Informatics and the Future of Pathology (and Medicine): Making a Case for The Need for Computational Pathologists

Michael J. Becich, MD PhD - becich@pitt.eduChairman, Department of Biomedical Informaticshttp://www.dbmi.pitt.eduUniversity of PittsburghSchool of Medicine

Slide 2

Disclosures by MJB· Corporate Support for API and APIII

– 750K projected for 2013 [Cerner, Misys, GE, IBM, IMPAC, McKesson - Cisco, Verizon, CAP Today - Aperio, Apollo, Applied Imaging, De-ID Corp, GE Medical Systems/Triple G, Nikon, Omnyx, Olympus, SCC Soft, Sysmex, SNOMED, PSA, ThermoFisher, Zeiss, multiple others]

· Startup/Public Companies (Royalties, Licensing or Stock - MJB):– Omnyx – Joint Venture with UPMC and GE (http://www.omnyx.com) –

digital pathology– De-ID (http://www.de-idata.com/) licensing payments to DBMI and DBMI

staff/faculty) – deidentification software for text medical records

· Consultancy– Empire Genomics – Physician Advisory Board (paid)– NinePoint Medical – Technical Advisory Board (http://www.ninepointmedical.com/) –

in vivo microscopy– Pathology Education Consortium (PEC) with Bruce Friedman (volunteer)– Cancer Center Consulting – MD Anderson, Moffitt Cancer Center, NFGC,

UMDNJ, U CO, VCU (honorarium)– CTSA Consulting – Duke, MCW, Northwestern, U AK, UC Davis, U Chicago,

UCLA, U KY, U NM, U MN, UC Davis, U WI/Marshfield, Wash U (honorarium)

Goals for today’s discussion

• “Disruptive Technologies” and their Impact on the Practice of Pathology

• CAP Transformations – wake up call• Redefining the populations we serve• Issues with AP and CP integration• The role of Pathology Informatics in

Computational Pathology – call to action!!

Goal• How will new technologies impact

the future of pathology?• Key areas of evolution:

– Molecular Path – Next Generation Sequencing– Imaging – Whole Slide Imaging– Personalized Medicine – Next Generation

Warehousing of Data, Tissue/Blood and DNA– Medical Records and “Real” Decision Support– AP/CP Integration (Patient Oriented Reports)

Objective

• Today we will discuss trends in technology in Medicine and Pathology that will impact the way our profession is practiced in the next 5 to 10 years.– Focus will be on making the case for

“Computational Pathologists” in Pathology Informatics Programs

– Impact on Pathology’s Future– How to enable this transformation?

Pathology Informatics is a Domain of

Clinical Informatics

Today’s Situation

• AP and CP are not integrated• Molecular Diagnostics has no

Laboratory Information system to support it

• Imaging integration is in its infancy• Decision Support is Crude• Pathologists are playing a passive

role in MMR, DS and Info Mgmt

How Did We Get Here?• Pathology Reports have not changed

in decades – this is a major problem• Original assumptions (pathologist as

consultant to MDs) about the scope of our practice may no longer be valid

• Pathology leadership is not Informatics savvy but progress is at hand.

• Training Programs do not support the Informatics/Tech needs of trainees

New Technologies and Their Impact• Whole Slide Imaging / Digital Pathology Workflow

– WSI technology is maturing rapidly– GE, Phillips, Siemens all launching products– “Companion Diagnostics” are enabling deeper (and more

complex) diagnostics

• Next Generation Sequencing (NGS)– Massively parallel sequencing is here and 2nd generation

machines (ABI, Illumina, etc…) are being replaced by 3rd generation technology (Ion Torrent, PacBio, etc…)

– Implications are that an entire human genome can be done in a laboratory in about a month for about $10K

– Goal with new technology is a few days and about $1K!!!

6/9/2007

Modified with permissionFrom Montalto,

2007 CAP Futurescape

Lung

http://www.pathologyinformatics.org/Resources/ldip2103.jpg

Today

Digital Can Improve Quality of Care in Pathology

H&E

1850 - Present

Automated subcellular localization of RRM1 in 187 stage I NSC Lung Cancer patients, stratifies patients following surgical treatment.

Lung

Automated IHCAQUATM

Modified with permissionFrom Montalto, 2007 CAP Futurescape

Advanced Diagnostics Enabled by Digital Pathology

Ginty F, The relative distribution of membranous and cytoplasmic Met is a prognostic indicator in stage I and II colon cancer , Clinical Cancer Research, June 15 2008

Diagnostic innovation/invention are key to our future

Circulating Tumor Cells

Use of Imaging Tools

Clinical and Anatomic Pathology Convergence

From Schwartz, CAP, 2009Perspective on the Future of Pathology

Digital Pathology Timeline360-sec20x scan

20-second40x multi-angle scan

60-sec20x scan

Multispectral imaging

Imag

ing

Pathology PACS

Enterprise image management

100 PetabytesPetabytes100 Terabytes

Sto

rage

Subspecialistwork flow

triage

Rapidsecondary

consultations

Computer-aided detection

Computer-aided diagnosis

Ap

pli

cati

ons

2007 2012 2017

* Source: Sg2 T3 Virtual Slide Imaging

Modified from: From Schwartz, CAP, 2009Emerging Developments and Your Future in Pathology

• This evolution will require development of sophistication in pathology departments in the areas of• Decision Support Tools• Intelligent Archiving• Image Processing and

Analysis• Computer Assisted

Vision for CAD• These are the domains of

Computational Pathology!!!

Industry recognizes the opportunity

Are diagnostics the new wonder drug on

Wall Street?

From Schwartz, CAP, 2009Perspective on the Future of Pathology

Slide 16

WSI is key to the evolution of Surgical Pathology

• Tumor diagnostics (which represents the majority of surgical pathology practice) are becoming increasingly important and complex– In our aging population patients survive with multiple cancer occurrences & die

with their tumors not from them• Pathology itself is changing from primarily diagnostics to increasingly

complex theranostics (personalized medicine)– Will require digital pathology/WSI for these advanced tools

• Unlike clinical pathology (high degree of automation and quality control) anatomic pathology is not automated– Doesn’t easily render itself to standardization and quality control measures.

• We need to begin the evolution of this important aspect of medicine as surg path case volume is expected to double in the next 5 years!!!

Personalized medicine and theranostics• Theranostics is applying the

power of pathology to predict therapeutic response

• Determining whether a treatment is working

• Monitoring healthy people to detect early signs of disease

• Producing safer drugs by predicting potential for adverse effects earlier

• Targeting groups of people most likely to benefit from a drug, while keeping its use from those who may be harmed by it

• Producing better medical products• Ready access to information• Decreasing health care costs

Modified from: From Schwartz, CAP, 2009Emerging Developments and Your Future in Pathology

Next Gen Sequencing

From Mark Boguski’s presentation at the IOM, July 19, 2011

Next Gen Sequencing

From Mark Boguski’s presentation at the IOM, July 19, 2011

From Mark Boguski’s presentation at the IOM, July 19, 2011

From Mark Boguski’s presentation at the IOM, July 19, 2011

From Mark Boguski’s presentation at the IOM, July 19, 2011

From Mark Boguski’s presentation at the IOM, July 19, 2011

As Medicine evolves from the treatment of illness to aggressive promotion of wellness – genomics/informatics will be key!!!!

DATA & SYSTEMS INTEGRATION

EVOLUTIONARY PRACTICES

DIS

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IGH

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Automated systems

Organized(error-reduction)

Nonspecific(treat symptoms)

1st generation diagnostics

Information Correlation

Personalized(disease prevention)

HEALTHCARE TODAY

HEALTHCARE TODAY

TRANSITIONAL MEDICINETRANSITIONAL MEDICINE

PERSONALIZED HEALTHCARE

Genetic Predisposition TestingGenetic Predisposition Testing

Clinical Clinical GenomicsGenomics

Molecular MedicineMolecular Medicine

CACA--diagnosisdiagnosis

Lifetime TreatmentLifetime Treatment

PrePre--symptomatic Treatmentsymptomatic Treatment

Digital ImagingDigital Imaging

Episodic TreatmentEpisodic Treatment Artificial Expert SystemArtificial Expert SystemElectronic HealthElectronic Health

RecordRecord

Moving from the treatment of illness to the aggressive

promotion of wellness

SOURCE: IBM LIFE SCIENCES SOLUTIONS

DATA & SYSTEMS INTEGRATION

EVOLUTIONARY PRACTICES

DIS

TR

IBU

TE

D H

IGH

-TH

RO

UG

HP

UT

AN

AL

YT

ICS

REV

OLU

TIO

NA

RY

TEC

HN

OLO

GIE

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Automated systems

Organized(error-reduction)

Nonspecific(treat symptoms)

1st generation diagnostics

Information Correlation

Personalized(disease prevention)

HEALTHCARE TODAY

HEALTHCARE TODAY

TRANSITIONAL MEDICINETRANSITIONAL MEDICINE

PERSONALIZED HEALTHCARE

Genetic Predisposition TestingGenetic Predisposition Testing

Clinical Clinical GenomicsGenomics

Molecular MedicineMolecular Medicine

CACA--diagnosisdiagnosis

Lifetime TreatmentLifetime Treatment

PrePre--symptomatic Treatmentsymptomatic Treatment

Digital ImagingDigital Imaging

Episodic TreatmentEpisodic Treatment Artificial Expert SystemArtificial Expert SystemElectronic HealthElectronic Health

RecordRecord

Moving from the treatment of illness to the aggressive

promotion of wellness

SOURCE: IBM LIFE SCIENCES SOLUTIONS

Modified from: From Schwartz, CAP, 2009Emerging Developments and Your Future in Pathology

Computational Pathology will be the key enabler!!!

Recommendation• Phase One

– Focus on Building Training Opportunities• Residency, Fellowships, Pathology Informatics 201X• Launch first Computational Pathology Fellowships

– Focus on Developmental Informatics Agenda• Secure Intramural and Extramural Funding• Take Leadership Role in New Technologies and CoSBBI

• Phase Two– Use Technologies for Transforming Pathology

• Report Integration, Data Warehousing, Next Generation Sequencing, Imaging, Decision Support

Pathology Informatics 2014 (formerly APIII) 19th Annual Meeting May 9th-13th, Pittsburgh, PA

http://apiii.upmc.edu

1996-1999 Anatomic Pathology, Imaging & Internet

2000-2003 Anatomic and Clinical Pathology

2004-2007 Oncology & Bioinformatics

2008-10 Imaging Informatics – Radiology and Pathology

2010-14 Merger of Lab InfoTech Summit and APIII to form “Pathology Informatics 201X”

http://www.pathinformatics.pitt.edu

Slide 28

Association for Pathology Informatics (API)http://www.pathologyinformatics.org

“…to advance the field of pathology informatics as an academic and a clinical subspecialty of pathology…”

Computational Pathology Fellowships• Why this “new” fellowship is key!

– Pathology Informatics is now established as a “division” or “subspecialty” in may practices• This is perceived as a service component to Pathology

Practice – the Information Technology component

– Academic Pathology Informatics is emerging• Struggles from the lack of defined research focus• PathoBioinformatics (coined by Friedman, 2007) is the

domain of Computational Pathology• This is the true “Informatics” component of Path Info

– These fellows will help build the research leaders!!!

Recommendation• Phase Three

– Partner with other Specialties• Oncology, Radiology and Biomedical Informatics

– Evolve a Pathology Centric Information Plan• Pathology Emerges as Medicine’s Information Specialist

– Leverage this position to create new opportunities• Molecular Pathology Enables Personalized Medicine• The Data, Tissue/Blood and DNA Trusted Source• Diagnostic Interventional Centers Fueled by Imaging

Systems and Staffed by Pathology/Radiology

Summary

• Pathology is uniquely situated to evolve towards taking information technologies that emerge and integrate them into deeply into the practice of medicine

• Aggressively recruit trainees in Computational Pathology and Pathology Informatics (my passion!!!)

• Influence leadership in Pathology to grow the solutions in this space!!!

Slide 32

• Park S, Parwani AV, Aller RD, Banach L, Becich MJ, Borkenfeld S, Carter AB, Friedman BA, Rojo MG, Georgiou A, Kayser G, Kayser K, Legg M, Naugler C, Sawai T, Weiner H, Winsten D, Pantanowitz L. The history of pathology informatics: A global perspective. J Pathol Inform. 2013 May 30;4:7. doi: 10.4103/2153-3539.112689. Print 2013.

• Lee RE, McClintock DS, Balis UJ, Baron JM, Becich MJ, Beckwith BA, Brodsky VB, Carter AB, Dighe AS, Haghighi M, Hipp JD, Henricks WH, Kim JY, Klepseis VE, Kuo FC, Lane WJ, Levy BP, Onozato ML, Park SL, Sinard JH, Tuthill MJ, Gilbertson JR. Pathology informatics fellowship retreats: The use of interactive scenarios and case studies as pathology informatics teaching tools. J Pathol Inform. 2012;3:41. doi: 10.4103/2153-3539.103995. Epub 2012 Nov 28.

• Gullapalli RR, Desai KV, Santana-Santos L, Kant JA, Becich MJ. Next generation sequencing in clinical medicine: Challenges and lessons for pathology and biomedical informatics. J Pathol Inform. 2012;3:40. doi: 10.4103/2153-3539.103013. Epub 2012 Oct 31.

• Gullapalli RR, Lyons-Weiler M, Petrosko P, Dhir R, Becich MJ, LaFramboise WA. Clinical integration of next-generation sequencing technology. Clin Lab Med. 2012 Dec;32(4):585-99.

• Fine JL, Grzybicki DM, Silowash R, Ho J, Gilbertson JR, Anthony L, Wilson R, Parwani AV, Bastacky SI, Epstein JI, and Jukic DM. Evaluation of whole slide image immunohistochemistry interpretation in challenging prostate needle biopsies. Hum Pathol, 39(4):564-72. 2008.

• Horbinski C, Fine JL, Medina-Flores R, Yagi Y, Wiley CA. Telepathology for Intraoperative Neuropathologic Consultations at an Academic Medical Center: A 5-Year Report. J Neuropathol Exp Neurol, 66(8):750-9. 2007.

• Raab SS, Grzybicki DM, Condel JL, Stewart WR, Turcsanyi BD, Mahood LK, Becich MJ. Effect of lean method implementation in the histopathology section of an anatomic pathology laboratory. J Clin Pathol. 2008 Nov;61(11):1193-9. Epub 2007 Aug 3. PMID: 17675533

• Gilbertson JR, Ho J, Anthony L, Jukic DM, Yagi Y, Parwani AV. Primary histologic diagnosis using automated whole slide imaging: a validation study. BMC Clin Pathol, 6:4. 2006.

• Becich, M.J. Patel A.A. and Jukic D.M. A Diagnostic Virtual Microscope System for Whole Slide Robotic Imaging: The Value of Virtual Slides for the Practice of Pathology. Gu, J. and Ogilvie, R.W., Eds., Virtual Microscopy and Virtual Slides in Teaching, Diagnosis and Research, Taylor & Francis, Boca Raton, 2005;19; 297-312.

• Becich, M.J. The role of the Pathologist as tissue refiner and data miner: The impact of functional genomics on the modern pathology laboratory and the critical roles of Pathology Informatics and Bioinformatics. Molec Diag. 2000;5(4):287-299.

Key Publications by Our Team – NOTE: Please e-mail me at becich@pitt.edu if you want PDFs

End of Talk – e-mail me at becich@pitt.edu if you have questions/clarifications not covered in the discussion.

NOTE: E-mail me if you want PDFs of articles or presentation.

Thank you for the invitation to present to the CoSBBI UPCI

Summer Academy.