Digital ImagingBehind the Scenes

Stacey Yates

•Implemented Workflow

•Challenges/Solutions

•Added Value

•Future Plans

Overview

Telepathology

Trestle robotic microscope installed for across-campus frozen section consults

Problems:▫Too Cumbersome for everyday use▫Scanning too slow for real-time review

Approximately 1 minute per slide▫Scan not retained from slide to slide

Where are we coming from?

Needs:▫Capability to view multiple slides at once

from anywhere▫Quickly and easily find images to be used

for teaching and research▫Ability to reference images from past cases

without waiting for requested slides.▫Enhance the learning experience for

trainees.

TelepathologyWhere are we coming from?

Starting the Process

• Digital Imaging Committee▫ Pathologists, Residents and

IT Staff

• Evaluated multiple scanners and database management packages

• Important Requirements:▫ Simple Database Management▫ Ease of Use▫ Speed and Quality of images

Equipment/

Infrastructure

Aperio ScanScope

• ScanScope XT: 120 slide capacity.

• All clinical scanning• 20x and 40x Magnification

BioImagene

• iScan

• 20X

• 160 slide capacity

• Currently research only

• Not linked to clinical image database

Storage

• Dell MD3000 PowerVault▫15 - 300gb Harddrives

• Dell MD1000 PowerVault▫15 – 300gb HarddrivesTotal Clinical Image Storage = 7.5 Terabyte

• Dell PowerEdge 2970▫Runs server software and services

• Dell PowerVault TL2000▫Backup Tape Library

Network

gigabyte

100 mb

100 m

b

100 mb

100 mb

3 blocks apart

Lets Get Started….

•Scanned only research and conference slides

•Became comfortable with the scanner and database

•Began instructing users on how to use Spectrum

•Small group of “Power Users” utilized Spectrum for conferences

February 2008

Oops!

• Problems found:▫Scanning process long and tedious

▫Manually entering patient/case information into

Image Database from LIS

▫Equipment Downtime and Storage Space

▫Learning curve for finding images Residents embraced the technology Pathologists did not want to use two separate

systems

▫ Image interface not good for educational purposes.

•The Plan:▫Group and individual training sessions

•The Result:▫Confusion▫Lack of interest

•Solution: ▫Viewing images directly from LIS

Learning CurveYou want me to do what?

Scanning ProcessMarriage of the LIS and Image Database

Before the marriage could take place Barcoding had to be implemented.

Barcode contains:Inside Accession #Block #Slide #

1. Histology is entered to create a label with barcode for each slide.

2. The barcode is temporarily attached to the slide.

Scanning ProcessMarriage of the LIS and Image Database

3. Each slide must be cleaned and free from dust and fingerprints

4. Once the slides are loaded a snapshot is taken of each of the slides.

Area of Interes

t

Scanning ProcessMarriage of the LIS and Image Database

5. Once the image is scanned an HL7 message is sent to our LIS containing the link to the image on the server and the barcode id.

6. The LIS then sends a message back to the Image database with identifying information:

▫ Medical Record Number▫ Patient Name▫ Birth date▫ Hospital▫ Part Type▫ Accession Number▫ Stain

Scanning ProcessMarriage of the LIS and Image Database

7. Image Database uses the information to file the slide under a new patient or attaches it to an already existing patient.

▫ The MRN number, patient name, date of birth and hospital must match.

8. Each slide is reviewed for quality, the label is removed and sent back for filing or returned to referring institution.

9. Verify each slide is linked to LIS and the information sent to Spectrum is correct.

Scanning ProcessMarriage of the LIS and Image

Database

Slides Received

Case Signed Out

Diagnostic Slides Selected

Barcode Printed

Slides Scanned

Slides Returned to Referring Institution

Slides Reviewed

Scanning ProcessThe Workflow

Timeline: Start to Finish

• 20X ▫ Label Slide with barcode = 1 minute▫ Prep slide for scanning = 1 minute▫ Scan slide = 6 minutes

Total = 8 minutes per slide• 40X

▫ Label Slide with barcode = 1 minute▫ Prep slide for scanning = 1 minute▫ Scan slide = 33 minutes

Total = 35 minutes per slide

• Most scans are between 500,000 mb and 1 gb• Turn around time usually 48 hours

Scanning Process

▫LIS integration increased productivity and took away some of the manual data entry

▫Ensured slides where filed with the correct patient information

▫Pathologists only used one program to access slides

▫Over 12,000 digital images linked to LIS

Problems Solved by LIS Integration

Learning CurveViewing Images through LIS

Learning CurveViewing Images through LIS

Equipment Downtime

•Over the past 2 years▫5 days of complete scanner downtime▫6 days of manual scanning due to scanner

hardware malfunction▫2 -3 days to catch up after downtime

•Back-up Plan?▫Bring 2nd Scanner on line

Image Storage

•April 2010▫Original 7.5 tb full▫18,078 images

•Today▫Added 25 tb ▫Currently 23,663 images

•Will we need more storage?

Education

▫Faculty can create sets of digital images▫Used as teaching tool for residents and

fellows

Study Sets

▫Quizzes are created to evaluate progress

EducationQuiz

▫Weekly case is presented▫Trainee’s get a chance to review▫Diagnosis is posted at the end of the week

EducationCase of the Week

Added Value

•Availability: immediate access to images for increased efficiency in patient care, education and research

•Permanent: no lost or broken slides•Portable: send images instead of slides for

consults, legal requests•Conferences: Ability to take images to

conferences instead of actual slides•Teaching: Create teaching sets and

quizzes using digital images

Future Challenges

•Viewing images remotely through Citrix▫Citrix will not work for viewing images

through LIS▫Citrix will allow the searching of the

Spectrum database and opening of images through Spectrum using ImageScope but is extremely slow

•Continue to build teaching sets to aid in the education of residents and students.▫Evaluate software to manage the educational

and clinical aspect of digital imaging

Future Challenges

•Currently requires one full-time position•Continue to build an image repository.•Image Analysis•Ability to search for images based on

diagnosis without opening each case in LIS

•De-identified searches for education and research purposes

Digital ImagingBehind the Scenes

Stacey Yates

Thank you!