Western swing—updates on
  cancer, errors, more

June 2005
Feature Story

Ed Finkel

Back-to-back conferences in August will bring the latest on cancer informatics, imaging technology, and error reduction to a West Coast audience and beyond.

A smorgasbord of academic, governmental, and industry-driven advances will roll out at the Granlibakken Resort and Conference Center in Tahoe City, Calif., with the Improving Hospital and Laboratory Safety conference on Aug. 22–23 and the APIII 2005 conference on Aug. 24–26, both sponsored by the University of Pittsburgh School of Medicine.

The 10th annual APIII conference will move from its longtime home at UPMC and present a greatest hits medley of sorts from past conferences that pathologists from the western United States might have missed, says Michael Becich, MD, PhD, a co-course director.

“A lot of the content of this meeting is drawn from prior [gatherings],” says Dr. Becich, vice chairman of pathology informatics, director of the Center for Pathology Informatics, and professor at UPMC. Fewer attendees have come from the western part of the country in past years, and “I think geography has a lot to do with it,” he says. “We wanted to take a road show of our best content out to the West Coast.”

The conference’s content has broadened over the years, he says, and though the APIII abbreviation lives on, the name has been changed from the original “Advancing Anatomic Pathology, Informatics, Imaging and the Internet” to the current “Advancing Practice, Instruction, and Innovation Through Informatics.” Recast this way in 2003, “We made it broader, with a focus of, ‘We’re going to drive down the highway and bring together pathology, oncology, and bioinformatics,’” he says.

This three-pronged approach is reflected in the courses. On the bioinformatics side, APIII will present a series of sessions about the National Cancer Institute’s Cancer Biomedical Informatics Grid, known as caBIG (http://cabig.nci.nih.gov), an infrastructure that has begun integrating data and other findings into what he calls “a World Wide Web for cancer research.”

“This is an exciting new program launched by the NCI that, in a very dramatic way, takes what’s happening in pathology informatics to central relevance in oncology informatics,” Dr. Becich says. “It has provided opportunities for pathology informatics programs and pathologists to participate in this gigantic, innovative data-sharing initiative for the research and clinical communities that serve cancer patients.”

CaBIG has disbursed $20 million in funding in its first year and will increase that to $34 million this year to further the goal of NCI director Andy von Eschenbach, MD, to eliminate pain, suffering, and death due to cancer within 10 years.

“His goal is not to eliminate cancer, but to eliminate deaths from cancer by controlling tumor growth,” Dr. Becich says. “If you don’t die from cancer, I’d say that’s a cure. It’s not getting rid of it, but instead letting patients die with their cancer rather than from their cancer.”

The courses on caBIG will present discussions of the overall initiative and how to manage tissue banks while maintaining patient confidentiality, and delve into some of the research funded through NCI, such as natural image processing of pathology reports, says John Gilbertson, MD, co-course director with Dr. Becich and assistant professor and director of research and development at the UPMC’s Center for Pathology Informatics.

Robert Beck, MD, vice president for information services and chief information officer at Fox Chase Cancer Center, Philadelphia, will give a general talk on the importance of caBIG, says Dr. Becich, who describes Dr. Beck as “one of the original pathology informatics gurus.

“He’ll provide a road map of how folks can get involved in caBIG, what caBIG is doing today, and what it will do down the road. Everyone is invited to get involved—there are no barriers. Most people who do get involved end up getting funded for their involvement.”

In a session titled “Set the Paraffin Free,” assistant professors Rebecca Crowley, MD, of UPMC, and Michael Feldman, MD, of the University of Pennsylvania School of Medicine, will tell their success story in putting 1 million pathology specimens from their two schools on the grid for researchers’ use. Their funding started last August, Dr. Becich says, which means they did it in less than a year.

What makes caBIG unique is how it’s paying people not just to develop software but also to use it, he says. “This program is funding other sites to take those tools and put them to use in their centers,” he says. “It’s the first time I’ve ever been involved in a program where people had the insight to invest more heavily in the rollout and implementation of the program than in the development.”

The presentations most directly related to pathology will center around the latest in imaging technology, says Dr. Becich, a proponent of whole-slide imaging who, in the spirit of full disclosure, adds that he’s a board member and paid consultant for imaging vendor Trestle.

“We’re going to drill deeply through a lot of our old content [from past conferences] and put it in the frame of what’s happening today, to provide to the APIII audience a state-of-the-state message about imaging in technology,” he says. “Whole-slide imaging is moving its way into the workplace. It’s revolutionary. As picture archiving systems were to radiology, whole slide is to pathology.”

These systems take digital imagery that never gets lost and can be requested by anyone, anywhere, Dr. Becich says. “You can move around glass slides as a digital piece of information,” he adds. “You never have to worry about losing clinically important glass slides as a result of someone else misplacing or damaging them.”

Dr. Gilbertson and Jonhan Ho, MD, a telepathology fellow at the University of Pittsburgh, will present a session on this digital pathology that has spawned a “small industry” in the past five years, Dr. Gilbertson says. “The key issue is, are we really on the cusp of a major translation between a person with a camera that’s on a microscope, taking a field of interest, to these robot devices that take entire slides automatically. That changes the entire paradigm of what imaging can be.”

While vendors have entered the field, he says, not everyone is convinced that shift is about to occur. The session will explore such questions as, “Is this a real platform? Is it going to mean anything, or is it going to be a toy? Where are we on this path, and how are we going to get there? Obviously, these haven’t become day-to-day,” he says.

The oncology-related courses will cover lab information systems and how they interact with pathology—“your basic pathology informatics issues, and how they are going to evolve over time,” Dr. Gilbertson says. “You have the virtual LIS with many laboratories working together, lab portals on the Internet, the next wave of innovation in LIS.” More specific sessions will focus on synoptic data entry, interacting with reference laboratories, and more, he says.

Bruce Friedman, MD, professor of pathology at the University of Michigan Medical School, will present a session on the virtual LIS. “Bruce has really been a leader at defining the new, emerging informatics architecture for clinical labs,” Dr. Becich says. “In the past, there used to be this big, one-size-fits-all LIS. Today it’s more a network of 10 to 15 different products.”

At the exhibitor showcase, conference attendees will be able to hear directly from some of the companies providing this technology. “This meeting is very strongly supported by the vendor community,” Dr. Becich says. “It’s as much their meeting, now, as it is a thought-provoking and discovery-based meeting.”

Adds Dr. Gilbertson, “A lot of the innovation comes from the vendor community, not the academic community. We have a number of people coming—some of the real leaders in imaging, for example, will be coming to discuss their technology.”

Error reduction within and beyond the laboratory will be the twin focuses of the Improving Hospital and Laboratory Safety conference that will kick off the week. Co-director Dana Grzybicki, MD, PhD, assistant professor at UPMC, says it’s the only national meeting of its kind in which such laboratory-related data and issues are discussed.

“There’s very few people in laboratory medicine currently who are actually doing formal health services research on laboratory practice, including patient safety and error reduction,” she says. “The main purpose of this is to be a forum—which is now the only forum—for the dissemination of current, cutting-edge information about error reduction [and] patient safety related to the laboratory.”

The conference is geared toward pathologists and what they can do to affect patient care and improve safety, though others in related fields who work regularly with lab personnel would have reason to be interested, says Stephen Raab, MD, course co-director and professor at UPMC, and chief and director of cytology at UPMC’s Shadyside Hospital.

“It’s really a conference for pathologists and other hospital people related to patient safety; our focus is heavily into the laboratory aspects of safety,” he says. “A lot of the speakers are going to talk about practical things they have done or know about. There’s different aspects of education, actual practice, the sociology behind the difficulties of making changes and how we can get around them.”

Pathologists and other laboratory employees will share research findings from federally funded work on how to reduce errors in anatomic and clinical pathology, Dr. Grzybicki says. “How can you redesign processes in laboratories; how can you change what most laboratories do now to make processes less costly, more efficient, and safer?” Dr. Grzybicki asks, illustrating what the approach will be.

Other speakers, who primarily are not pathologists, will talk about interacting with colleagues in other hospital departments to achieve many of the same goals, Dr. Grzybicki says. “The other part is going to be, how can you form partnerships in trying to form your systems so that patients get better care related to laboratory services?” she says. Such speakers “are quality people and administrative people involved in quality improvement in hospitals. They are very interested in trying to apply methods that have long been used in industry.”

Physical and psychological barriers now separate laboratory employees from the rest of the organization, Dr. Grzybicki says. “We want to bring together people from the clinical realm and the laboratory realm to see if we can work together and form collaborations,” she says. “The laboratory is kind of this black box where physicians send specimens in and get answers out. There is not nearly as much communication about how to improve patient care, and we think there could be.”

Keynote speaker John Banja, PhD, associate professor and clinical ethicist at the Emory University Center for Ethics, will attempt to crack this can of worms, Dr. Grzybicki says. “He’s going to talk about something that everyone who does patient safety research at hospitals knows about and deals with and is frustrated by, but nobody is very open about it: the psychosocial aspects of the culture of medicine that prevent people from wanting to admit errors, to report errors,” she says.

“Of course, if people are not willing to admit they exist, there’s not much you can do to change them,” she adds. “It’s going to be an important keynote session. I also expect it’s going to be controversial. We are hoping for that and want to engage people to talk about this in an open way.”

Dr. Raab will zero in on improving patient safety by examining pathology errors, a presentation based on research funded by the Agency for Healthcare Research and Quality, part of the National Institutes of Health. “We’re giving a session on practical approaches to anatomic pathology and how to make anatomic pathology labs safer,” he says. He will demonstrate “actual interventions we’ve done in labs across the country, why they work, why they don’t work.”

Dr. Grzybicki says the health services research will add statistical grounding to the anecdotal success stories. “We’re not just going to be talking about stuff we thought of, and tried in our laboratory, and it worked,” she says. “That [research] will add a certain validity to what we talk to people about.” The five-year NIH-funded project is now in its third year, and past attendees have asked for updates, she adds.

The related topic of quality assurance best practices will be the subject of Dr. Grzybicki’s session, based on a three-year grant from the Centers for Disease Control and Prevention that she received last September. “The purpose of that project is to look at some of the quality assurance and quality improvement processes that we already do in laboratories but aren’t standardized,” she says.

Take turnaround time, for example. “You can measure it in a lot of different ways,” Dr. Grzybicki says. “Obviously if everybody is measuring this differently, comparing laboratories is impossible, and second, it makes that quality metric, in a way, meaningless. The CDC has decided that it would like to start exploring these differences and has funded research to inform pathologists and other laboratory professionals about this variability.” The goal, she adds, is to provide information so that recommendations can be made about standardizing these processes.

A third federally funded researcher, Mark Roberts, MD, associate professor and chief of decision sciences and clinical systems modeling at UPMC, will be a speaker at the conference. “He’s going to talk about doing theoretical modeling of processes in the hospital to help answer questions related to best practices, including best practices related to patient safety,” Dr. Grzybicki says. “It will expose people to another set of methods that is being used to try to answer questions related to patient safety.”

Extending best practice principles from industry and safety science into the hospital will be the focus of sessions by UPMC administrators Tamra Merryman, vice president of patient care services, and David Sharbaugh, CPA, director of quality improvement and information analysis. “Related to the laboratory are so many hospital processes such as bedside testing, test ordering, and how to redesign clinical practices,” Dr. Raab says. “It’s going to cover redesigning point-of-care testing, phlebotomy testing, any tests that are ordered by clinicians and how they obtain that material, and bar coding and how that prevents mislabeling.”

Adds Dr. Grzybicki, “We’ve discovered there are some things we can change in the collection and transport of those specimens that allow us to be more efficient and make fewer errors.”

Though patient safety has been a popular topic since the Institute of Medicine report on the subject in 1999, thus far talk has outdistanced action in traditional higher education curricula, according to survey research compiled by Bridget Calhoun, MPH, chair of the physician assistant training program at Duquesne University, Pittsburgh.

Calhoun will present the findings of her survey, sent to medical schools, physician assistant programs, and nurse practitioner programs. “People have said, ‘We’ve got to incorporate this into our curriculum,’” Dr. Grzybicki says. “The data she has shows there’s very little integration. We want to talk about how we can address this lack of formal education because health professionals in training need to learn about this while they’re in training, not afterward when they’ve already begun practicing without a core of knowledge about quality improvement and patient safety.”