Extending Your ReachPathology in the Age of Digital ImagingExtending Your ReachPathology in the Age of Digital Imaging

Jared N. Schwartz, MD, PhD FCAPPresident, College of American Pathologists

Extending Your ReachPathology in the Age of Digital Imaging

• What can we learn from the Internet development story?

• What is happening in healthcare?• How will it impact pathology?• What drives innovation & adoption?• Threat or opportunity?

The Internet StoryThe Internet Story

“Victorian Internet”: Telegraph

• Used extensively by the U.S. Government during the American Civil War, 1861 - 1865

• Morse Code was dots and dashes, or short signals and long signals

• Electronic signal standard of +/- 15 v. is still used in network interface cards today

• Invented in the 1840s.• Signals sent over wires

established over vast distances

More than 100 years later, the Internet is born

1968: DARPA (Defense Advanced Research Projects Agency) contracts with BBN (Bolt, Beranek & Newman) to create ARPAnet (packet switching)

1972: First email sent

1974: Transmission Control Protocol (TCP) specification by Vint Cerf established

1984: Internet with its 1000 hosts converts en masse to using TCP/IP for its messaging

1989: Tim Bemers-Lee creates the World Wide Web

2004: Web reaches 1 billion users

1969: UCLA to Stanford

“Do you see the L?”

“Yes, we see the L,” came the response.

“We typed the O, and we asked, “Do you see the O?”

“Yes, we see the O.”

“Then we typed the G, and the system crashed…”

Yet a revolution had begun

Dr. Leonard Kleinrock, UCLA

The Internet solved several challenges

• Basically inventing digital networking as we know it

• Survivability of an infrastructure to send and receive high-speed electronic messages

• Reliability of computer messaging

To get a market of 50 million people participating…

• Radio took 38 years

• TV took 13 years

• Once it was open to the general public, the Internet reached the mark in just 4 years!!!

* Delivered to the President and the U.S. Public on April 15, 1998 by Bill Daley, Secretary of Commerce and Chairman of the Information Infrastructure Task Force

0 500 1,000 1,500 2,000 2,500 3,000 3,500 4,000

Oceania/Australia

Middle East

Africa

Latin America/Caribbean

North America

Europe

Asia

Population by Region Internet Users by Region

Internet Usage: June 2008

15.3%15.3%

21.3%21.3%

5.3%5.3%

24.1%24.1%

73.6%73.6%

48.1%48.1%

59.5%59.5%

World Average21.9%

Source: Internet World Stats: http://www.internetworldstats.com/stats.htmEstimated Internet users is 1,463,632,361 for Q2 2008Estimated World Population is 6,676,120,288 for mid-yr 2008Copy@2008, Miniwatts Marketing Group

…and they are mostly communicating in English

The Internet continues to change our lives

The Internet continues to change our lives

• New vocabulary and meanings for existing words (e.g., viruses and worms)– HTML: Hypertext Markup

Language– URL: Uniform Resource

Locator– Hyperlinks– WWW: World Wide Web– TCP: Transmission Control

Protocol– IP: Internet Protocol

• New ways to think about data and build information

• New ways to communicate and break language barriers

• New ways to work and work locations

• New challenges (e.g., security, spam, access)

Fascinating…

…but what does this have to do with pathology??

Our landscape is changingOur landscape is changing

Automation and roboticsAutomation and robotics Molecular TargetingMolecular Targeting

NanotechnologyNanotechnology

Personalized MedicinePersonalized Medicine

Technology is an accelerator…

BiomarkersBiomarkers

BioinformaticsBioinformatics

…but technology is not the only driver

Government regulations are inhibiting progress

• Applying arcane standards to new technologies

• Requiring more paperwork not less• Continuous battles over

government agency oversight responsibilities (CMS, FDA, and CDC)

• Inconsistent application of requirements; different standards of practice

• New roles for pathologists and others not recognized

Recent developments in the world economy will

only worsen the pressure on health care spending

Recent developments in the world economy will

only worsen the pressure on health care spending

…and most of the rest of the developed world is

experiencing a shortage of pathologists

Newfoundland–May 2008

India–Nov 2007

Australia–Jul 2008

Canada–May 2008

United Kingdom–Jan 2008

China–Mar 2007

Pathology must focus on expanding value

• Right patient• Right test• Accurate results• Reported on the right

patient

Quality care requires

quality testing

• Reported to the correct clinician in a way they can understand and brings value to the treatment plan

We are clinicians with a direct impact on patient care

Pathology

…so what’s it going to take?

…so what’s it going to take?

1680s: English Tripod Microscope

1595: 1st Compound Microscope

Mid-1700s: Cuff-style microscope; 1st to provide ease of use and accurate focusing mechanisms

It has taken us 500 years to get to this point!!

1998: State of the art contains accessories for DIC, fluorescence, polarized light, phase contrast, and photomicrography

1899: Ernst Leitz Compound Binocular Microscope

Pathologists need a bias for

action

Pathologists need a bias for

action

Necessity is the mother of all innovation…and adoption

• Reduce time from biopsy to diagnosis

• Increase productivity• Expand access to expertise

and special stains

Some will always see the glass as half full

• Slower than current microscopy• Adds a step to the process• Pathologists resist change• Has not been fully vetted in the

literature• Capital investment barrier is high• Operating costs may exceed current

practice• Lack of stands; non-interoperable

solutions• No integration with existing AP

systems

“Construct barriers to progress”

• Look to professional societies to impose certification standards

• Encourage professional societies to lobby for restrictive laws

• Rely on hospitals to reinforce institutional credentialing requirements

• Rely on insurance companies to enforce reimbursement only hospital-credentialed physician services

• Employ marketing techniques to raise public awareness of pathologists’ local contribution to health care

We’ve considered every potential risk, except the risk of avoiding all risks.

We’ve considered every potential risk, except the risk of avoiding all risks.

It’s just a matter of time40-sec

20x scan20-second

40x multi-angle scan

20-sec20x scan

Multispectral imaging

Ima

gin

g

Pathology PACS

Enterprise image management

100 PetabytesPetabytes100 Terabytes

Sto

rag

e

Subspecialistwork flow

triage

Rapidsecondary

consultations

Computer-aided detection

Computer-aided diagnosis

Ap

pli

ca

tio

ns

2007 2012 2017

* Source: Sg2 T3 Virtual Slide Imaging

There has never been a greater need for

pathology expertise and resources

It’s knocking!!!

Digital Imaging expands our tool kit and extends our reach

• Broaden practice statewide, regionally, internationally

• Extend expertise with CAD• Collaborate with peers; possibly increase

demand for 2nd opinions• Improve your value as the gatekeeper for

subspecialty expertise and for patient information, and integration of diagnostic data from any source

• Better serve patients

It’s time to bust out

…and maximize use of all tools available to us to assume new and expanded

roles

Our Vision

When it comes to the future, there are three kinds of people: those who let it happen, those

who make it happen, and those who wonder what happened.

~ John M. Richardson, Jr.