College of American Pathologists
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Blazing another path through digital wilderness

February 2002
Eric Skjei

Adding images to reports easily and economically has been the aim of Eric F. Glassy, MD, for the past five years. His solution, dubbed ImagedPath, shows early signs of meeting that need simply and elegantly.

"I started working on the program in 1996," says Dr. Glassy, who is a partner with Affiliated Pathologists Medical Group, Torrance, Calif. "At that time, I was just interested in putting four pictures on a report." Like many of his colleagues, Dr. Glassy found that most off-the-shelf software applications didn’t quite do the job. "Photoshop makes a poor word processor, and Word makes a poor image-manipulation program," he says.

After experimenting with traditional page-layout packages, such as PageMaker, Quark, Freehand, and Illustrator, Dr. Glassy settled on FileMaker, a popular desktop database program. "I like the ease of using a relational database, and it met our group’s requirements for a cross-platform solution that was also easy to use," he says.

Modules of the ImagedPath program, which is still in development, are being beta-tested at several sites in southern California, including Cedars Sinai Medical Center and Dr. Glassy’s hospital, Little Company of Mary.

Not a full-blown anatomic pathology system and "not a panacea," as Dr. Glassy puts it, ImagedPath is designed solely to create image-rich anatomic pathology reports-and to do that as well and as simply as possible. The program can be used on a Mac or PC, standalone or in a networked environment. It is designed to store and retrieve digital images and to facilitate the process of including them in reports, along with text annotations, other text elements, patient demographic data, branding elements such as provider logos, and patient education information.

ImagedPath is made up of several modules. The general pathology function and prostate and breast modules are operational. Other modules—skin, liver, and gastrointestinal—are still in development. When it is complete, the product will also include an online help function, search capabilities, and features that help users create customized graphics and reports.

One of Dr. Glassy’s goals was to make ImagedPath user-friendly, so support personnel can use it and pathologists can concentrate on interpreting specimens and capturing digital images. "I’ve tried to make it as simple as possible to minimize workflow disruption," he says. "I built the product so that it would support a workflow process in which the pathologist takes the photo, stores it on a central database, or inputs it directly on a support person’s PC or Mac." The support person then imports the image or images directly into ImagedPath using basic point-and-click functions, works through the other straightforward steps in creating the report, and prints it.

Like many pathologists, Dr. Glassy finds the image-handling capabilities of commercial anatomic pathology packages less than adequate. The effort he and other pathologists have exerted creating homegrown solutions, he says, is a tacit judgment of the limitations of these alternatives. "Not only does it underscore the lengths we are willing to go to generate a great report, it is also a commentary on the weakness of the current commercial anatomic pathology systems in this particular respect," he says.

Part of the problem, Dr. Glassy suggests, is that many commercial AP package-based imaging solutions are wedded to MS Word. "Word is a fine word-processing package, but it’s not designed to handle images well," he says. Using Word to handle images requires a fair amount of manipulation of Word’s templates and, even then, the adjustments don’t always deliver acceptable results. "Word templates don’t always manage placement of the images on the page well," he adds, "nor does this solution offer the advantage of a database solution," which lets you easily add canned text, annotation, and other elements, such as help screens.

But growing competition from large commercial labs that have, in recent years, been supplying image-rich reports to their clients has intensified the need for imaging. "Large labs like Dianon/Urocor and, more recently, LabCorp are providing reports with images, and it is difficult for pathologists in small groups to compete," Dr. Glassy says. "I wanted to create a report tool that was better than anything that the ’big boys’ were doing and put that tool into the hands of the average pathologist."

The completed prostate and breast ImagedPath modules are relatively robust and detailed. The breast module includes graphical representations for Scarff-Bloom-Richardson scores for gland formation, nuclear atypia, and mitotic activity. The prostate module includes Gleason scores and areas for adding information about the site, length of core, percent of carcinoma, and presence of high-grade prostatic intraepithelial neoplasia. It also supports ways to create biopsy images that show cancerous areas in red. "Urologists are very interested in showing what percentage of carcinoma is involved in that core biopsy, so we wanted to create a graphical representation for how much of the core is involved," Dr. Glassy says.

Dr. Glassy is particularly proud of the prostate module. "It has taken a lot of work to complete and is designed to help create a ’teaching moment’ between the urologist and the patient," he says.

The format of the prostate report is based on input from urologists, including several at the Cedars Sinai Medical Center Prostate Cancer Center. A typical ImagedPath prostate report might contain half a dozen pages:

  • The first, a standard cover sheet, includes the patient’s name, case
        number, demographics, who performed the procedure, and provider logo.
  • The second page contains a summary of findings, including biopsy
        findings with cancerous areas shown in red, Gleason score patterns, and
        several images with captions and annotations showing intraepithelial
        neoplasia, core biopsy, and carcinoma (high power).
  • The third page shows a prostate core biopsy report, with Gleason scores
        and cancerous areas.
  • The fourth page includes a Partin table prognostic summary report that
        indicates probabilities that carcinoma has spread outside the prostate,
        penetrated the capsule of the prostate, or spread to seminal vesicles or
        lymph nodes.
  • The last pages conclude with educational material describing Gleason
        scores, tumor staging, and PIN precursors to cancer, as well as
        prostate-specific antigen data and a list of related Web sites.

    For a demonstration disk (Mac or PC) and more information, contact Dr. Glassy at or visit the Web site

    Eric Skjei is a writer in Stinson Beach, Calif.