10/30/2015 1 8003. In‐Sourcing Digital Consults: Is it For Me? Toby C. Cornish, MD, PhD Assistant Professor Director of Pathology Informatics Johns Hopkins University In the past 12 months, I have not had a significant financial interest or other relationship with the manufacturer(s) of the product(s) or provider(s) of the service(s) that will be discussed in my presentation. Speaker Disclosure The Johns Hopkins Hospital • Baltimore, Maryland, USA • Founded 1889 • 1,059 beds • Surgical pathology caseload of ~80k cases per year • 5 total hospitals in Baltimore/D.C. metro area Pathology Consult Service at JHH • True consults and confirming (“transfer”) consults • Expert consults provide value to all parties: – To the patient – To the submitting pathologist – To the consulting pathologist Consult case volume: 1985‐2014 3410 4143 3668 4020 3902 4357 4597 5436 5632 6826 8466 9648 11386 11960 13278 16501 19743 21340 23786 22775 24628 28177 33385 33936 33512 32972 36559 36256 33700 33069 0 5000 10000 15000 20000 25000 30000 35000 40000 Cases Five Year Moving Average JHH Consult Service 2013 (Jan‐Dec) Case type Number of cases True 26,482 Confirming 6,770 Total 33,252 Case type Number of cases True 1,521 Confirming 687 Total 2,208 Surgical Pathology Cytopathology
Transcript
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8003. In‐Sourcing Digital Consults: Is it
For Me?
Toby C. Cornish, MD, PhDAssistant Professor
Director of Pathology Informatics
Johns Hopkins University
In the past 12 months, I have not had a significant financial interest or other relationship with the manufacturer(s) of the product(s) or provider(s) of the service(s) that will be discussed in my presentation.
Speaker Disclosure
The Johns Hopkins Hospital
• Baltimore, Maryland, USA
• Founded 1889
• 1,059 beds
• Surgical pathology caseload of ~80k cases per year
• 5 total hospitals in Baltimore/D.C. metro area
Pathology Consult Service at JHH
• True consults and confirming (“transfer”) consults
• Expert consults provide value to all parties:
– To the patient
– To the submitting pathologist
– To the consulting pathologist
Consult case volume: 1985‐2014
34104143
36684020
39024357 4597
54365632
68268466
964811386
1196013278
16501
1974321340
2378622775
24628
28177
3338533936
3351232972
3655936256
3370033069
0
5000
10000
15000
20000
25000
30000
35000
40000
Cases
Five Year Moving Average
JHH Consult Service 2013 (Jan‐Dec)
Case type Number of cases
True 26,482
Confirming 6,770
Total 33,252
Case type Number of cases
True 1,521
Confirming 687
Total 2,208
SurgicalPathology
Cytopathology
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Consult Service at JHH
• Domestic true consult volumes have flattened out
• Our international consultation volumes are relatively low compared to domestic
• Can we use digital pathology expand our international volume?
• What about China?
Why China?
Graphic Courtesy of Ms. Chrystal Adams, Xifin, 2013 Source: Li Jing, South China Morning Post, Feb. 7, 2014
Chinese Market
• The potential Chinese consultation market is estimated to be around $1.3 billion
• Human specimens, including glass histology slides, cannot be sent out of China
• Language and payment create significant barriers
Chinese Market, cont.
• Strong central push toward telemedicine and telepathology in China
– Notice on Strengthening the Administration of Telemedicine Consultation, Ministry of Health (1999)
– National Health and Family Planning Commission (NHFPC) Circular 51 on Telemedicine (2014)
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Implementing digital telepathologyfor international consultations
International Telepathology
• Many notable examples:
– Armed Forces Institute of Pathology (AFIP)
– UICC Telepathology Center (2000)
– iPath platform (c. 2002)
– MECES platform (2011)
– Virtual International Pathology Institute (VIPI)
– SAHZU‐UCLA Joint Academic Center for Diagnosis (2010)
JH wish list for features
• Web‐based
• Easy to use for our admins and pathologists
• Low up front investment in time/money
• Optional LIS interfacing
• Pre‐existing Chinese partner(s)
• Mechanisms to address language barriers
• Facilitation of payment for services
Considerations & Challenges
• Technical
• International
• Legal
• Human
• Business
Technical Considerations
• Standard medical information requirements still apply:
– Security
– Privacy / Confidentiality
– Data integrity
– Availability
Technical Considerations
• Specific to telepathology:
– Content delivery
• Location of Digital Slide Repository (i.e. server)
• Network performance: bandwidth & latency
• “Great Firewall of China”
– Platform choice
– Vendor interoperability
• No standard Whole Slide Image (WSI) format exists
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Content Delivery
• Serving WSI viewer imagery with high performance and high availability
• Poorly thought out content delivery can cripple an otherwise highly functional system
• Depends upon:– Bandwidth and latency
– What is being moved:• Whole slide images (WSIs)
• Viewport imagery for a viewer
Remote DSRLocal
Image data needed byWSI Viewer (Viewer data)
Remote Digital Slide Repository
Don’t do this!It will work, but is a suboptimalsolution for China.It might be workable in other international situation
WSI ZoomViewer: A Vendor Neutral HTML5 Whole Slide Image Viewer. Tseytlin E, ParwaniAV, Cable W, Pantanowitz L. WSI ZoomViewer: A Vendor Neutral HTML5 Whole Slide Image Viewer. Presented at Pathology Informatics 2015.
DIY: Advantages
• Complete control over the platform
• Complete control over branding / marketing
• Complete control over client relationships
• Customize to fit your workflow and information systems
• No vendor fees
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DIY: Disadvantages
• Building and maintaining the platform yourself can be costly & time‐consuming
• User support
• Hardware management
• No pre‐built client relationships
• Manage all translation & collection activities
Customer‐hosted Vendor System
UCLA ‐ SAHZU Collaboration
• Second Affiliated Hospital of Zhejiang University (SAHZU)
• Created SAHZU‐UCLA Joint Academic Center for Diagnosis
• c. 2010 – present
– Initially Implemented on an Aperio Spectrum Server hosted in Hongzhou, China
– Since re‐engineered to use a local PathXL server
Customer‐Hosted: Advantages
• Relatively straightforward setup for telepathology portion
• Complete control over client relationships, branding, marketing, etc.
• No per‐case vendor fees
• May be able to leverage the system for other use cases
Customer‐Hosted: Disadvantages
• May still have to build portions (depending on product)
• Maintenance fees
• Hardware management
• Firewall / VPN issues
• If the server resides with the submitting site, no ability to bring on additional client sites
• No pre‐built client relationships
• Vendor product may not be have a consultation‐specific workflow
• Need to optimize content delivery
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Vendor Consultation Network
Vendor Consultation Network
• Joined two networks:– Xifin ProNet (formerly PathCentral)
– Leica/Aperio ePathAccess Network
• Business model:– Vendor provides an online marketplace and platform for consultants and contributors
– Vendor charges the consultant and/or contributor either an annual fee or a per‐case fee
• “First and largest” esoteric clinical laboratory conglomerate in China
• Over 3000 hospital clients, including 1100 level 3 hospitals
• Serving more than 600 cities, and 31 provinces
• Annual growth rate of over 50% in both sales and employees for the past 4 years
System Overview
Contributing Pathologists
Central Lab
Consulting Pathologists
ConsultationNetwork
Case submission
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Contributing Pathologists
Consulting Pathologists
Reporting
ConsultationNetwork
Creating a Consultation Request1. Scanned WSIs are
associated with case
2. Patient and case information is entered
3. Scanned documents and additional image files can be attached to the case
4. A consult request letter is attached
Chinese language localization of user interface
Consultation Request
View WSIs
View outside documents
View WSIs in the Case
Final Diagnosis Report.pdf
Entering the Diagnosis
Enter text diagnosis here
Attach final Report PDFhere
Send report
Considerations & Challenges
• Technical
• International
• Legal
• Human
• Business
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“20% technology and 80% sociology”
– A description of medical informatics attributed to Reed Gardner (or occasionally Homer Warner)
International Barriers: Language
• We do have translation services at the hospital level, but are not using them
• We receive information in English and return reports in English
• The user interface of the software needs to be localized for use in China
International Barriers: Payment
• In China, consultations are out‐of‐pocket expenses for the patient
• Fluctuating currency exchange rates
– Either reimbursement for services or cost for services subject to change
– Must be willing to accept some risk in exchange rates (or convince someone else to)
Source: Google Finance
Chinese Yuan per USD: past 5 years
Chinese Yuan per USD: past 1 year
Legal: Contracts
• Initially, our lawyers were comfortable with contracts with the network consultation platform only
• Now, we are getting contracts directly with the hospitals to which we plan to supply consultation services
• Getting push‐back from Chinese hospitals who want a memorandum of understanding instead
Legal: Ambiguity
• Chinese laws and regulation of international telemedicine are sparse
• National Health and Family Planning Commission (NHFPC) Opinion on Telemedicine (August, 2014)
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NHFPC Medical Issue 2014 Number 51 NHFPC Medical Issue 2014 Number 51
• Recent conversations with the Director of the National Health and Family Planning Commission have clarified:
– The opinion does not constitute law or regulation
– The opinion serves as guidance for provincial health bureaus to implement telemedicine
– No provincial regulations have resulted from the opinions
NHFPC No. 51: Agreements
• Our lawyers are of the opinion that this applies to international telemedicine
• “Cooperation agreement” ‐> formal contract
NHFPC No. 51: Informed Consent
• All patients must consent in writing when telemedicine services will be used
Malpractice insurance
• Chinese hospitals are self‐insured
• This makes our lawyers nervous
• Has added additional language to our contracts to distance us from any primary responsibility for the diagnosis
Human Factors
• Would our pathologists be accepting of digital consults?– No pathologists refused to be part of the digital consultation group despite being able to opt‐out
– 29 pathologists on the roster
• Human issues remain– Forgotten usernames, passwords (no Single Sign On)
– Confusion about SOPs
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Special Stains
• How do we get additional stains on cases?
• Normally, we would request blocks or unstained slides
• Tissue can’t leave China
• Rely on the contributing lab to perform the stain
• Makes having a large reference lab partner advantageous
• No formal mechanism for requesting stains ‐‐ use the “send message” function
Volume
• Case volumes have been low
• Low volumes make the process “occasional” rather than routine
• Low volumes are tolerable because we haven’t invested large sums of money
• Single biggest issue
Contrast to UPMC & UCLA
• UCLA
– Directly partnered with SAHZU
– Over 2000 cases since 2010
• UPMC
– Directly partnered with KingMed Diagnostics
– 1251 cases (from 1/2012 to 8/2014)
Re‐thinking our approach in China
• Two key aspects have been missing:
1. Direct relationships with partners in China
2. Better marketing of services in China
Building relationships in China
• Started working directly with several groups in China
• Growing multifaceted relationships that include educational, collaborative, and consultative pieces
• Engaging with a Chinese Consultation Platform (Bingsheng)
Building relationships in China
• Most notably, Zhejiang DIAN Diagnostic, Ltd
– Largest publically‐traded reference lab in China
– We have launched a number of initiatives, including digital consultation
• Also talking directly with several top cancer hospitals in China
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Collaborative Agreement Signing 3/25/2015
Marketing JH Pathology in China
• Estimated about 80‐85% of Chinese Pathologists don’t speak English
• We have an abysmally small Chinese‐language footprint
