Dr Christel DANIEL IHE Anatomic Pathology co-chair IHE Anatomic Pathology DICOM WG26 IHE Anatomic Pathology - San Diego 2011.

Dr Christel DANIEL

IHE Anatomic Pathology co-chair

IHE Anatomic Pathology DICOM WG26

IHE Anatomic Pathology - San Diego 2011

Agenda

Results of recent IHE efforts PathLex Better use of DICOM in Anatomic

Pathology workflow– DICOM Modality Work list


Overview

Intra hospital integration profiles– Anatomic Pathology Workflow (APW)

Ordering and performing anatomic pathology examinations

Community– Anatomic Reporting for Public Health (ARPH)

Sending anatomic pathology reports to public health organizations

– Anatomic Pathology Structured Report (APSR) Sharing/exchanging structured anatomic pathology

reports as CDA documents


Organization of Anatomic Pathology Technical Framework

20102010 20112011

Revision 2.0 July 23, 2010Draft for Trial Implementation

2010 & 2011 Supplements for Trial Implementation


Anatomic Pathology Workflow (APW)

Establishes the integrity of basic pathology data acquired for examinations being ordered for an identified patient

Defines the actors and transactions involved in– Ordering and reporting aspects of the workflow

Order entry, report creation and transmission.

– Imaging aspects of the workflow Image acquisition, storage and distribution among

multiple systems.


Anatomic Pathology Workflow (APW)

Order Placer

Image Mgmt

Acquisition Modality

Order Mgmt

Order Filler

Care Ward Anatomic Pathology Laboratory

Hospital

Image Archive/Image Manager

(PACS)

Order result tracker

Report Mgmt


APW actors & transactions


Standards used

HL7 v2.5– OML^O21/ORL^O22 (PAT-1, 2 &4)– ORU^R01 + report (PAT-3)

DICOM– DICOM 2003 PS 3.4: Modality Worklist SOP Class (PAT-5 & 6) – DICOM 2007 PS 3.4: Storage Service Class– DICOM 2007 PS 3.4: Storage Commitment Push Model SOP

Class– DICOM 2007 PS 3.4: Query/Retrieve Service Class– Supplement 122 : Specimen Identification Module and Revised

Pathology SOP Classes– Supplement 145 : Whole Slide Image Information Object

Definition (WSI IOD)


Test cases

Different « subspecialties »– Surgical pathology (4 cases)– Biopsies (2 cases)– Cytopathology (2 cases)– Autopsy (1 case)– TMA (1 case)

Complex relationships specimen/container– 1 specimen per container– Several specimen per container


Test casesSpecimen model : Usual situation

Specimen can be identified by containers’ ID

Gross imaging

Virtual slide


Test cases Unusual situation: Tissue Micro Array

More than one derived specimen on slide coming from the different blocks coming from different parts and from different patients


Anatomic Pathology Reporting to Public Health (ARPH)

Joint initiative : IHE AP, HL7 AP, NAACCR (North American Association of Central Cancer Registries), CDC (Centers for Disease Control).

Defines the actors and transactions involved in anatomic pathology reporting to public health organizations.

Global Perspective of Cancer Surveillance– International Association of Cancer Registries

241 Registries (Voting Member) from all 6 continents– North American Association of Central Cancer Registries

All Canadian Provinces All US States All US Territories and Jurisdictions


Order Filler


Report Sender

Hospital

Anatomic Pathology Reporting to Public Health (ARPH)

Healthcare community

Report Receiver

Public Health Report Mgmt

Report Sender

Anatomic Pathology Laboratory

Clinics

ARPH actors & transactions


Standards used

HL7 v2.5– ORU^R01 message (PAT-10)

LOINC SNOMED CT NAACCR*

– Standards for Cancer Registries Volume V: Pathology Laboratory Electronic Reporting v3.0

– Search Term List International Classification of Diseases, 10th

rev (and 9th rev)*NAACCR - North American Association of Central Cancer Registries (www.naaccr.org)


Anatomic Pathology Structured Report (APSR)

Joint IHE and HL7 anatomic pathology initiative Content integration profile standardizing

Anatomic Pathology Structured Report (APSR) using HL7 CDA

– APSR as CDA documents including Anatomic Pathology observations bound to images or regions of interest

– Shared or exchanged within a community of care providers using existing integration profiles defined by IHE Information Technology Infrastructure

Unique opportunity to share/exchange Anatomic Pathology Structured Reports that are semantically interoperable at an international level


Scope

APSR for surgical pathology– 21 CDA templates

Generic APSR template– All fields of anatomic pathology (inflammatory, vascular, traumatic,

metabolic diseases as well as cancer) 20 organ-specific cancer APSR templates

– “Traditional” anatomic pathology observation using light microscopy (including immunohistochemistry, FISH, etc)

Further cycles– Forensic (autopsy, toxicology)– Special ancillary techniques (flow cytometry, cytogenetics,

electronic microscopy)– Research (TMA, etc)


BackgroundFrom clinical document models…

Recent recommendations for required, preferred, and optional elements for any APR of surgical pathology, regardless of report types [Goldsmith 08]

National initiatives– Anatomic Pathology SR (Netherlands, Germany, Australasia)– Cancer APSR

US - CAP (College of American Pathologists)– 67 cancer checklists and protocols (October 2009)

France - SFP (French society of pathology) – INCa (French National Cancer Institute)

– Minimum data sets for cancer APSR in 20 locations (85% of new cancers in France) (required by accrediting bodies)

Australasia– 6 templates for cancer APSR

UK Royal college

Goldsmith, J.D., et al., Reporting guidelines for clinical laboratory reports in surgical pathology. Arch Pathol Lab Med, 2008. 132(10): p. 1608-16.

Background … to IT templates

Non healthcare IT standard– CAP electronic Cancer Checklist

Healthcare IT standard– CEN archetypes

Australia

– HL7 CDA Most reliable standard for clinical document templates Existing implementation guides for the APSR ?

– Netherlands, Germany


Order Filler


Document Source

Hospital

Anatomic Pathology Structured Report (APSR)

Healthcare community

Document Repository

Document sharing

Anatomic Pathology Laboratory

Clinics

Document Source

APSR actors & transactions

Content (Anatomic Pathology Structured Report) is created by a Content Creator consumed by a Content Consumer.

Sharing or transmission of content from one actor to the other – XDS, XDM and XDR Integration Profiles, described in

Volume 3 of the Anatomic Pathology Technical Framework.


CDA Document Content Module (n=21)

Any APSR CDA document content module is composed of a header and a structured body.

2 types of CDA Document Content Modules Generic APSR (1.3.6.1.4.1.19376.1.8.1.1.1)20 organ-specific cancer APSR


CDA Section Content Modules (n=6)

CDA Entry Content Module (n=5)e.g Diagnosis entry

Diagnoses on all specimens that are delivered to the pathology reported separatly

Additional pathologic finding(s), results of ancillary studi(es) & images

In case of cancer, this section includes the cancer checklists

Anatomic Pathology Observation

[0..*] <value> (zero to many response)coded (code, coding system, version, display name)

[0..*] <qualifier> (post coordinated expression)

numeric (integer or real, unit)textual

The CDA Iceberg

Pathologist/clinician sees

Machine sees


The pathologist/clinician sees…


The pathologist/clinician sees…


The machine sees…

<ClinicalDocument xmlns='urn:hl7-org:v3'> <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>  <templateId root='1.3.6.1.4.1.19376.1.8.1.1.1'/>  <templateId root='1.3.6.1.4.1.19376.1.8.1.1.2'/>  <templateId root='1.3.6.1.4.1.19376.1.8.1.1.2.1'/> ...remainder of the header not shown ... <component> <structuredBody> <component> <section> <templateId root='1.3.6.1.4.1.19376.1.8.1.2.1'/> <code code='22636-5' displayName=’Pathology report relevant history' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <title>Relevant information provided by the ordering physician</title> <text> Tissue submitted: left breast biopsy and apical axillary tissue </text> <entry> ... </entry> <component> <section> <templateId root='1.3.6.1.4.1.19376.1.8.1.2.1'/> <code code='42349-1' displayName= ‘Reason for referral’ codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <title>Reason for anatomic pathology procedure</title> <text>Breast mass - left breast</text> <entry> ... </entry> </section> </component> <component> IHE Anatomic Pathology - San Diego 2011

DICOM Modality Work list

Better use of DICOM in Anatomic Pathology workflow


What is anatomic pathology?It is not radiology

Order – => reportImaging procedure

step is optional Specimen-driven

– One study = one or more specimen (one or more patients)

– Slides always available

Order – => imaging

procedure => report

Patient driven– One study = one

patient


Modality Work list: Requested procedure, accession number & Study

Order & Requested procedure– The Order Filler translates the received Orders into Requested

Procedure(s) identified by Order Filler Numbers and automatically assigns Study Accession Numbers

Accession number <-> Order Filler Number– The unique identifier assigned by the Pathology Information

System of an Anatomic Pathology laboratory to an imaging Study.

– As expressed in DICOM Supplement 122: The concept of “accession” in Anatomic Pathology has been determined to be sufficiently equivalent to an “accession” in Radiology so that the existing Accession Number at the Study level may be reused for the same purpose and with essentially the existing definition.

– For Anatomic Pathology, like in Radiology, the Accession Number may correspond to the Order Filler Number, as specified in HL7 v2.x.


Modality Work listProcedure step & Series

Procedure Step– A Procedure Step (“Work Order Step”) is an atomic

operation belonging to Requested Procedure, to be performed on one specimen by a single type of device (e.g. immune-histo-chemistry automaton, staining automaton, image acquisition modality).

Some Procedure Steps are dedicated to image acquisition Series

– A subset of an imaging Study acquired from a single specimen by a single acquisition modality.

– Whenever an image is acquired from a new specimen or involves a new acquisition modality a new Series is created.

– A new series is also created when an image is acquired for an existing study after the original order has been fulfilled.


Modality Work listRequested procedures & procedure steps

OR123: Lungectomy– DP07110: Lungectomy

DP07110-A: Left upper lobe (gross image)– DP07110-A-1: Frozen section, mass

DP07110-A-1-1: FS DP07110-A-1-2: H&E

– DP07110-A-2: Entire mass DP07110-A-2-1: H&E (WSI)


Order

Study“Case”

OrderFiller IDAccession Number

=One

Requested procedure

Two “procedure

steps”

SeriesTwo “

(imaging) procedure

steps”


Order : “AP examination of Breast biopsy”

– Requested procedure : “Imaging of AP examination of Breast biopsy” (at the patient level)

= ACCESSION NUMBER = OrderFiller ID

(Imaging) procedure step: “scanning Slide DP07110-A-5-1”

(at the specimen/derived specimen level)

Order : “Mammography”– Requested (imaging)

procedure : “mammography”

(at the patient level)= ACCESSION

NUMBER = OrderFiller ID


Modality Work list

– A mechanism defined to support the imaging workflow, by which the Patthology Information System provides the attributes of the imaging subject to modalities.

– In anatomic pathology, the imaging subject is a specimen derived from the patient.

– Query Modality Worklist: “Based on a query entered at the Acquisition Modality, a modality worklist is generated listing all the items that satisfy the query. This list of Scheduled Procedure Steps with selected demographic information and information about specimen is returned to the Acquisition Modality.”

The Modality Worklist provides patient, order (study) and specimen identification and description to be included in the acquired images.

The attributes of the Specimen Module have been defined in a ‘Macro’ construct, and added to the Scheduled Procedure Step Module of Modality Worklist.



Order : “AP examination of Breast biopsy”

– Requested procedure Procedure step:

“scanning Slide DP07110-A-5-1”

Worklist (attributes of the imaging subject)

– List of requested procedures (patient/study level)

– List of procedure steps (specimen/series level)

Order : “Mammography”

– Requested (imaging) procedure : “mammography”

Worklist (attributes of the imaging subjec )

– List of requested procedures (patient/study level)


Modality Work listSpecimen description

DICOM Supp 122 : “Robust new Specimen Module at image level of hierarchy”

Specimen short/detailed textual descriptionIncluding specimen ancestry description in case of

derived specimen– In conformance with DICOM supp122, the short textual

description of a specimen retrieved from the Order Filler is a concatenation of the short description of the specimen and all the short descriptions of the specimen ancestry

– Example : Whole Slide Image of DP07110-A-5-1 DP07110-A: Left upper lobe

– DP07110-A-5: Left upper lobe/Tumor DP07110-A-5-1:H&E DP07110-A-5-1: Left upper lobe/Tumor/H&E


More information

Googlegroup : [email protected]

Road map– http://wiki.ihe.net/index.php?

title=Anatomic_Pathology

Dr Christel DANIEL IHE Anatomic Pathology co-chair IHE Anatomic Pathology DICOM WG26 IHE Anatomic Pathology - San Diego 2011.

Documents

anatomic pathology reports

ihe ap

dicom dicom

report pat

report creation

hl7 cda apsr

workflow image acquisition

workflow order entry