IHE Anatomic Pathology DICOM WG 26 Dr Christel

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IHE Anatomic Pathology DICOM WG 26 Dr Christel DANIEL IHE Anatomic Pathology co-chair IHE

IHE Anatomic Pathology DICOM WG 26 Dr Christel DANIEL IHE Anatomic Pathology co-chair IHE Anatomic Pathology - San Diego 2011

Agenda l l l Results of recent IHE efforts Path. Lex Better use of

Agenda l l l Results of recent IHE efforts Path. Lex Better use of DICOM in Anatomic Pathology workflow – DICOM Modality Work list IHE Anatomic Pathology - San Diego 2011

Overview l Intra hospital integration profiles – Anatomic Pathology Workflow (APW) § l Ordering

Overview l Intra hospital integration profiles – Anatomic Pathology Workflow (APW) § l 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 IHE Anatomic Pathology - San Diego 2011

Organization of Anatomic Pathology Technical Framework 2010 Revision 2. 0 July 23, 2010 Draft

Organization of Anatomic Pathology Technical Framework 2010 Revision 2. 0 July 23, 2010 Draft for Trial Implementation 2011 2010 & 2011 Supplements for Trial Implementation IHE Anatomic Pathology - San Diego 2011

Anatomic Pathology Workflow (APW) l l Establishes the integrity of basic pathology data acquired

Anatomic Pathology Workflow (APW) l l 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. IHE Anatomic Pathology - San Diego 2011

Anatomic Pathology Workflow (APW) Hospital Care Ward Anatomic Pathology Laboratory Image Mgmt Image Archive/

Anatomic Pathology Workflow (APW) Hospital Care Ward Anatomic Pathology Laboratory Image Mgmt Image Archive/ Image Manager (PACS) Order Mgmt Order Placer Acquisition Modality Report Mgmt Order Filler Order result tracker IHE Anatomic Pathology - San Diego 2011

APW actors & transactions IHE Anatomic Pathology - San Diego 2011

APW actors & transactions IHE Anatomic Pathology - San Diego 2011

Standards used l HL 7 v 2. 5 – – l OML^O 21/ORL^O 22

Standards used l HL 7 v 2. 5 – – l OML^O 21/ORL^O 22 (PAT-1, 2 &4) ORU^R 01 + 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) IHE Anatomic Pathology - San Diego 2011

Test cases l Different « subspecialties » – – – l Surgical pathology (4

Test cases l Different « subspecialties » – – – l 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 IHE Anatomic Pathology - San Diego 2011

Test cases Specimen model : Usual situation Specimen can be identified by containers’ ID

Test cases Specimen model : Usual situation Specimen can be identified by containers’ ID Gross imaging Virtual slide IHE Anatomic Pathology - San Diego 2011

Test cases Unusual situation: Tissue Micro Array More than one derived specimen on 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 IHE Anatomic Pathology - San Diego 2011

Anatomic Pathology Reporting to Public Health (ARPH) l l l Joint initiative : IHE

Anatomic Pathology Reporting to Public Health (ARPH) l l l Joint initiative : IHE AP, HL 7 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 IHE Anatomic Pathology - San Diego 2011

Anatomic Pathology Reporting to Public Health (ARPH) Hospital Care Ward Anatomic Pathology Laboratory Healthcare

Anatomic Pathology Reporting to Public Health (ARPH) Hospital Care Ward Anatomic Pathology Laboratory Healthcare community Report Receiver Order Filler Report Sender Public Health Report Mgmt Clinics Report Sender Anatomic Pathology Laboratory

ARPH actors & transactions IHE Anatomic Pathology - San Diego 2011

ARPH actors & transactions IHE Anatomic Pathology - San Diego 2011

Standards used l HL 7 v 2. 5 – l l l LOINC SNOMED

Standards used l HL 7 v 2. 5 – l l l LOINC SNOMED CT NAACCR* – – l ORU^R 01 message (PAT-10) Standards for Cancer Registries Volume V: Pathology Laboratory Electronic Reporting v 3. 0 Search Term List International Classification of Diseases, 10 th rev (and 9 th rev) *NAACCR - North American Association of Central Cancer Registries (www. naaccr. org) IHE Anatomic Pathology - San Diego 2011

Anatomic Pathology Structured Report (APSR) l l Joint IHE and HL 7 anatomic pathology

Anatomic Pathology Structured Report (APSR) l l Joint IHE and HL 7 anatomic pathology initiative Content integration profile standardizing Anatomic Pathology Structured Report (APSR) using HL 7 CDA – – l 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 IHE Anatomic Pathology - San Diego 2011

Scope l APSR for surgical pathology – 21 CDA templates § Generic APSR template

Scope l APSR for surgical pathology – 21 CDA templates § Generic APSR template – § – l 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) IHE Anatomic Pathology - San Diego 2011

Background From clinical document models… l l Recent recommendations for required, preferred, and optional

Background From clinical document models… l l 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) – § 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 – § 67 cancer checklists and protocols (October 2009) 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 l Non healthcare IT standard – l CAP electronic

Background … to IT templates l Non healthcare IT standard – l CAP electronic Cancer Checklist Healthcare IT standard – CEN archetypes § – Australia HL 7 CDA § § Most reliable standard for clinical document templates Existing implementation guides for the APSR ? – Netherlands, Germany IHE Anatomic Pathology - San Diego 2011

Anatomic Pathology Structured Report (APSR) Hospital Care Ward Anatomic Pathology Laboratory Healthcare community Document

Anatomic Pathology Structured Report (APSR) Hospital Care Ward Anatomic Pathology Laboratory Healthcare community Document Repository Order Filler Document Source Document sharing Clinics Anatomic Pathology Laboratory Document Source

APSR actors & transactions l Content (Anatomic Pathology Structured Report) is created by a

APSR actors & transactions l Content (Anatomic Pathology Structured Report) is created by a Content Creator consumed by a Content Consumer. l 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. IHE Anatomic Pathology - San Diego 2011

CDA Document Content Module (n=21) Any APSR CDA document content module is composed of

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 IHE Anatomic Pathology - San Diego 2011

CDA Section Content Modules (n=6)

CDA Section Content Modules (n=6)

CDA Entry Content Module (n=5) e. g Diagnosis entry Diagnoses on all specimens that

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

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 IHE Anatomic Pathology - San Diego 2011

The CDA Iceberg Pathologist/clinician sees Machine sees IHE Anatomic Pathology - San Diego 2011

The pathologist/clinician sees… IHE Anatomic Pathology - San Diego 2011

The pathologist/clinician sees… IHE Anatomic Pathology - San Diego 2011

The pathologist/clinician sees… IHE Anatomic Pathology - San Diego 2011

The pathologist/clinician sees… IHE Anatomic Pathology - San Diego 2011

The machine sees… <Clinical. Document xmlns='urn: hl 7 -org: v 3'> <type. Id extension="POCD_HD

The machine sees… <Clinical. Document xmlns='urn: hl 7 -org: v 3'> <type. Id extension="POCD_HD 000040" root="2. 16. 840. 1. 113883. 1. 3"/> <!-- conformance to a generic APSR content module --> <template. Id root='1. 3. 6. 1. 4. 1. 19376. 1. 8. 1. 1. 1'/> <!-- conformance to a cancer APSR content module --> <template. Id root='1. 3. 6. 1. 4. 1. 19376. 1. 8. 1. 1. 2'/> <!-- conformance to a breast cancer content module --> <template. Id root='1. 3. 6. 1. 4. 1. 19376. 1. 8. 1. 1. 2. 1'/> . . . remainder of the header not shown. . . <component> <structured. Body> <component> <section> <template. Id root='1. 3. 6. 1. 4. 1. 19376. 1. 8. 1. 2. 1'/> <code='22636 -5' display. Name=’Pathology report relevant history' code. System='2. 16. 840. 1. 113883. 6. 1' code. System. Name='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> <template. Id root='1. 3. 6. 1. 4. 1. 19376. 1. 8. 1. 2. 1'/> <code='42349 -1' display. Name= ‘Reason for referral’ code. System='2. 16. 840. 1. 113883. 6. 1' code. System. Name='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

Better use of DICOM in Anatomic Pathology workflow DICOM Modality Work list IHE Anatomic

Better use of DICOM in Anatomic Pathology workflow DICOM Modality Work list IHE Anatomic Pathology - San Diego 2011

What is anatomic pathology? It is not radiology l Order => report Imaging procedure

What is anatomic pathology? It is not radiology l Order => report Imaging procedure step is optional l – l Specimen-driven – – One study = one or more specimen (one or more patients) Slides always available Order – l => imaging procedure => report Patient driven – One study = one patient IHE Anatomic Pathology - San Diego 2011

Modality Work list: Requested procedure, accession number & Study l Order & Requested procedure

Modality Work list: Requested procedure, accession number & Study l Order & Requested procedure – l 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 HL 7 v 2. x. IHE Anatomic Pathology - San Diego 2011

Modality Work list Procedure step & Series l Procedure Step – A Procedure Step

Modality Work list Procedure step & Series l 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). § l 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. IHE Anatomic Pathology - San Diego 2011

Modality Work list Requested procedures & procedure steps l OR 123: Lungectomy – Order

Modality Work list Requested procedures & procedure steps l OR 123: Lungectomy – Order DP 07110: Lungectomy § Study “Case” Order. Filler ID Accession Number = One Requested procedure DP 07110 -A: Left upper lobe (gross image) DP 07110 -A-1: Frozen section, mass l DP 07110 -A-1 -1: FS l DP 07110 -A-1 -2: H&E – DP 07110 -A-2: Entire mass l DP 07110 -A-2 -1: H&E (WSI) – Series Two “ (imaging) “procedure steps” IHE Anatomic Pathology - San Diego 2011

Modality Work list Requested procedures & procedure steps l Order : “AP examination of

Modality Work list Requested procedures & procedure steps l Order : “AP examination of Breast biopsy” – Requested procedure : “Imaging of AP examination of Breast biopsy” (at the patient level) = ACCESSION NUMBER = Order. Filler ID l (Imaging) procedure step: “scanning Slide DP 07110 -A-5 -1” (at the specimen/derived specimen level) l Order : “Mammography” Requested (imaging) procedure : “mammography” (at the patient level) – = ACCESSION NUMBER = Order. Filler ID IHE Anatomic Pathology - San Diego 2011

Modality Work list – – – A mechanism defined to support the imaging workflow,

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. IHE Anatomic Pathology - San Diego 2011

Modality Work list Requested procedures & procedure steps l Order : “AP examination of

Modality Work list Requested procedures & procedure steps l Order : “AP examination of Breast biopsy” – Procedure step: “scanning Slide DP 07110 -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 procedure l l Requested (imaging) procedure : “mammography” Worklist (attributes of the imaging subjec ) – List of requested procedures (patient/study level) IHE Anatomic Pathology - San Diego 2011

Modality Work list Specimen description DICOM Supp 122 : “Robust new Specimen Module at

Modality Work list Specimen description DICOM Supp 122 : “Robust new Specimen Module at image level of hierarchy” l Specimen short/detailed textual description Including specimen ancestry description in case of derived specimen l – – In conformance with DICOM supp 122, 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 DP 07110 -A-5 -1 § DP 07110 -A: Left upper lobe – DP 07110 -A-5: Left upper lobe/Tumor l DP 07110 -A-5 -1: H&E l DP 07110 -A-5 -1: Left upper lobe/Tumor/H&E IHE Anatomic Pathology - San Diego 2011

More information l l Googlegroup : ihe-anatomic-pathologycommittee@googlegroups. com Road map – http: //wiki. ihe.

More information l l Googlegroup : ihe-anatomic-pathologycommittee@googlegroups. com Road map – http: //wiki. ihe. net/index. php? title=Anatomic_Patho logy IHE Anatomic Pathology - San Diego 2011