1. W. Scott Campbell, Ph.D., MBA University of Nebraska Medical Center
A Conceptual Process to Capture Microscopic Findings by the Surgical Pathologist
W. Scott Campbell, Ph.D., MBA
University of Nebraska Medical Center

2. Acknowledgements Steven H. Hinrichs, MD William W. West, MD
University of Nebraska Medical Center
Acknowledgements
Steven H. Hinrichs, MD
Chairman of UNMC Department of Pathology/Microbiology
William W. West, MD
Surgical Pathologist – breast cancer specialist, UNMC
James R. Campbell, MD
Internal Medicine - UNMC

3. University of Nebraska Medical Center
Objectives
Present research into whole slide imaging (WSI) process to capture pathology findings
Discuss incorporation of SNOMED CT
Discuss current issues
Solicit input and feedback

4. Anatomic Pathology Workflow
University of Nebraska Medical Center
Anatomic Pathology Workflow
Microscope replaced by scanner and computer monitor

5. Current Practice Problems Pathologist examines slides
University of Nebraska Medical Center
Current Practice
Pathologist examines slides
Identifies relevant abnormal tissue morphologies
Reaches conclusion and generates report
Problems
Reports are primarily natural language
Microscopic findings interpreted but not reported
Reports and report details not computable

6. University of Nebraska Medical Center
Whole Slide Imaging
WSI allows images of tissue features to be outlined (marked up) and annotated
Annotations can be encoded in SNOMED CT
Annotations can be rolled up into final report and much more….

7. Opportunities using SNOMED CT
University of Nebraska Medical Center
Opportunities using SNOMED CT
Structured, mineable pathology reports
Scaffolding for CDSS
Mineable image libraries
Information re-use
Public health, registries
Research
Knowledge Capture and representation

8. Typical Pathology Report
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Typical Pathology Report
Final Diagnosis: RIGHT BREAST, VACUUM-ASSISTED NEEDLE CORE BIOPSY: - DUCTAL CARCINOMA IN SITU WITH EXTENSIVE PERIDUCTAL SCLEROSIS AND INFLAMMATION. - FOCUS SUSPICIOUS BUT NOT DIAGNOSTIC FOR MICROINVASION. - GROWTH PATTERN: SOLID. - NUCLEAR GRADE: HIGH. - NECROSIS: PRESENT. - MICROCALCIFICATION IN DCIS: YES. Microscopic Report: Performed

9. Ductal carcinoma of female breast
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Ductal carcinoma of female breast
Nodular Focus
Necrosis
Epithelial hyperplasia with atypia

10. Epithelial Hyperplasia with atypia
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Epithelial Hyperplasia with atypia
Epithelial hyperplasia with atypia |IS A| |clinical finding|: |finding site| = |structure of small lactiferous ducts|, |associated morphology| = ( |epithelial hyperplasia| |atypia suspicious for malignancy), |finding method| = ( |hematoxylin and eosin stain method| |histopathology test| |light microscopy|)

11. Possible Invasive Carcinoma of Breast
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Possible Invasive Carcinoma of Breast
Possible invasive ductal carcinoma
Should trigger differential stains

12. Possible invasive carcinoma of breast CDSS
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Possible invasive carcinoma of breast CDSS
Possible invasive carcinoma |IS A| |situation with explicit context|: { |finding context| = |known possible|, |associated finding|= |clinical finding|= ( |finding site| = |lactiferous duct structure|, |associated morphology| = |infiltrating duct carcinoma|, |finding method| = ( |hematoxylin and eosin stain method| |histopathology test| |light microscopy|)), |temporal context value| = |current – unspecified|, |subject relationship context| = |subject of record|}
Trigger special differentiating Stains

13. Mineable Image Repositories or Visual CDSS
University of Nebraska Medical Center
Mineable Image Repositories or Visual CDSS
Expansive library of images; searchable
Ductal Carcinoma in situ with Micropapillary Growth Pattern

14. Can involve complicated expressions: Focal Hyperplasia w/o atypia
University of Nebraska Medical Center
Can involve complicated expressions: Focal Hyperplasia w/o atypia
Focal hyperplasia without atypia |IS A|
|situation with explicit context|:
{ |finding context| = |known present|,
|associated finding|= |clinical finding|=
( |finding site| = |breast structure|,
|associated morphology| = |focal epithelial hyperplasia|
|finding method| = ) |hematoxylin and eosin stain method|+
|histopathology test| |light microscopy|)),
|temporal context value| = |current – unspecified|,
|subject relationship context| = |subject of record|} +
{ |finding context| = |known absent|,
( |finding site| = |epithelial cell|,
|associated morphology| = |atypia suspicious for malignancy|,
|finding method| = ( |hematoxylin and eosin stain method|+

15. Issues to Address Storage and retrieval Data capture
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Issues to Address
Storage and retrieval
Normal form
Expression Repository
Data capture
Development
Production
Terminology elements

16. Clinical Finding Storage Model – Normal Form
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Clinical Finding Storage Model – Normal Form
Evolve into Expression Repository Model in Close to user form?

17. Proposed Process Pathologist outlines region of interest
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Proposed Process
Pathologist outlines region of interest
Pick lists presented (normal form, close to user form) that are contextually relevant
Finding sites
Abnormal Morphologies
Associated Findings
Probability/Presence/Absence

18. System Interaction Diagram
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System Interaction Diagram

19. User Interface - How best to capture findings
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User Interface - How best to capture findings
Developmental process
GUI prompting for response using normal form concepts
Free text
Administrative Review
Production process
Close to user form
Free text with administrative review

20. Terminology Issues Situations Concept definitions Concept model
University of Nebraska Medical Center
Terminology Issues
Concept definitions
Architectural and tissue morphometries
Missing concept definitions
Hyaline casts
Atypical epithelial hyperplasia
Immunohistochemistry staining methods
Concept model
Discrete Measurements
Histologic grade
Abnormal Morphology or Observable?
Situations

21. University of Nebraska Medical Center
Future Directions
Develop microscopic examination SNOMED CT local extension defining a subset of anatomic pathology
Bind WSI modality with structured annotation data structure
Development of contextual value set in a subset of anatomic pathology
Bind structured microscopic exam information to structured anatomic pathology report and subsequent synoptic reports

22. University of Nebraska Medical Center
Thank you

23. University of Nebraska Medical Center