1) Hospital General de Ciudad Real. Spain 2) Castilla-La Mancha Health Care Services (SESCAM) 3) University of Castilla

1. in the management and integration of virtual slides in PathologyMarcial García Rojo(1), Carlos Peces(2), Jose Sacristan(2), Gloria Bueno(3) 1) Hospital General de Ciudad Real. Spain 2) Castilla-La Mancha Health Care Services (SESCAM) 3) University of Castilla-La Mancha

2. Presentation objective • We describe our experience in the use of emerging IT standards in Pathology, including the integration of Virtual Slides in Pathology general workflow. • A regional project on digital pathology is presented • This digitalization effort has been of special benefit for second opinion (teleconsultation), continuing medical education, and quality assurance in Pathology.

3. _ _ _ _ _ _ GUADALAJARA STM-1 CUENCA STM-1 E3 Talavera TOLEDO STM-1 STM-1 ALBACETE CIUDAD REAL Infrastructures developmentSANITEL: Communication network BACKBONE inter-province communication network Gigabit Ethernet ring in province capitals 155 Mbps circuits ATM between TO & AB-CR-CU-GU

4. Hospital 1 Primary care centre 1 Primary care centre 2 Hospital 2 YKONOS. Population-based patient database search engine Images Central database

5. Standards in Pathology • Integration in Pathology Information Systems has not yet been achieved. • Standardization efforts are progressing to provide integration in healthcare information technology (IT) systems, such as: • CEN TC 251 (pr EN13606): electronic health record • HL7: messages • DICOM: images • IHE initiative (http://www.ihe.net/): How to use standards • Fist goal is to elaborate a document, the Pathology Technical Framework that identifies the workflow, the IHE actors (i.e. functional components, application roles), and shows the transactions between them.

6. IHE Definition • IHE is an initiative by healthcare professionals and industry to improve the way computer systems share healthcare information. • IHE promotes the coordinated use of established standards such as DICOM and HL7 to address specific clinical needs in support of optimal patient care. • Systems developed in accordance with IHE communicate with one another better, are easier to implement, and enable care providers to use information more effectively.

7. Sitios web relacionados • Integrating the Healthcare Enterprise – Europe: http://www.ihe-europe.org/ • IHE.net: http://www.ihe.net/(American College of Cardiology, Healthcare Information and Management Systems Society and the Radiological Society of North America) • IHE Technical Frameworks: http://www.ihe.net/Technical_Framework/index.cfm • IHE-UK: http://www.ihe-uk.org/ • IHE-France: http://www.gmsih.fr/tiki-index.php?page=IHE

8. The IHE Process (annually) • Identify Interoperability Problems • Specify Integration Profiles • Test Systems at the Connectathon • Publish Integration Statements for use in Request For Proposals (RFPs)

9. 2. Specify Integration Profiles • Experienced healthcare IT professionals identify relevant standards and define how to apply them to address the problems, documenting them in the form of IHE integration profiles. • Examples: Use of HL7 (ADT) to send a request of pathology study from the HIS to PIS, and how to retrieve pathology images using DICOM

10. IHE Pathology. An example of problems to deal with • Pathology images are in a digital format but often without any organization. Model for integration: IHE • A model in digital radiology (Scanner and magnetic resonance) DICOM • DICOM: Digital Imaging and Communications in Medicine, refers to a file header standard. • DICOM headers can “wrap” many commonly used image file types, including JPEG and TIFF • Can we apply DICOM standard in pathology? How this is done with virtual slides? WG26

11. IHE promotes standards:Advantages of DICOM • Organization: Central repository of medical images for all medical specialties: PACS • Integration with e-Health Record • One viewer for all medical images • Independence of • devices manufacturers • proprietary file formats

12. Actors in Pathology Information Framework • Actors: information systems or components of information systems that produce, manage, or act on information associated with operational activities in the enterprise. • Acquisition Modality – Acquires and creates medical images, e.g. a Computed Tomography scanner or Nuclear Medicine camera. A modality may also create other evidence objects such as Grayscale Softcopy Presentation States for the consistent viewing of images or Evidence Documents containing measurements. • Order Filler – A pathology department-based information system that provides functions related to the management of orders received from external systems or through the department system’s user interface. • Order Placer – A hospital or enterprise-wide system that generates orders for various departments and distributes those orders to the correct department, and manages state changes of those orders. • Image Archive – Provides long term storage of evidence objects such as images, presentation states, Key Image Notes and Evidence Documents. • Image Display – Offers browsing of patients’ studies. In addition, it may support the retrieval and display of selected evidence objects including sets of images, presentation states, Key Image Notes, and/or Evidence Documents.

13. Transactions in the Pathology Technical Framework • Transactions: Interactions between actors that transfer the required information through standards-based messages. • Filler Order Management – • Contains all the messages required between the Order Filler (PIS) and the Order Placer (HIS) for the notification of a new filler order, as well as the creation of the placer order that reflects it. • Ensure that each filler order will be represented by a placer order, and will have both a filler order number and a placer order number. • It can also be used for order modification or cancellation. • Modality Worklist Provided – • Based on a query entered at the Acquisition Modality, • Listing all the items that satisfy the query. • List of Scheduled Procedure Steps with selected demographic information and information about specimen is returned to the Acquisition Modality.

14. HL7: A common languaje • Messages between applications: • MSH|^~\&|APA||||20050714150127||ORM^O01|-11407200515012714|R|2.3|PID||1|1||MOD_NOMB^MOD_APE1^MOD_APE2||19410907000000|F|||^^^^||||||||||||||||||||PV1|||^|||^|||||||||||||0|||||||||||||||||||||||||||ORC|XO|-1|05B0000003||CM|||||||||||| • MSH|^~\&|APA||||20050714150134||ORU^R01|-11407200515013414|R|2.3|PID||1|1||MOD_NOMB^MOD_APE1^MOD_APE2||19410907000000|F|||^^^^||||||||||||||||||||PV1|||^|||^|||||||||||||0|||||||||||||||||||||||||||ORC|XO|-1|05C0000001||CM|||||0^DESCONOCIDO||10009^GOMEZ , ALICIA|||||OBR|1|-1|05C0000001|^^^^|||20050714145607||0|^^^|F|||20050714000000|^^^^^|10009^GOMEZ , ALICIA^^|||GI^GINECOLOGIA|||20050714145607|||F||0^^^^^^^^^|||||10002^GARCIA^F.^H.^^||||20050714145607|0||^^^^|OBX|1||73^MUESTRA^L^A^|0|CERVIX CT1|^^^^|||0||||||^^^^|^^^|^^^^|OBX|2||^MATERIAL REMITIDO^L^^|1|CITOLOGIAS/ RASPAT CV/ A) CERVIX CT1|^^^^|||0||||||^^^^|^^^|^^^^|OBX|3||^DATOS CLINICOS^L^^|2||^^^^|||0||||||^^^^|^^^|^^^^|OBX|4||^MACRO^L^^|2||^^^^|||0||||||^^^^|^^^|^^^^|OBX|5||^MICRO^L^^|2|A ) celulas vaginales normales|^^^^|||0||||||^^^^|^^^|^^^^|OBX|6||^MICRO^L^^|3| |^^^^|||0||||||^^^^|^^^|^^^^|OBX|7||^DIAGNOSTICO^L^^|4|A ) CITOLOGIA NORMAL|^^^^|||0||||||^^^^|^^^|^^^^|OBX|8||^DIAGNOSTICO^L^^|5| |^^^^|||0||||||^^^^|^^^|^^^^|OBX|9||T83000^SNOMED^L^^|6|CERVIX|^^^^|||0||||||^^^^|^^^|^^^^|OBX|10||M00120^SNOMED^L^^|7|CITOLOGIA NORMAL|^^^^|||0||||||^^^^|^^^|^^^^|

15. File format problems • PACS systems manage images which are DICOM-compliant. • DICOM files are limited in size to 2GB. • Most DICOM systems cannot manage TIFF files with a tiled organization, and/or TIFF files with JPEG or JPEG2000 compression. • For these reasons it is generally not possible to import Aperio SVS files directly into PACS.

16. Our project:Serendipia • Serendipity: The faculty of making fortunate discoveries by accident. • Knowledge transference opportunities are common, but the key driver in order that transference to take place (encouraging serendipity) are: • The need of the receptor organisation • Perspective by donor and receptor • Adequate resources in order transference to happen • However, concordance between donor and receptor is not easy and often, serendipity is a key factor in success. • Organizations must improve Serendipia probabilities, offering adequate resources and structures. • (British National Space Centre. 2004)

17. Telepathology HOSPITAL B HOSPITAL A Sender Second opinion

18. SERENDIPIA Project specific objectives • Pathology Information System (LIS) • Image management (including virtual slides) • Increasing automation in Pathology laboratory • Object identification: Code bar, RFID • Specific workstation for pathologists (high resolution: reports, washable: gross/autopsies) • Data entering (user interface) • Viewing images and text data • Communication interactive tools • Information searches • Knowledge management

19. Pathology workflow

20. Standards: IHE. Actors & Transactions

21. SESCAM integration design Virtual slide viewer Virtual slide server DICOM viewer Virtual slide repository Path report managing (LIS) App server J2EE Gross station Micro photo Autopsy room Virtual slide scanner

22. Storage needs • Hospital clinical workload: • Number of specimens per year: 5,000 to 40,000. • # slides per case: 5 • Not every case is digitized. Initially, only those requiring collaborative work or when they are of high scientific or teaching interest. • Range of size per slide: 0.5 – 4 GB • Medium size (40x), using JPEG2000 compression: 1 Gigabyte -> 100 times an X-ray film.

23. Storage needs per hospital • On line storage for 4 years (1st phase): • Albacete Hosp. (800 beds): 40 Terabytes. • Almansa (100 beds): 8 Terabytes. • Villarrobledo (100 beds): 8 Terabytes. • Alcázar de San Juan (400 beds): 32 Terabytes. • Tomelloso (100 beds): 8 Terabytes.

24. Architecture: Components • Pathology Information System (Novopath) • PACS 5.6 (Udiat): JPGEG2000 links • Web application J2EE (Satec) • Image Server software and viewer (Aurora) • Virtual slide (Aperio) • User management: LDAP, Kerberos • Balancing web access by hardware, clustering • Integrations by HL7 messaging, no intermediary file

25. Server LDAP Solaris 9 iAS/WEB Environment Application server/Web Linux RH 4.0/iAS J2EE/Aurora BD Environment Servidor de BBDD SIAP Linux RH 4.0 SIAP Oracle Cluster SERVICES PACS server W2003 SQL Server 2005 Server Backup Linux RH Environment 2Gb 2Gb PACS/APERIO Tapes library Environment BACKUP Storage server Architecture Reference Hospital

26. Virtual slides • Virtual microscopy: Aperio ScanScope • XT: 120-slides / CS: 5 slides • Speed: (15 X 15 mm): <2 min/slide, 20x (frozen s) • Resolution: 40x: 0.25 μm/pixel • Spectrum™ Plus: Multiuser & muti-site • Image analysis (Quantification IHQ) • Files:JPEG2000 • (original files are single file (TIFF/SVS), or a directory with multiple files (CWS-Composite WebSlide)

27. Documents Containers Cassettes Slides Bar code Direct print: Leica/Sakura(2D: datamatrix) Label (resistant) with bar code: Radiofrequency (RFID): tissue blocks and slides Object identification

28. RFID: Identifying with radiofrequency • Low/high frequency. Passive/active • label (“tag”) • Reader • Only RFID • Both • (RFID & bar code) • Mobile devices • Single protocol / multi-protocol • Pending: Better standardization • Example: identification of slides by scanner

29. Specific workstations • Reading (high res.) wkst and teleconsultation • Autopsy and gross room: Washable keyboards, mouse and screen. 4 Mpixels 30”(75.62 cm) Pitch: 0.250 mm Size:2560 x 1600 Brightness: 200(Dicom)/ 370 (max) cd/m2 3 Mpixels 20.8” (52.8 cm) Pitch: 0.207 mm Size:2048 x 1536 Brightness: 500(Dicom)/ 800 (max) cd/m2

30. Small hospital Code bar reading containers / slides Gross station Wash. Keyb. mouse Label printer Photomicroscopy Scanner(<5 slides) Storage (8 TB) Reference Hospital Code bar reading container /cassettes/slides Autopsy room Reading wkst Videoconferencing Voice recognition Scanner >50 slides Storage (40 TB) Telepathology portal Serendipia Project in summary

31. Support centre • Centralizing malfunctions or breakdowns notifications and technical consultations. • Permanent, 7x24, 365 days a year availability. • On line information about incidences and notifications. • Two software engineers for support team. • Corrective, evolutionary & Preventive maintenance. Staff training plan

32. CONCLUSIONS • Eight public hospitals have been included in the initial phase, including integration with enterprise health record. Cost: 3,5 million euros. • Improving and automating critical processes • Faster and more reliable diagnoses (frozen sect.) • Foster intra- and interdepartamental consultation • Remote consultation and distant collaborative work will attenuate the shortage of pathologists. • Better follow-up of the diagnostic process • Introducing image processing and analysing tools

33. 9th European Congress on Telepathology http://www.seapcongresos.com/telepathology2008/

34. IHE & DICOM. Collaborate with standardization bodies! • Christel Le Bozec • Christel.Lebozec@spim.jussieu.fr • Marcial García Rojo • marcial@cim.es