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IHE PALM and DICOM WG26

Anatomic Pathology Physical Sample Creation Process and Related Data

(De-identified Examples from Duke University Health System)

March 11, 2019

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Digital Histology Workflow

Receive Specimen

Accession

Gross Bench (Tissue Block Creation)

Block Transport

Block Process

Block Embed

Block Cut (Glass Slide Creation)

Slide Stain

Slide Coverslip

Slide Image

Slide QC and Publish

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Pre-specimen Events

  • EHR Patient registration
  • EHR Encounter creation
  • Consent
  • EHR Order for pathology
  • Specimen collection triggered from order
  • Container label triggered from collection
  • Specimen marked as sent
  • Specimen marked as received in the laboratory

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Specimen arrives in a barcode labeled plastic specimen container or “bucket”

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A1

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No Barcode = NOT Supported

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Information System Transactions

  • LIS Accessioning creates “case”, “containers”
  • LIS Grossing creates “blocks”
  • LIS Histology processing creates “slides”
    • Physical glass slide with barcoded label applied
    • Digital scan automatically created in fully digital primary diagnosis workflows
  • LIS Microscopic review creates “diagnostic report”
  • LIS Verification publishes report to EHR chart
  • LIS Task (internal lab order) creates “special stains”, “IHC”, “digital scans”
    • Digital scan automatically created when slide returned for storage possibly based on criteria (such as metadata in LIS information model, e.g. best blocks for tumor)
    • Digital (re)scan manually created based on LIS task placement, e.g. for QA
  • LIS Task may be triggered by PACS (annotation or interface request)

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Radiology vs Pathology Workflow

  • Provider places order for Radiology imaging
  • Imaging study is scheduled
  • Patient arrives at scheduled time for study. Patient demographics and order details available in scanner worklist
  • Scan initiated from worklist; digital assets acquired by scanner
    • Worklist not typically needed for Pathology
  • Scanner deposits images in PACS and/or VNA
  • Radiologist annotates images in PACS and then follows PACS/RIS driven workflow
  • Dictates findings into electronic scribing system
  • PACS/RIS publishes finalized report to the EHR
  • Provider places order for lab/pathology test
  • Collection may occur immediately or may be scheduled for a future date/time
  • Workflow typically begins with specimen collection, followed by transport to laboratory
  • Lab staff accessions, labels before moving to gross bench
  • Gross imaging potentially occurs at multiple points during gross examination
    • Upon arrival, upon inking, upon sectioning for block designations
  • Microscopic imaging occurs following tissue processing, embedding, glass slide production with possible digital scanning
  • Digital analytics follows
  • Pathologist interacts with LIS and/or PACS for data entry, image viewing, analytics and reporting
    • Reflex imaging and analytics may occur

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Key Elements of the Pathology Report

  • Header with patient, encounter, and case identifiers
  • Clinical information to include questions for the pathologist to answer
  • Diagnoses
    • Gross examination, to include some kind of mapping of what each tissue block represents, which in turn from which representative glass slides are generated (H&E stained or others), which in turn from which one or more digital images are generated
    • Microscopic examination
    • Immunohistochemistry

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Header

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Gross Examination

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Diagnoses

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Gross Examination

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Diagnoses

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DICOM Data Model in Radiology

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https://www.slideshare.net/DevDays/mohannad-hussain-dicom-and-imaging-tools

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Patient Jane Doe

Study Pathology

SP19-0021

(Study Instance UID)

Gross Container A Procedure Step

Series for Gross Images of Uterus in Container A

Uninked image

Series for Gross Images of Ovary in Container A

Gross Container B Procedure Step

Micro WSI Procedure Step for Slide Scan

A1-1

H&E 20x

Slide Series

A1-1-1

A1-1-1 Image H&E 20x Base Layer

A1-1-1

Image Localizer (thumbnail)

A1-1-1

Image Label

Slide Series

A1-1-2 (e.g. because rescan initiated by tech for QC)

Procedure Step for Slide Scan A1-1

H&E 40x (pathologist initiated)

Study Specimen Radiograph 12322

Study

Procedure Steps

Series

Image