Practical Image File Management

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Practical Image File Management

• Beyond an Integrated Solution

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Digital Imaging Advantages

• Image quality assessed at capture time no
  developing delays
• Images immediately available (for pathologists,
  clinicians)
• Presentations for conferences with much shorter
  notice
• Images easily duplicated with 100 fidelity
• Images cant be lost (as easily)
• Images can be accessed from many places
  self-service
• No film costs no developing costs
• Eliminates need for storage space for slides,
  slide tracking procedures, slide developing
  procedures, slide labeling procedures, and slide
  retrieval/re-filing procedures

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Digital Imaging Disadvantages

• Resolution of usable images generally poorer
  than traditional 35mm film cannot rely on
  subsequent magnification
• Acquisition software and procedures vary from
  manufacturer to manufacturer can be more
  difficult to learn
• Up front costs tend to be higher
• Staying current software goes out of date before
  hardware
• Need to develop an electronic storage system and
  cataloguing procedures to assure the preservation
  and availability of the images

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Digital vs Traditional Photography
Digital
Traditional
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High Magnification Digital Images
Anterior structures of normal adult eye
Ear of patient with Beckwith-Wiedemann Syndrome
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Practical Aspects of a Digital Imaging Solution

• A successful deployment will be determined more
  by ones attention to the practical details
  rather than the technical details
• Solutions require careful consideration of needs
  and workflow issues
• Need to consider ALL three aspects of the process
  
• Acquisition
• Storage
• Utilization
• Begin with the last step Utilization

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Digital Image Utilization

• What will the images be used for?
• Documentation
• Viewing at signout
• Embedding in patient reports
• Projection at conferences
• Incorporation into lectures/presentations
• Quantitative image analysis
• Building an educational resource
• Avoid trap I want the highest quality images at
  highest resolution, since I dont know for sure
  what I will use the images for.

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Putting it all togetherImplementing Digital
Imaging

• Discussions are driven / motivated by what you
  plan to do with the images (hopefully)
• Research, planning, budgeting processes all focus
  on the hardware
• What are we going to use to acquire the images?
• What are we going to use to display the images?
• Image file storage and management are often
  overlooked, and if not properly planned and
  implemented, can lead to overall project failure

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Digital Image Storage and Management
Options for a Solution

• Buy it
• Integrated Vendor Solutions
• Stand-alone image management software
• Build it

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Typical Vendor Approach to Integrated Imaging

• Case-centric Acquisition
• Bring up case acquire image(s) into case
• Integrated Image Capture
• A limited selection of compatible imaging
  hardware is available
• LIS calls capture module which acquires the
  images and hands it back to the LIS
• Allows entry of information about the images
• Handles issues associated with image storage and
  access
• Stores the image and entered information in an
  internal, perhaps even proprietary format
• Captured Images can be...
• ...viewed from multiple workstations in
  association with the case
• ...embedded within clinical reports

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Advantages of Integrated Imaging Solutions
(from an image storage/management perspective)

• Off-the-shelf solution
• Minimal set-up time
• Built in Dont need to think about it
• Image storage is invisible to the user
• it just happens
• Images are stored with the current case,
  decreasing the chances of misfiling
• Accommodates storage of information (such as when
  acquired, who by, etc) about each image
• Allows access to and use of images within the LIS

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Disadvantages of Integrated Imaging Solutions
(from an image storage/management perspective)

• Image acquisition limited by/to
• ...workstations running the LIS
• ...hardware which the LIS will recognize
• ...case locking / workflow issues
• Images may be trapped in the LIS
• Images not available for use for other purposes
  without exporting
• Exporting often has to be done one image at a
  time
• Access to images may be lost if migrate to a
  different LIS
• Access to the images is limited to those who have
  access to the patient data
• All image types treated essentially the same

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Our Problem(s)

• We knew we wanted to move to digital images
• We have CoPath
• Runs under Windows, but we have all Macs deliver
  application using Citrix
• PICSPlus module requires camera to be attached
  to computer running CoPath
• We already had some digital cameras, none of
  which were approved by Cerner for use with
  CoPath
• Wanted to use images for patient reports, but
  also for teaching, presentations, etc.
• We didnt want our images trapped in the LIS
• ....... therefore......BUILD IT

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Digital Image Storage and Management
Image acquisition devices AND image utilization
needs will likely change over time however, your
initially chosen image storage methodology will
probably outlast every other part of the overall
solution

• Workflow Issues to be Considered
• Where will the images be acquired (one place,
  many places)?
• What types of images will be acquired digitally
  (gross, microscopic, EM, documents)?
• Who will need access to the images and how will
  they get access?
• Where will the images be accessed from?
• What type of image access is needed (view,
  download, annotate)?
• How long will the images be available/accessible?
  
• How many images do you expect to have?

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Digital Image Storage and Management
(continued)

• Technical Issues to be Considered
• What file format will be used for the images
  (JPEG, TIFF, J2K)?
• Where will the images be stored (hardware
  device)?
• What is the structure of the image storage
  (directories, database)?
• How will the images get into storage (who, what
  tools)?
• What assurances are there that images are stored
  in the right place?
• Positive identification of images while in
  storage and when exported
• Does access to the images need to be restricted?
  If so, how?
• How will the images be backed-up? Incremental or
  bulk?
• Is the storage solution scalable? How scalable?
• How will images be archived/purged?
• Are the answers to the above the same for all
  image types?

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Solution to the Integrated Imaging Problem

• Disconnect image acquisition from image filing
  and storage
• Two step process
• Acquire image and place in a holding area
• Move image from holding area to final storage
  location(s)
• Separates acquisition hardware/software
  requirements from the LIS
• Allows multiple acquisition methods to feed a
  universal storage
• Changes to the LIS do not require modifications
  to the acquisition solutions
• Dual image storage modalities
• One in the LIS for integration into reports
• One as flat image files, organized and managed
  based on the type of images, for easy
  accessibility and maximal usability

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Image File Naming Convention
To assure that images are uniquely identified,
associated with the correct case, and readily
located, a standardized naming convention is used
for ALL CLINICAL IMAGES
PPYYYY-AAAAAAcNN-dddd.fff
File extension image file format (should be .jpg)
1 or 2 Letter Specimen Prefix (eg, S, A, SB)
1 character lower case image type code
4 digit year
OPTIONAL Dash plus up to 4 character (lower
case) description abbreviation
g gross photograph m photomicrograph c
cytology i immunofluorescence e electron
micrograph r imaging study f FISH study d
document a additional study u unknown x
external report y Yale Path report z
requisition form
6 digit accession number (with leading zeros)
2 digit sequential number (start with 01 for each
type code)
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Yale Pathology Clinical Imaging
Gross Image Capture
Photomicrographs
Electron Micrographs
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ImgUpload for the Macintosh
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Intranet Access to Image Repository
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Document Imaging
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Document Imaging

• Paperless is a common buzz-word in modern
  information management
• Electronically imaging documents yields many of
  the same advantages as going digital does for
  images
• Accessibility
• Availability
• Storage
• Not all documents are created equal
• Requisitions
• External Results
• Pathology Reports

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Document Imaging
Requisitions at Accession evaluation and
billing No No 6 months 2 years
External Reports anytime when
available No Perhaps forever unclear
Path Reports Case Signout N/A Yes N/A forever
unclear

• When Acquired
• When Needed
• Does it Change?
• Embed in Path Report?
• How long needed?
• How long archived?

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Requisition Handling Issues

• Sometimes contain useful clinical information
• Desirable to have available at time of signout
• Frequent sorting
• Primary copy sorted to allow collating with
  working drafts
• Gross room copy sorted for filing
• Billing copy transferred to Accounting service
  for Registration
• Sorted after signout for filing
• Removed from working drafts and sent for
  microfilming
• Need to be retained for minimum of 2 years

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Requisition Handling Costs

• With gt90,000 cytology specimens and gt45,000
  surgical specimens per year, represents about
  150,000 unique documents, most of which are
  copied at least once to support our workflow
• Department was spending 15-25K per year for
  microfilming or contracted digital archiving
  services
• The major cost is man-hours spent sorting,
  copying, collating with working drafts,
  distributing, resorting, removing from working
  drafts, removing staples, resorting, sending for
  microfilming
• Minimum of 5-10 hrs / day department-wide, or
  approximately 1 FTE
• Does NOT include time spent looking
  for/retrieving documents

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Electronic Requisition Forms

• We do not get the information electronically
• Scanning solutions must consider
• Workflow needs
• Scanning speed
• Appropriate/accurate labeling of files (scanned
  documents) to allow retrieval
• Error handling
• Availability of scanned documents for review by
  attendings
• Long term storage of scanned documents

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Document Archiving Solution

• Create barcode labels and affix to documents
• Scan documents
• Use software to read barcode labels and rename
  documents
• Resample/downsize the documents
• Use existing image filing solution to file the
  documents in a separate file repository
• Use existing image Upload software for manually
  addressing unreadable barcodes

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Document Labeling Before Scanning

• Want to label documents with barcodes
• Requisition forms do not arrive pre-barcoded
  significant outreach material
• Would like to label with the accession number
  not known in advance
• Human readable as well as machine readable
  desired
• Confidence in filing
• Allows manual filing of unreadable barcodes
• Solution System-generated barcode slide-labels
• Required creating a custom application object in
  CoPath
• Can make on the fly ability to make more
• Can use existing label printers
• Label size small enough not to obscure document
• Barcode labels can also be used on other things
  (eg specimen containers)

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Creating Document Labels in CoPath
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Document Scanning

• Document Scanning Requirements
• Produce images of sufficient resolution to allow
  resolving small barcodes
• Fast automatic feed
• Easy to use without training
• Accommodate variability in paper weight, quality,
  and smoothness
• Reliable maintained (preferably by someone else)
• Redundant and Multi-site
• Solution Upgraded our rented copiers to ones
  with scanning capabilities
• Copier can create TIFF files (black and white)
  and scan to a networked drive
• Small incremental cost
• In some cases, needed to run new network lines

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Scanned Document Images
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Labeling Reality
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Requisition Image Filing

• Automate the filing process have software read
  the barcodes
• Barcode Reading Software issues
• Barcode size must accommodate 11 alphanumeric
  characters
• Small barcode font requires high resolution label
  printer and scanner
• Software needs to be resistant to variations in
  label placement and alignment
• Solution Custom Software
• Scanned document (5100x6600 550KB TIFF) placed in
  a Requisition Drop folder
• Folder action immediately detects file and runs a
  Perl script
• Perl script uses Barcode Reading Software from
  Softek to read accession number
• Also uses Image Processing software to
  down-sample the image into a 1000x1294 pixel,
  270KB JPEG image
• New JPEG image file renamed to image file naming
  convention and placed into the Image Drop folder
• Image filing engine files the document in the
  requisition repository

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Yale Pathology Clinical Imaging
Requisition Form
Images in Reports
Gross Images
Electron Micrographs
Photo-micrographs
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Requisitions Available via Existing Web Interface
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Outcome

• We are currently accumulating
• 2,500 images per month
• 5,000 requisition forms per month from Sept 2005
  through Apr 2007 (Surg Path only)
• gt12,000 requisition forms per month since
  implementing in Cytology
• 4 document scans per day have to be manually
  filed because the bar-code could not be read
• In most cases, the person scanning forgot to put
  the bar-code label on
• No more sending of requisitions for microfilming
• Unexpected benefit requisitions readily
  available for responding to insurance denials
• Have also created a final report repository

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Thank you for your time and attention
The Yale Pathology ITS Team Dr. Peter
Gershkovich Aggie Daley János Löbb Katie
Henderson Brian Paquin Sophia Gyory Garry
Archer Wolfgang Freis Emma Walz-Vaitkus
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Practical Pathology Informatics Demystifying
informatics for the practicing pathologist
John H. Sinard, MD, PhD

• The Scope of Pathology Informatics
• Desktop Computers Hardware
• Desktop Computers Software
• Networking and the Internet
• Databases
• Pathology LIS Relationship to Institutional
  Systems
• Evaluating Anatomic Pathology Information Systems
• Digital Imaging in Anatomic Pathology
• Video Microscopy and Telemicroscopy
• Electronic Interfaces and Data Exchange
• Case Identification by Diagnosis
• External Regulations Pertinent to LIS Management
• Pathology Informatics and the Future of Medicine