1. Leeds Institute of Molecular Medicine Pathology and Tumour Biology Understanding work practice within histopathology: implications for design Rebecca Randell 1, Rhys Thomas 3, Roy Ruddle 3, Phil Quirke 2, Darren Treanor 1,2 1 Leeds Teaching Hospitals NHS Trust, 2 Leeds Institute of Molecular Medicine, University of Leeds, 3 School of Computing, University of Leeds www.virtualpathology.leeds.ac.uk darrentreanor@nhs.net Pathology Visions, San Diego, October 2010

2. Leeds Institute of Molecular Medicine Pathology and Tumour Biology Disclaimer This is independent research carried out by us at the University of Leeds/ Leeds Teaching Hospitals NHS Trust funded by the UK National Institute for Health Research (NIHR)

3. Leeds Institute of Molecular Medicine Pathology and Tumour Biology Overview Context Background Methods – workplace study of histopathology Findings Implications of our findings –For design of systems –For implementation of digital pathology generally

4. Leeds Institute of Molecular Medicine Pathology and Tumour Biology Context

5. Leeds Institute of Molecular Medicine Pathology and Tumour Biology Context Leeds Teaching Hospitals Trust –Fully subspecialised department for 15+ years now –Single site, all specialties –38 FTE consultant/ attending pathologists –30 trainees –~250,000 H&E slides/ year in “histopathology” (ie surgical pathology excluding cytopathology) –Scanning since 2003 –4x aperio scanners (2XT, 2 CS) –Scan 1800 slides/ month for teaching and research –All online at www.virtualpathology.leeds.ac.uk www.virtualpathology.leeds.ac.uk

6. Leeds Institute of Molecular Medicine Pathology and Tumour Biology Background

7. Leeds Institute of Molecular Medicine Pathology and Tumour Biology The promise of digital microscopy Improved workflow Ease of obtaining second opinions Easy access to archived slides Reduced risk of misidentification of slides Integration of decision support etc. etc….

8. Leeds Institute of Molecular Medicine Pathology and Tumour Biology So where are we now? Slow uptake Scepticism and uncertainty –amongst both users (pathologists) –and commissioners (managers, hospitals, health services)

9. Leeds Institute of Molecular Medicine Pathology and Tumour Biology ‘The Powerwall project’ NHS National institute for Health Research (NIHR) funded project (2009-2012) Multi-user Powerwall for education Single-user workstation for diagnostic work Aim to develop a virtual slide workstation as fast as, or faster than, the conventional microscope

10. Leeds Institute of Molecular Medicine Pathology and Tumour Biology Project overview Study work practices and workflow Develop a digital microscope Evaluate the system with pathologists

11. Leeds Institute of Molecular Medicine Pathology and Tumour Biology Project overview Study work practices and workflow Develop a digital microscope Evaluate the system with pathologists

12. Leeds Institute of Molecular Medicine Pathology and Tumour Biology Methods

13. Leeds Institute of Molecular Medicine Pathology and Tumour Biology Detour 1: Why? ‘Failed’ systems are common in IT and in healthcare IT: –Designs based on idealised accounts of work practice –Rejected by users –Systems not used as intended (workarounds)

14. Leeds Institute of Molecular Medicine Pathology and Tumour Biology Detour 2: Workplace studies to understand current practice Workplace studies –Area of human computer interaction ‘concerned with the ways in which tools and technologies feature in work and interaction in organisational environments’ (Heath and Luff, 2000) –‘overwhelmingly naturalistic, ethnographic studies, involving... ‘thick description’ of human conduct and cooperation in complex technological environments’ (Luff et al., 2000) Tend to use –Interviews (to clarify aspects of the work in complex settings –observation (to see how the work is actually done) –video (to capture and measure details) Results tend to be qualitative

15. Leeds Institute of Molecular Medicine Pathology and Tumour Biology Workplace study of histopathology: Study design 1.Interviews (9) 2.Observations (10) –Approx. 1 hr observing routine work –1 cut-up; 2 sessions preparing for multidisciplinary team (MDT) meeting (tumour board); 2 MDT meetings; 1 teaching session 3.Video recordings of routine reporting work –Capture details of interaction –Annotated, to quantify how time is spent

16. Leeds Institute of Molecular Medicine Pathology and Tumour Biology Findings

17. Leeds Institute of Molecular Medicine Pathology and Tumour Biology Interviews Attitudes Perceived benefits Perceived limitations Barriers to adoption

18. Leeds Institute of Molecular Medicine Pathology and Tumour Biology Attitudes (1) Huge variation in interviewees’ enthusiasm for virtual slides for clinical work ‘We haven’t got enough money to do what we’re doing now. And the investment that you’d need to really make digital pathology taken on as for routine I think is unjustifiable.’

19. Leeds Institute of Molecular Medicine Pathology and Tumour Biology Attitudes (2) ‘These [gesturing to microscope] can all go in the scrap heap. I just think it liberates us so much as well. I mean we can work from home, couldn’t we? Or from Mars. [...] I can’t wait actually, quite frankly. I really would like to be able to start working this way. I think it’s just going to be revolutionary...’

20. Leeds Institute of Molecular Medicine Pathology and Tumour Biology Perceived benefits (1) – second opinions ‘You’ve got to bundle up your slides, write a letter, send it off, get it lost in the post, but [...with digital pathology you can...] pick up the phone [...] and say ‘Just have a look at this,’ you know, you look at it together, you’re chatting about it on the phone‘ ‘I would do it a lot more, absolutely. [...] Because it’s easier and quicker and much easier to do. Which is a great thing generally, isn’t it, for pathology?’

21. Leeds Institute of Molecular Medicine Pathology and Tumour Biology Perceived benefits (2) - efficiency ‘You don’t have all the glass work, filing, you don’t have to constantly file loads of glass and pull it out and re-file it and so on.’ Other perceived benefits in –Teaching –MDT meetings

22. Leeds Institute of Molecular Medicine Pathology and Tumour Biology Perceived limitations Lack of familiarity was a recurrent theme ‘It just takes a bit of getting used to, open it up, zooming in and out and going round. And sitting at a computer screen as opposed to looking down a microscope. It’s just retraining yourself about it...’

23. Leeds Institute of Molecular Medicine Pathology and Tumour Biology Barriers to digital microscopy ‘Thinking of how often in the last few days [Name of LIS] has been down. [...] And I think that’s probably my main concern. That the NHS does not give me any confidence whatsoever from an IT point of view and I can’t see how they’re going to do it. They’re very good at being optimistic but the delivery’s always a major disappointment.’ Surprisingly, safety was generally not a concern – and many felt it would be improved by better workflow with digital pathology

24. Leeds Institute of Molecular Medicine Pathology and Tumour Biology Observation results

25. Leeds Institute of Molecular Medicine Pathology and Tumour Biology ‘Glass work’

26. Leeds Institute of Molecular Medicine Pathology and Tumour Biology Physical layout

27. Leeds Institute of Molecular Medicine Pathology and Tumour Biology Collaboration Informal discussion: unusual or difficult case Formal second opinion: within or without department Discussion before MDT meetings (tumour boards)

28. Leeds Institute of Molecular Medicine Pathology and Tumour Biology Video study 5 gastrointestinal histopathologists, alone with video camera, approx. 7 hours & 50 cases recorded Viewing slide, dictating, viewing clinical details, annotating slides, writing notes, referring to book

29. Leeds Institute of Molecular Medicine Pathology and Tumour Biology Qualitative analysis of video Eyes free use of microscope Frequently doing more than one task –loading slide while viewing clinical details –dictating report while viewing slide Seamless movement between slide, request form, LIS and other items

30. Leeds Institute of Molecular Medicine Pathology and Tumour Biology Quantitative analysis of video MeasurementMedianAverageRange Time to complete a case4m 45s7m11s1m 30s – 56m19s Slides per case23.51 – 47 Time to view a slide41s58s3s – 9m 41s

31. Leeds Institute of Molecular Medicine Pathology and Tumour Biology

32. Leeds Institute of Molecular Medicine Pathology and Tumour Biology 3 cases, 5 slides Mix of activities

33. Leeds Institute of Molecular Medicine Pathology and Tumour Biology Workflow in the office: “long” and “short” cases

34. Leeds Institute of Molecular Medicine Pathology and Tumour Biology Doing more than one thing at a time… 1.Dictating while looking at clinical details/ request form 2.Referring to LIS while filling in form to request immunohistochemistry

35. Leeds Institute of Molecular Medicine Pathology and Tumour Biology Video analysis: Time utilisation (Only?) 60% of time was spent looking at the microscope image 20% of time was spent dictating the report –Either all at the end, or all through the case 11% of time viewing clinical details/ macroscopic description –Varied from 2 seconds to 2 minutes

36. Leeds Institute of Molecular Medicine Pathology and Tumour Biology Video analysis: Time utilisation Other activities –Annotating slides (56 times across 37 cases) –Making handwritten notes –Referring to books (6 times) –Interruptions (including requests for second opinions!)

37. Leeds Institute of Molecular Medicine Pathology and Tumour Biology Implications

38. Leeds Institute of Molecular Medicine Pathology and Tumour Biology Implications for design Pathologists find the microscope easy to use – “Eyes free interaction” –So digital pathology workstations must be easy to learn and use Seamless movement between information sources is needed (e.g. Viewing clinical details, other reports, other systems) –But how and to what extent? Support for collaboration is needed –Must be rapid –Must facilitate collaboration within department and between departments Training and support is very important –Mastering the microscope controls takes 6-12 months

39. Leeds Institute of Molecular Medicine Pathology and Tumour Biology Project overview Study work practices and workflow Develop a digital microscope Evaluate the system with pathologists

40. Leeds Institute of Molecular Medicine Pathology and Tumour Biology Project overview Study work practices and workflow Develop a digital microscope Evaluate the system with pathologists

41. Leeds Institute of Molecular Medicine Pathology and Tumour Biology Final detour: Implications for uptake of digital pathology We believe digital pathology has the potential to improve workflow and increase efficiency if properly implemented Tempting to think that 10-20% improvements in efficiency are possible within the reporting time but... –A significant amount of time was spent doing more than one activity (e.g. Dictating while loading next slide) –Not all time “saved” by being more efficient can be assumed to be recycled and used productively –This assumes that, for viewing images, virtual slides are as efficient as the microscope

42. Leeds Institute of Molecular Medicine Pathology and Tumour Biology “assumes that viewing virtual slides is as efficient as the microscope” – the elephant in the room In previous work we found that virtual slide viewing was 60% less efficient than the microscope for a suite of tasks* –And 400-700% less efficient for some search tasks! * Treanor,D Quirke, P “The virtual slide and conventional microscope – a direct comparison of their diagnostic efficiency,” in The Journal of Pathology, vol. 213 (presented at Pathological Society of Great Britain and Ireland, Glasgow: Wiley, 2007), 1A-65A

43. Leeds Institute of Molecular Medicine Pathology and Tumour Biology Baseline With digital pathology? *Not to scale – this graphic underestimates the proportion of time spent doing microscopy as 50% and assumes only a 10% efficiency gain on sorting slides etc How would this affect the working week? 30% 60%

44. Leeds Institute of Molecular Medicine Pathology and Tumour Biology There's no point being 10-30% more efficient at organising the glass and paper if viewing the virtual slide is less efficient than the microscope –Viewing is a bigger component of our day than sorting Apart from wasting time, inefficiency viewing images leads to fatigue...and fatigue leads to error –Some pathologists tell us that slide/paper sorting time is therapeutic, a mental break So can we make virtual slides as efficient as the microscope and get productivity gains in sorting slides? Consider this a challenge!

45. Leeds Institute of Molecular Medicine Pathology and Tumour Biology Acknowledgements Funding –National Institute for Health Research, UK Leeds Powerwall team, School of Computing –Roy Ruddle, Rhys Thomas, John Hodrien Leeds Institute of Molecular Medicine –Phil Quirke –David Turner, Alex Wright, Martin Waterhouse, Mike Hale, Nick Roberts Leeds Teaching Hospitals NHS Trust –Consultant and trainee pathology staff, laboratory staff and management

46. Leeds Institute of Molecular Medicine Pathology and Tumour Biology Questions?

47. Leeds Institute of Molecular Medicine Pathology and Tumour Biology References Heath and Luff (2000) ‘Technology in Action’ Cambridge University Press Luff, Hindmarsh, and Heath (2000) ‘Workplace Studies: Recovering Work Practice and Informing System Design’ Cambridge University Press