1. Digital Imaging Behind the Scenes Stacey Yates

2. Implemented Workflow Challenges/Solutions Added Value Future Plans Overview

3. Telepathology Trestle robotic microscope installed for across- campus frozen section consults Problems: ▫Too Cumbersome for everyday use ▫Scanning too slow for real-time review  Approximately 1 minute per slide ▫Scan not retained from slide to slide Where are we coming from?

4. Needs: ▫Capability to view multiple slides at once from anywhere ▫Quickly and easily find images to be used for teaching and research ▫Ability to reference images from past cases without waiting for requested slides. ▫Enhance the learning experience for trainees. Telepathology Where are we coming from?

5. Starting the Process Digital Imaging Committee ▫Pathologists, Residents and IT Staff Evaluated multiple scanners and database management packages Important Requirements: ▫Simple Database Management ▫Ease of Use ▫Speed and Quality of images

6. Equipment/Infrastructure

7. Aperio ScanScope ScanScope XT: 120 slide capacity. All clinical scanning 20x and 40x Magnification

8. BioImagene iScan 20X 160 slide capacity Currently research only Not linked to clinical image database

9. Storage Dell MD3000 PowerVault ▫15 - 300gb Harddrives Dell MD1000 PowerVault ▫15 – 300gb Harddrives Total Clinical Image Storage = 7.5 Terabyte Dell PowerEdge 2970 ▫Runs server software and services Dell PowerVault TL2000 ▫Backup Tape Library

10. Network gigabyte 100 mb 3 blocks apart

11. Lets Get Started…. Scanned only research and conference slides Became comfortable with the scanner and database Began instructing users on how to use Spectrum Small group of “Power Users” utilized Spectrum for conferences February 2008

12. Oops! Problems found: ▫Scanning process long and tedious ▫Manually entering patient/case information into Image Database from LIS ▫Equipment Downtime and Storage Space ▫Learning curve for finding images  Residents embraced the technology  Pathologists did not want to use two separate systems ▫Image interface not good for educational purposes.

13. The Plan: ▫Group and individual training sessions The Result: ▫Confusion ▫Lack of interest Solution: ▫Viewing images directly from LIS Learning Curve You want me to do what?

14. Scanning Process Marriage of the LIS and Image Database Before the marriage could take place Barcoding had to be implemented. Barcode contains: Inside Accession # Block # Slide #

15. 1.Histology is entered to create a label with barcode for each slide. 2.The barcode is temporarily attached to the slide. Scanning Process Marriage of the LIS and Image Database

16. 3.Each slide must be cleaned and free from dust and fingerprints 4.Once the slides are loaded a snapshot is taken of each of the slides. Area of Interest Scanning Process Marriage of the LIS and Image Database

17. 5.Once the image is scanned an HL7 message is sent to our LIS containing the link to the image on the server and the barcode id. 6.The LIS then sends a message back to the Image database with identifying information: ▫Medical Record Number ▫Patient Name ▫Birth date ▫Hospital ▫Part Type ▫Accession Number ▫Stain Scanning Process Marriage of the LIS and Image Database

18. 7.Image Database uses the information to file the slide under a new patient or attaches it to an already existing patient. ▫The MRN number, patient name, date of birth and hospital must match. 8.Each slide is reviewed for quality, the label is removed and sent back for filing or returned to referring institution. 9.Verify each slide is linked to LIS and the information sent to Spectrum is correct. Scanning Process Marriage of the LIS and Image Database

19. Slides Received Case Signed Out Diagnostic Slides Selected Barcode Printed Slides Scanned Slides Returned to Referring Institution Slides Reviewed Scanning Process The Workflow

20. Timeline: Start to Finish 20X ▫Label Slide with barcode = 1 minute ▫Prep slide for scanning = 1 minute ▫Scan slide = 6 minutes  Total = 8 minutes per slide 40X ▫Label Slide with barcode = 1 minute ▫Prep slide for scanning = 1 minute ▫Scan slide = 33 minutes  Total = 35 minutes per slide Most scans are between 500,000 mb and 1 gb Turn around time usually 48 hours

21. Scanning Process ▫LIS integration increased productivity and took away some of the manual data entry ▫Ensured slides where filed with the correct patient information ▫Pathologists only used one program to access slides ▫Over 12,000 digital images linked to LIS Problems Solved by LIS Integration

22. Learning Curve Viewing Images through LIS

23. Learning Curve Viewing Images through LIS

24. Equipment Downtime Over the past 2 years ▫5 days of complete scanner downtime ▫6 days of manual scanning due to scanner hardware malfunction ▫2 -3 days to catch up after downtime Back-up Plan? ▫Bring 2 nd Scanner on line

25. Image Storage April 2010 ▫Original 7.5 tb full ▫18,078 images Today ▫Added 25 tb ▫Currently 23,663 images Will we need more storage?

26. Education ▫Faculty can create sets of digital images ▫Used as teaching tool for residents and fellows Study Sets

27. ▫Quizzes are created to evaluate progress Education Quiz

28. ▫Weekly case is presented ▫Trainee’s get a chance to review ▫Diagnosis is posted at the end of the week Education Case of the Week

29. Added Value Availability: immediate access to images for increased efficiency in patient care, education and research Permanent: no lost or broken slides Portable: send images instead of slides for consults, legal requests Conferences: Ability to take images to conferences instead of actual slides Teaching: Create teaching sets and quizzes using digital images

30. Future Challenges Viewing images remotely through Citrix ▫Citrix will not work for viewing images through LIS ▫Citrix will allow the searching of the Spectrum database and opening of images through Spectrum using ImageScope but is extremely slow Continue to build teaching sets to aid in the education of residents and students. ▫Evaluate software to manage the educational and clinical aspect of digital imaging

31. Future Challenges Currently requires one full-time position Continue to build an image repository. Image Analysis Ability to search for images based on diagnosis without opening each case in LIS De-identified searches for education and research purposes

32. Digital Imaging Behind the Scenes Stacey Yates Thank you!