Picture Perfect: Imaging Strategies in Pathology

1. Picture Perfect: Imaging Strategies in Pathology Cerner Health Conference 2005 Orlando, FL October 9 – 12, 2005

2. Why Do Imaging in Pathology? • UPMC Perspective • Strengthen the reporting of results in anatomic pathology • Provide images for tumor boards and build libraries of images for teaching • Correlation between microscopic appearance, the clinical presentation, and gross specimen appearance • Image on reports as “A Marketing Tool”

3. Why Do Imaging in Pathology? • Cerner Perspective • Promotes a single, central point of data for each specimen • Temporary states such as tissues during gross can be recorded • Requisitions, diagrams, lab results, consult reports, plus other pertinent info are tied directly to AP data • Quicker access to pertinent microscopic information • No need to request retrieval from storage and re-locate area of interest on the slide • Images access from any enabled workstation can eliminate tedious slide or paperwork retrieval activities • Images are directed to permanent storage immediately, minimizing impact due to misfiling or misplacement • Images on reports are cool – our clients want cool reports!

4. Overview of our Plan • The 2001 Image Solution Project • Upgrade UPMC’s Imaging Solution to accommodate: • Better integration with AP system • Improve correlation of different phases of the specimen via image use • Enhance teaching curriculum via image use by keeping a file of all interesting cases • Enhance tumor board presentations exporting selected images into PowerPoint • Include images on patient reports

5. Challenges Associated with Imaging • Software-hardware compatibility • Gross and microscopic camera types • Scanner types • Workflow • EASE of use • Image storage • Local Area Network (LAN) support • Deployment and support of image capture workstations over the UPMC Health System • Inability of results interface (HL7) or archival systems to store and/or manage images

6. Meeting Challenges Head-on • Hardware/Software Compatibility • Assessment of current hardware • Grossing Stations • 5 existing Sony Video cameras at became go-forward hardware • Microscopic workstations • 11 Existing Sony Video cameras would be used • Added 12 Spot Insight digital camera workstations • Scanners • 3 Scanners used at transcription workstations • Worked with vendor to find new compatible cameras • Camera compatibility is on-going issue as technology changes

7. On-Going Technology Changes • Researching New Hardware and Compatibilities • Research cycle generally follows Bill’s release cycle • Workstation hardware, OS, and acquisition devices all need to work together • Steps undertaken: • Install PICSPlus on designated Test Environment workstation • Acquire new hardware/OS • Obtain loaner acquisition device of interest • Test, Test, and Test again! • Cost justification ever-present challenge • Staff is happy to get new toys!

8. Meeting Challenges Head On (continued) • Needs and Workflow • Demands from Grossing Bench • Easy… maintain current standards • Demands from the Pathologists • Specific requests for digital cameras in personal offices • New workflows investigated and implemented for scanning • requisitions • reports

9. Meeting Challenges Head On (continued) • Image Storage • Image capture predictions were way off • In actuality, approximately 2300 images are acquired per month • We check storage stats daily! • Expansion of storage space done • Local Area Network Configuration • 12 acquisition devices were added • Images are captured and viewed from 4 out of 9 different hospitals • Storage is on a single image server • Image Server Maintenance and Backups

10. Meeting Challenges Head On (continued) • Deployment throughout UPMC Health System • Deployment Plan • Since we had an existing solution, all workstations came on-line at same time • Educating the end-users • initial one-on-one training for Spot Insight and Scanner users • Continuous Education • High turnover in transcription; staff predominately takes on this training • Training is on-going for new residents and fellow • Image Acquisition “Go Live”

11. Meeting Challenges Head On (continued) • Supporting Imaging Workstations and Users • Support Needs • At the beginning, support requests predominately due to training issues • including my own education • Once things settled down, now I see • As cameras age, these issues increase; most cameras are 5 years old • White balance is most prevalent issue • found California vendor to refurbish cameras, effectively resetting camera’s standard default setting

12. Meeting Challenges Head On (continued) • Interfaces & Other Systems cannot handle Images • HL7 Result Interfaces are used to transmit results to hospital system • We do not transmit reports with imbedded images to other systems • Printing Reports with Images • Consulted with other sites using images on reports for Printer recommendations • Lexmark C910 Model • Our clients are very happy with image-enabled reports!

13. Advances in Imaging: Internet Ready Devices • Nikon COOLSCOPE: • Microscope with built-in digital camera: used for capturing and consultation over the network

14. Internet Ready Devices (continued) • Nikon DS-U1 PC based camera: • Observation, photography and networking are all possible with this single unit

15. Our Imaging Solution In Pathology • The PICSPlus Advantage: • Provides a solution for management of macroscopic and microscopic images and related case information • Images can be acquired using a wide variety of equipment: digital and video cameras and TWAIN compatible devices • Ability to import send-out report files, annotated diagrams and imported copies of requisitions

16. PICSPlus (v2.4) Use at UPMC • Server Scalability/Multiple servers available • 1 server, high acquisition rate that might change • PICSPlus Maintenance Module • Image Server and Acquisition Workstation Activity • Used quarterly to monitor usage • “Lost” Image detection tools • Nice to have, hoping I never have to use! • Selectable image quality for reports • Default quality setting works well for us • Updated Acquisition Module Implemented • Need for this dictated by hardware problem

17. Image Acquisition • Updated Acquisition Features Gained • Report linkages indicated in Gallery • Streamlined Matrox acquisition • Template definition per workstation

18. Image Acquisition • Acquisition of images through the image gallery manager window • Provides a simple key stroke to acquire images into the gallery • Ability to switch options, import from TWAIN, import from file or import from Matrox

19. Image Gallery Manager

20. Image Gallery Manager • PICSPlus Gallery Manager contains the following components: • File Menu – close manager and return to CoPathPlus • Edit Menu – delete selected image file(s) • Attachment Menu – import from file,export from file, import from Matrox, import from TWAIN • Option Menu – select default templates (PICSPlus Template Dictionary, gross image, microscopic image, etc.) and import action (import from File, TWAIN or Matrox) per workstation • Parameters – assigned to selected image file • Linked to Reports – indicates whether an image is included on any patient reports and the report status

21. Importing Reports

22. Importing Diagrams

23. Image View Manager • PICSPLus View Manager contains the following components: • Zoom controls – allows you to increase of decrease the size of the image in the viewer • Annotation feature – objects placed on images to focus on a specific area of interest • Copy to Clipboard – ability to copy the image with annotations to the Clipboard • Burn Annotations – allows you to PERMANENTLY apply the annotation to the image

24. PICSPlus Report Gallery No specific guidelines for acquisition volumes and report assignments

25. Images on Patient Report

26. Reporting Considerations • Report Manager Functionality • Report image gallery displays all the image(s) selected to be on the patient’s report • To transfer image(s) from the image gallery to the report gallery, click and drag! • Benefits and Cautions • Image(s) on reports is a very effective marketing and educational tool • Clinicians are warned that image(s) on reports are for reference purposes, not clinical diagnosis

27. Thank You Any Questions or Comments? We have Cerner experts in the audience to handle solution-specific questions

29. PICSPlus v2.5 Features • Preview of Coming • Attractions

30. PICSPlus General Features • 2 new activities streamline workflow and reduce window painting requirements: • PICSPlus Image Entry/Edit • PICSPlus Report Image Select

31. PICSPlus Image Entry/Edit

32. Updated Image Gallery

33. PICSPlus Report Image Select

34. PICSPlus Report Manager

35. Gallery Review Feature • Gallery Review functions cycle through slides in sequence as found in respective gallery • Image Gallery Review shows PICSPlus Gallery images • Report Gallery Review shows Report Gallery images • Use timed review or press spacebar to move • Display Setup configures: • Timer • Magnifier height, width, and shape • Times Magnification

36. Image Gallery Review with Setup Window

37. Image Gallery Review with Right-Click Menu

38. Image Gallery Review with Magnifier

39. PICSPlus View Manager Features • Redesigned Image Review and Annotation features: • Four tabs of data and tools in View Manager: Marks, Process, Color, and Info • Updated annotation tools • Orientation options to Flip and Mirror with degrees designated • Moving magnifier in maximized view & Gallery Review • Picture in Picture Mark, can use to add lab logo • Undo operations

40. View Manager:Marks Tab

41. View Manager:Process Tab

42. View Manager:Colors Tab set Blue

43. View Manager: Info Tab

44. Images on Signed Out Cases Image on Report Image not on Report • Image Annotations • NOT allowed if image on S/O report • Allowed if image NOT on S/O report

45. Tools and Utilities • New install is more “gentle” and straight-forward • when activating a PICSPlus Add-on in Wkstn Setup, the system tells you when to run Workstation Add-on Install • Nothing is assumed, add each desired component • JPEG-2000 compression schema recovers disk • Scheduled Background conversion • “Just in Time” conversion • Support of 26 major file formats for import • Previously just jpeg, tiff, and bmp were supported • Multi-page tiff images supported