Digital wonders dazzle in Pittsburgh
Video conferencing to allow pathologists to talk to pediatric
surgeons in a distant operating room? Ho-hum in Ann Arbor. Internet-based
telepathology consultations on slides from a hospital in Palermo,
Italy, in real-time? No big deal in Pittsburgh. Mt. Everest-sized
data warehouses, originally developed for satellites and climate
forecasting, being adapted for pathology? Old news in Baltimore.
So it went at the fourth annual Advancing Pathology Informatics,
Imaging and the Internet (APIII) conference, held in Pittsburgh
last October. Participants discussed eye-popping technology as if
it were the norm. A vast buffet of the latest digital wonders for
pathologyfilmless cameras, image databases, Web servers, and
morewas the topic of discussion for three days. But the spice
in every dish was "when?" "When will my group be able to afford
this?" "When will this technology be ready for prime time?" "When
will my competitors adopt it?"
To hear the panelists in Pittsburgh tell it, the answers could
be "right now" or "maybe never." But all agreed it is not too late
to consider the digital revolution and what it may allow and how
it may alter the practice of pathology. As Eric Schubert, MD, of
Memorial Hospital, Chattanooga, Tenn., said during his chronicle
of a still-incomplete attempt to handle thousands of images electronically:
"Are you behind by not having it? No, not yet. But you will be.
It’s catching on."
Like water in a hurricane, informatics and the Internet could
seep into every nook and cranny of pathology. Which is not to say
the attendees in Pittsburgh resigned themselves to changes beyond
their control. To the contrary, there was a sense of anticipation
that the seemingly unstoppable increases in the power of the integrated
circuit could assist pathologypotentially more than any other
medical specialty. The meeting’s keynote speaker, Steven McGeady,
vice president and director, Internet Health Initiative, Intel Corp.,
explained that easily enough. McGeady outlined what he said was
all too often the effect of the Internet on any industrya
diminution of power for established, centralized authorities and
an accumulation of power by newly energized and informed individuals.
The travel industry, financial industry, and book industry have
weathered such changes, he said.
In medicine, McGeady commented, the days of putting a patient’s
test results online are here. Pathologists, by controlling the majority
of data central to a patient’s medical record, may have a historic
chance to help patients manage the digital details of their medical
destinies, he stated.
In other words, the right approach to technology may allow patients
to rely on pathologists to a much greater degree than is the case
today. A principal behind the APIII meeting, course director Michael
J. Becich, MD, PhD, agreed. "Pathology, by its very nature, is disease-specific
information, and that is the primary driver for patients to seek
out information," he said.
"There’s only one product that I’m really concerned with in pathology,"
Dr. Becich added. "That’s our reports. Any stra-t---egy that focuses
on improving value-added services has got to include the pathology
report. Information systems are essential for this. If we don’t
learn how to externalize our data in our information systems, we
will be lost."
The computer systems of even the most sophisticated academic departments
fall short of where they should be, warned Dr. Becich. In the future,
he suggested, anatomic pathology reports will have to be united
with clinical pathology reports; a hospital’s laboratory information
system will have to be fully integrated with computers used by pathologists;
and images will have to be incorporated into all of the above at
the touch of a few keys.
Exhorted Dr. Becich: "We need to make the pathology report portable
to the patient, easy to move around, and flexible and [able to interact]
with all of these health care repository channels. Pathology should
lead the charge. We can’t follow. We need to lead the charge." As
an example, Dr. Becich noted that his wife, a neurologist, is being
inundated with paperwork, much of it from pathologists.
"She’s got charts in the garagecharts on the kitchen table.
And pathology, she says, is the major part of the problem," he related.
"We send out the cumulative, the integrative, the stat, and yesterday’s
report. It’s all the same data, but it’s on five pieces of paper.
Thirty percent of the time, she’s making decisions based on tests
that she ordered and that the patient paid for but that are not
there when she needs the information."
Better reports, Dr. Becich conceded, have eluded even him, an
associate professor and director of pathology informatics at the
University of Pittsburgh Medical Center. "I’m perceived as a leader,
and I have been awarded as an Internet Health Hero by Intel, but,
quite frankly, I can’t do this on a production basis, and I’ve been
talking about this for three years," he said.
More upbeat is the following statistic: A separate Web page for
the university’s transplantation pathology division helped spark
a 300 percent increase in consultations for UPMC physicians.
Even better, Dr. Becich forecasted, officials at the Health Care
Financing Administration are beginning to see the wisdom of using
digital technologies to extend the reach of the most experienced
pathologists. "We are very close to having billing codes for telepathology
consultation," he said. "There will be revenue opportunities here.
You need to be a player. You need to have a digital strategy. If
you have consulting opportunities you can leverage, there are also
opportunities for growing your practice. If we build it appropriately,
they will come, and our value will increase accordingly in the health
That already appears to be happening in Massachusetts.
Conference speaker Michael Laposata, MD, PhD, director of clinical
laboratories at Massachusetts General Hospital, Boston, walked the
audience through a deceptively low-key but extremely versatile solution
to his own curbside consult problem.
As Dr. Laposata related, he often found himself unable to leave
the hospital without giving colleagues informal advice about a patient
with a clotting problem.
To minimize the need for curbside consults, which he perceived
as providing only a few "passing bullets" to the physician being
consulted, he instituted two programs. One was an option to use
a series of reflex test algorithms in coagulation to increase the
efficiency of test selection and eliminate the need for the patient
to return for blood draws on multiple occasions until a diagnosis
is reached. The other was a daily interpretation rounds, as found
in anatomic pathology, to provide physicians ordering complex batteries
of coagulation tests with a narrative paragraph on the diagnosis,
often after obtaining clinical information about the patient.
A survey of physicians at Massachusetts General Hospital receiving
coagulation interpretations indicated that 71 percent ordered fewer
laboratory tests as a result of an interpretation. In addition,
58 percent said the interpretation reduced the time to diagnosis,
and 71 percent reported that it helped prevent a misdiagnosis. The
overall approval rating for the narrative interpretations in coagulation
was 98 percent.
Use of the thyroid-stimulating hormone test in one algorithm to
limit further thyroid testing has cut the cost per test from $16
to $6.25 in Massachusetts General’s endocrinology laboratory, stated
The algorithms and interpretations enabled Dr. Laposata and his
colleagues to secure considerable amounts of new business from the
surrounding area. The message for laboratories elsewhere, Dr. Laposata
proposed, may be that decisions about whether to move hospital laboratories
off-site will be made partly on the basis of whether a hospital
laboratory and its pathologists can provide interpretive and consultative
APIII speaker Michael Gagnon offered a similar heartening story.
Gagnon, director of business development and informatics at the
University of Vermont, Department of Pathology, offered an account
that is unique to his corner of the world and that may be of interest
to anyone who uses or is considering using an ordinary Internet
browser program, such as Netscape Navigator. The latter is Gagnon’s
main information retrieval and delivery vehicle. (For physicians,
the browser can be a powerful, inexpensive software tool that can
rapidly present information, including images and tabular data or
text, via hospital or desktop-based computers.)
As a veteran database expert, Gag-non appeared to think grandly
(envisioning statewide disease-forecasting capabilities in future
years) and conservatively (guarding against mission-creep or the
addition of nice but non-es-sent-ial elements). The origins of his
system in Vermont were humble, but they worked dependably. Some
of the early stages of development proved the overall concept was
not a boondoggle. "We built an online test catalog, a telephone
directory online, the ability to record cumulative reports for one
of our big physician offices," he explained.
Gagnon noted that one traditional difficulty with database design
has involved making a wide variety of hardware and software work
together. This systemic issue forced him to implement a robust,
simple design. "We put more weight on system interoperability than
features and functions," he noted. "System interoperability may
be far more important in the long term than the actual features
and functions you get. I’ve preached this for a long time."
Gagnon used garden-variety software, eliminating licensing fees.
He also used a simple Internet computer code, HTML. As Gagnon explained,
"We wanted low-bandwidth solutions; our state is pretty rural. No
intricate things going down that browser, just pretty much plain-vanilla
HTML. Most customers do have PCs. If they don’t, we provide them.
It’s that important that we have good data coming in to serve that
In other words, Gagnon could not assume that his users had new
or fancy modems or access to more futuristic devices for cruising
the information superhighway. Partly because of that limitation,
his programmers could not get too detailed. They restricted themselves
to bare-bones HTML, eschewing more powerful but less universal alternatives.
But the Spartan system in Vermont includes several features that
should save the hospital considerable amounts of money. For example,
as Gagnon explained, samples are bar coded in physicians’ offices,
reducing the potential for data entry errors later. Next, the system
automatically detects which billing codes go with which types of
tests. The system can spot inappropriate combinations of tests and
codes or those that were not reimbursed.
Noted Gagnon: "You can find all the tests where the letters ’G-L-U-C’
appear in the test. Obviously this is a nice standalone, but it
would be a whole lot nicer if you embedded it into the order entry,
and you did the order right then. I can add tests and diagnoses,
and I can ask the system to check the compliance. And it will tell
me, ’Oh, glucose is not covered under this diagnosis.’ And if I
wanted to know what does cover glucose, I can press a button and
it shows me." Such assistance from his system, Gagnon predicted,
will save his facility $250,000 annually.
Gagnon also described how he has made his system up-to-the-minute
and easy for busy physicians to master. The Web site contains a
page that shows users how to change the paper on their printers.
As he explained, "It reduces the number of phone calls I have to
While the motivating factor for the project at the University
of Vermont has been mostly economicGagnon conceded he hopes
to discourage competitorsthe project has a philosophical foundation.
"It’s really important that we get ourselves out in front of patients
to differentiate ourselves," Gagnon said, referring to pathologists.
He cited statistics about the use of alternative health care and
the tens of billions of dollars paid out-of-pocket by patients dissatisfied
with traditional medicine. "It’s clear people are choosing alternatives
and are willing to pay for it," he stated. "We have this ’Intel
inside’ problem in the labs. We need to get ourselves out there.
We need to establish ourselves."
Although much of the Pitts- burgh meeting was practical
in orientation, there was a sense that digital technologies could
have clinical importance beyond the next software release from Microsoft.
The presentation by Stephen S. Raab, MD, PhD, of Allegheny University
Hospitals, Pittsburgh, was a case in point. Dr. Raab’s background
in cytology has not deterred him from becoming knowledgeable about
outcomes researchand that informatics topic, in turn, bears
directly on how pathologists use technology.
"If you come out with a diagnosis of cancer," Dr. Raab said, "it
doesn’t mean as much to a clinician as using the diagnosis of cancer,
calculating the likelihood ratio, predicting the probability of
disease in the patient given that diagnosis. Likelihood ratioseven
though we don’t do them in pathologyhave been advocated for
a long time in clinical medicine."
But Dr. Raab added that the field of outcomes research has produced
an unequivocal but not especially surprising finding, which is that
pathologists often disagree about the interpretation of a particular
slide or section. Understanding how to minimize interobserver variability,
he said, could help pathologists anticipate the needs of clinicians
and patients, not be blindsided by them.
As an example, Dr. Raab cited the independent evaluation of how
pathologists assess bronchial brush specimenswith and without
the benefit of knowing the patient’s history. Data clearly show
more accurate diagnoses result when pathologists know a patient’s
history. Added Dr. Raab, "Even though we don’t interpret diagnoses
like this, there have been advocates in the clinical literature
that we should be interpreting results like this, because this is
what affects patient care."
While the relevance of outcomes analysis is just now being determined,
it is evident that the pathologist’s report could stand to be re--examined.
"If you look at the literature," said Dr. Raab, "you can see that
there has been poor agreement among pathologists on the information
product of what we’re sending out. But there hasn’t been much [research]
done on what does this mean for patient care, or what does this
mean for pathology practices?"
Equally far-reaching was the lecture by James H. Harrison Jr.,
MD, PhD, associate director of pathology informatics at the University
of Pittsburgh Medical Center. Dr. Harrison began by delving into
the terminology of data warehousing and data mining. He defined
the latter as the extraction of knowledge from data. Said Dr. Harrison,
"It may be more useful to define it operationally as the detection
and reporting of meaningful data patterns in large integrated data
He also introduced a less conventional term that he hoped would
gain wider acceptance, the "data-opsy," modeled on "biopsy." Dr.
Harrison defined data-opsy as "the extraction and analysis of a
sample of data from the medical record to identify clinically important
In Dr. Harrison’s view, a data set could be: text, images, or
statistics. And he is not imagining merely asking the computer to
find rudimentary information, such as all patients with a particular
condition. Rather, he is actively exploring the use of computers
in ways that begin to approximate human problem-solving. Neural
networks, he pointed out, allow physicians to tell a computer in
general terms what they are interested in and let the computer use
its methodical, tirelessly mechanical processes to find more of
In Pittsburgh, Dr. Harrison related, such techniques are already
helping the educational aspect of his program. "We were able to
find rules that screened out patients with drug-level profiles that
suggested the need for followup," he explained. "We let the students
go out and evaluate the cases. It was a great way to match up students
with cases that were appropriate for what they were studying at
the time. Few of those cases would have come to the students in
training if we hadn’t been able to look through large volumes of
data to find them."
Dr. Harrison also noted what is on the cutting edge, what might
work down the road. Today, he said, the computer might need hours
or even overnight to return an answer or a set of patients. But
in the future, if the data sets are configured and assembled properly,
it may be able to provide virtually instantaneous responses. Such
tools are not yet widely available in clinical settings, he added.
But they will be. "You can explore the data by submitting queries
that are designed to return populations of patients, then, based
on analysis of that data, you can immediately submit additional
queries to focus on the populations of greatest interest," he explained.
So what might these data warehouses do? Predict clinically significant
events. Shed light on the effects of actual clinical practice over
time. Even forecast which financial and medical resources will be
required for a particular patient. That all sounds promising, but
Dr. Harrison closed his remarks on a more subdued note. "If pathologists
do not take ownership of this area," he said, "the management of
this data and the resources required to produce it will pass out
of the control of pathology."
Mark Uehling is a freelance writer in Chicago.