1. Wednesday August 16, 2006 APIII 2006 Vancouver Breakout Session A2 Integrating whole slide images into clinical workflow Jonhan Ho, MD Dermatopathology Fellow, UPMC

2. Wednesday August 16, 2006 APIII 2006 Vancouver Breakout Session A2 Purpose How do we integrate whole slide images into a pathologist’s workflow?

3. Wednesday August 16, 2006 APIII 2006 Vancouver Breakout Session A2 Objectives 1.Present an overview of current pathology workflow 2.Discuss the steps needed to fit a scanner and its output into clinical anatomic pathology workflow 3.Present a working example of integrated clinical WSI

4. Wednesday August 16, 2006 APIII 2006 Vancouver Breakout Session A2 Diagram of pathology workflow Office Gross room Histology Pathologist

5. Wednesday August 16, 2006 APIII 2006 Vancouver Breakout Session A2 Pathologist’s workflow Paperwork Pt. demographics Surgeon Clinical history Specimen information Gross description Previous accessions Accession number Microscope Objective Slide Accession number Part Block Stain Slide description Slide preview Diagnostic visual information Inflow Final Report Outflow

6. Wednesday August 16, 2006 APIII 2006 Vancouver Breakout Session A2 Pathologist’s workflow with WSI Paperwork (APLIS) Pt. demographics Surgeon Clinical history Specimen information Gross description Previous accessions Accession number Microscope (WSI) Objective Slide (APLIS/WSI) Accession number Part Block Stain Slide description Slide preview Diagnostic visual information Inflow Final Report Outflow

7. Wednesday August 16, 2006 APIII 2006 Vancouver Breakout Session A2 Sources of information using WSI Microscope ObjectiveScanner Slide Slide unique identifierBarcode/APLIS Accession numberBarcode/APLIS PartBarcode/APLIS BlockBarcode/APLIS StainBarcode/APLIS Slide description (levdp)Barcode/APLIS Slide previewScanner Diagnostic visual informationScanner

8. Wednesday August 16, 2006 APIII 2006 Vancouver Breakout Session A2 Manual WSI implementation Steps required to import WSI (not vendor specific) 1.Scan the slide 2.Open the image 3.Look at the label image 4.Open the APLIS 5.Find the case 6.Match up part/block/stain/instance of slide 7.Rename the image 8.Move the image 9.Repeat for each image

9. Wednesday August 16, 2006 APIII 2006 Vancouver Breakout Session A2 Manual WSI implementation Steps required to view WSI (not vendor specific) 1.Open application 2.Browse to proper folder 3.Browse to proper file 4.Open the image

10. Wednesday August 16, 2006 APIII 2006 Vancouver Breakout Session A2 A working prototype of WSI clinical workflow integration The “Back End”

11. Wednesday August 16, 2006 APIII 2006 Vancouver Breakout Session A2 Automatic WSI Implementation Microsoft.NET 2.0 Microsoft IIS 6.0 SQL Server 2005 AJAX (Asynchronous Javascript and XML)

12. Wednesday August 16, 2006 APIII 2006 Vancouver Breakout Session A2 Automatic WSI implementation Steps required to import WSI 1.Scan the slides 2.Import the images 1.Read/decode the barcode 2.Query the APLIS for a match 3.Query the APLIS for patient metadata 4.Query the APLIS for specimen metadata 5.Query the scanner for image metadata 6.Wrap metadata as XML wrapper around image 7.Writes WSI database entry 8.Move the image 9.Rename the image to Unique ID 10.Repeat for next image

13. Wednesday August 16, 2006 APIII 2006 Vancouver Breakout Session A2 Automatic WSI implementation Steps required to import WSI 1.Scan the slides Web service monitors folder for new images 2.Import the images 1.Read/decode the barcode (2D, Datamatrix) Accession number – SYS04-123456 Part – 1 Block – A Stain – H&E Slide Label – “FS” (frozen section) Query scanner for decoded barcode information 2.Query the APLIS for a match “A match exists, proceed”

14. Wednesday August 16, 2006 APIII 2006 Vancouver Breakout Session A2 Automatic WSI implementation Steps required to import WSI 3.Query the APLIS for patient metadata Last name, first name Gender Social security number Medical record number Birthdate 4.Query the APLIS for specimen metadata Ordering physician Clinical history Accession number, date/time Assigned pathologist Part, block, stain slide description Part description

15. Wednesday August 16, 2006 APIII 2006 Vancouver Breakout Session A2 Automatic WSI implementation Steps required to import WSI 5.Query the scanner for image metadata Study/series dates/times Image info (pixels, h/w, compression, x-y, etc.) Scanner info (make, model, serial number, IP address, spatial sampling, lens, etc.) And many others… 6.Rename the image to Unique ID 1.2.840.152371.157.229.221.31.20050322.112447.332.1 7.Wrap metadata as XML wrapper around image 8.Writes database entry Includes all metadata 9.Move the image 10.Repeat for next image

16. Wednesday August 16, 2006 APIII 2006 Vancouver Breakout Session A2 A working prototype of WSI clinical workflow integration The “Front End”

17. Wednesday August 16, 2006 APIII 2006 Vancouver Breakout Session A2 Human computer interaction How ‘useful’ is an application? How intuitive is the software? Fosters user loyalty –iPod –Stentor

18. Wednesday August 16, 2006 APIII 2006 Vancouver Breakout Session A2 Workflow integration

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22. Wednesday August 16, 2006 APIII 2006 Vancouver Breakout Session A2 Pathologist scanning behavior Highly repetitive actions –Slow panning –Changing objectives Concentration is maintained on the subject at hand –Usually is in center of optical field

23. Wednesday August 16, 2006 APIII 2006 Vancouver Breakout Session A2

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25. Wednesday August 16, 2006 APIII 2006 Vancouver Breakout Session A2

26. Wednesday August 16, 2006 APIII 2006 Vancouver Breakout Session A2 Issues Lack of a ‘unique slide identifier’ –Requires a change to the APLIS (additional fields and relationships) Lack of barcode support –Restricts large scale use ‘Moving target’ –File format changes –Software updates

27. Wednesday August 16, 2006 APIII 2006 Vancouver Breakout Session A2 Moving forward Establishing standards –Known, predictable output format –DICOM WG26 –LDIP Investigating ‘workflow accelerators’ –Offer pathologists better ways to examine tissue Workflow for pathologists and for histology already exists, software must accommodate this workflow (and not vice versa)