4,457 scans from 2,749 I/O cases2008: 4,457 scans from 2,749 I/O cases 2009: 9,454 scans from 7,541 I/O cases2009: 9,454 scans from 7,541 I/O cases 2010 (projected): 12,000 scans from 11,000 I/O cases2010 (projected): 12,000 scans from 11,000 I/O cases

Faculty AcceptanceFaculty Acceptance Interest in implementation on laptops and iPadInterest in implementation on laptops and iPad Interest in inclusion of in-house casesInterest in inclusion of in-house cases

Extension of “One Stop Shopping” model Extension of “One Stop Shopping” model to educational and research applicationsto educational and research applications

““value added” application of WSI value added” application of WSI under development: under development:

telepathology for brandingtelepathology for branding

Provides subspecialty expertiseProvides subspecialty expertise

Addresses needs of small rural hospitals Addresses needs of small rural hospitals with limited case volumeswith limited case volumes

Supports educational goals (source of Supports educational goals (source of teaching material for residents and teaching material for residents and fellows)fellows)

Supports faculty development (enhances Supports faculty development (enhances their regional and national reputation)their regional and national reputation)

Provides a new revenue streamProvides a new revenue stream

one primary impediment limits capture one primary impediment limits capture of the “value added” of WSI for of the “value added” of WSI for

telepathology for brandingtelepathology for branding

other impediments that limit capture other impediments that limit capture of the “value added” of WSI for of the “value added” of WSI for

telepathology for brandingtelepathology for branding

UPS Next Day AirUPS Next Day AirUSPS Express Mail Overnight GuaranteedUSPS Express Mail Overnight GuaranteedCost to referring institutionCost to referring institution

>$150 for scanner (plus personnel costs)>$150 for scanner (plus personnel costs) Overnight shipping cost for 100 slides and blocks per day is Overnight shipping cost for 100 slides and blocks per day is

<$4K per year (about 40 years to recover investment) <$4K per year (about 40 years to recover investment)

Lack of software interfaces to support billing and Lack of software interfaces to support billing and reporting for Wash U as primary providerreporting for Wash U as primary provider

collaboratorscollaborators

Washington University Department of PathologyWashington University Department of Pathology Mike IsaacsMike Isaacs Emily BrophyEmily Brophy Walter ClermontWalter Clermont the IT gangthe IT gang

Barnes Jewish HospitalBarnes Jewish Hospital Joan RossiJoan Rossi Kevin SelleKevin Selle