He concludes in his editorial:

“Where, then, does this leave the status of Web 2.0 with respect to medical issues? One may appropriately state that its potential for education and practice enhancement is real and considerable. It is also true that electronic publications of scientific data are easier than ever and more widely disseminated than hard-copy contributions. However, definite problems exist regarding the veracity of some e-articles in medicine, proliferation of “charlatanesque” entries in the electronic medical literature, misconceptions about the production of “personalized” e-medical data, and the lack of compatibility and accessibility of computerized information from one medical system to another. These issues must be resolved before Internet-centered facts can be integrated confidently into diagnostic and therapeutic paradigms.”

The two papers in AJCP this month are available below:

Pathology in the Era of Web 2.0. William E. Schreiber MD and Dean M. Giustini MLS, MEd.

Abstract:

In the past few years, the term Web 2.0 has become a descriptor for the increased functionality of Web sites, including those with medical content. Most physicians do not know what Web 2.0 means or how it can impact their work lives. This review provides some background on the evolution of Web 2.0 and describes how its features are being incorporated into medical Web sites. Some potential applications of Web 2.0 in pathology and laboratory medicine are discussed, as are the issues that must be considered when adopting this new technology.

Pilot Study of Linking Web-Based Supplemental Interpretive Information to Laboratory Test Reports. Brian H. Shirts, MD, PhD, Adi V. Gundlapalli, MD, PhD and Brian Jackson, MD.

Abstract:

Electronic medical records have the ability to link to reference material, providing clinicians with immediate access to information relevant to patient care. Adding relevant links to laboratory test results could add value while minimizing the volume of ancillary text presented.

We provided Web-based universal resource locator (URL) links with all results of 7 laboratory tests ordered at ARUP Laboratories (Salt Lake City, UT). URL links provided were modified 7 months later, and use between initial and subsequent URLs was tracked to establish frequency and duration of access to supplemental Web information.

Monthly Web-site hit rates for individual tests varied from 0.00% to 3.00% (median, 0.12%). Rare and specialty tests averaged higher hit rates. There was no decay in hit rate 9 months after URLs were removed from test reports.

We conclude that links to reference material are accessed by clinicians. The use of Web links months after links were no longer published raises an important issue of long-term maintenance and the resources required to support these features.

Computerworld – A Harvard Medical School study that looked at some of the nation’s “most wired” hospital facilities found that computerization of those facilities hasn’t saved them any money or improved administrative efficiency.

The recently released study evaluated data on 4,000 hospitals in the U.S over a four-year period and found that the immense cost of installing and running hospital IT systems is greater than any expected cost savings. And much of the software being written for use in clinics is aimed at administrators, not doctors, nurses and lab workers.

The study comes as the federal government prepares to begin dispensing $19 billion in incentives for the health industry to roll out electronic health records systems. Beginning in 2011, the Health Information Technology for Economic and Clinical Health (HITECH) Act will provide incentive payments of up to $64,000 for each physician who deploys an electronic health records system and uses it effectively.

The problem “is mainly that computer systems are built for the accountants and managers and not built to help doctors, nurses and patients,” the report’s lead author, Dr. David Himmelstein, said in an interview with Computerworld.

Himmelstein, an associate professor at Harvard Medical School, said that in its current state, hospital computing might modestly improve the quality of health care processes, but it does not reduce overall administrative costs. “First, you spend $25 million dollars on the system itself and hire anywhere from a couple-dozen to a thousand people to run the system,” he said. “And for doctors, generally, it increases time they spend [inputting data].”

Himmelstein said that only a handful of hospitals and clinics realized even modest savings and increased efficiency — and those hospitals custom-built their systems after computer system architects conducted months of research.

Read rest of story and download article below

Download AJM10662S200.pdf (107.1K)

DermatopathologyConsultations.com demonstrates how innovative pathologists are stepping up to apply new information technologies to make it easier for local pathologists to refer cases to expert subspecialist pathologists. The fact that Zembowicz and his colleagues are getting second opinion case referrals from other countries outside the United States is an early sign that—when it comes to recognized pathology subspecialty expertise—borders won’t mean much. Physicians will want their specimens reviewed by the best pathologist subspecialist in the field, regardless of where that individual lives and works.

I completely agree. While digital pathology often evokes concerns about offshoring pathology services, the fact of the matter is the vast majority of sub-specialty expertise and capacity is right here in the US of A. If we wanted to, as a pathology community, we could create vast opportunities for onshoring pathology services.

DPC blog has some comments on the story as well.

Click here to view the embedded video.

From the website:

The technique used in this table is already utilized suc­cessfully as a compliment to the conventional autopsy. Apart from avoiding cutting in the body the doctors can see things that are difficult to discover in a conventional autopsy. Furthermore, the technique opens up for new op­portunities in countries where autopsies are not accepted due to cultural reasons. The technique can also revolution­ize the traditional health care in many areas.

The intuitive way in which these images can be manipulated seems to me to add significantly to the usefulness of these scans. A multi-touch interface like this would be an interesting alternative for navigation of digitized slides.

a) Optical layout (b) Current prototype (c) Brightfield image of fluorescent beads. (d) Fluorescent images of beads shown in (c).

Counterintuitively, in these parts of the world, excellent cell phone service is often available. From the article:

. . . we have built a mobile phone-mounted light microscope and demonstrated its potential for clinical use by imaging P. falciparum-infected and sickle red blood cells in brightfield and M. tuberculosis-infected sputum samples in fluorescence with LED excitation. In all cases resolution exceeded that necessary to detect blood cell and microorganism morphology, and with the tuberculosis samples we took further advantage of the digitized images to demonstrate automated bacillus counting via image analysis software.

Software on the phone can catalog and analyze the images, and important data can be gathered for epidemiological purposes. Another quote:

Not only could such a mobile phone microscopy system help alleviate the problems of inadequate access to clinical microscopy in developing and rural areas, but it would provide those areas remote access to digital record keeping, automated sample analysis, expert diagnosticians, and epidemiological monitoring – the latter enhanced by the ease of location-tagging patient data by cellular triangulation or GPS location data.

(a) Thick smear of Giemsa-stained malaria-infected blood. (b) Thin smear of Giemsa-stained malaria-infected blood. (c) Sickle-cell anaemia blood.

This is an awesome idea.

1. Validation: Laboratories are required to perform validation testing on prior samples to ensure that the new test or new method is performing in a clinically meaningful manner.
2. Post Implementation monitoring: In the initial period after a test becomes available for prospective testing on clinical patients, most laboratories perform a higher than normal level of monitoring of test performance in order to ensure that there are no problems or that any problems are resolved.
3. Proficiency testing: Laboratories are required by College of American Pathologists and CLIA to perform periodic testing of the performance of the assay to ensure that the test that was initially validated is still performing as expected for the samples tested.

With Information Systems, regulations and accreditation hold information system support staff and faculty responsible for validation and for post-implementation (go-live) monitoring of any change to the Information systems.

However, where is the proficiency testing? We can show logs of what we have done to validate and monitor our systems, but how does any regulatory agency know that any information system is adequate for its use?

• Can the information system handle the volume of information that it is currently being given? What if there is a sudden increase in volume?
• What are the disaster recovery plans for the information system? Do they have backups? How quickly are those backups able to be restored? Do they have redundant hardware in case of a hardware failure?
• How many downtimes does a system have? Why? How long are they? Is this reasonable?
• Is the system business-continuous? Shouldn’t all systems have some impetus to gain true business-continuity since healthcare is a 24/7 business with frequent time-sensitive needs to gain information?
• How does a test order look in the entry system? Does the system require that certain fields be completed before the order is sent? Does the provider have an easy way to get help if the order that he/she is looking for is not available in the order catalog?
• For paper orders, does the information system flag the person entering the order into the system to gather any missing information, effectively preventing them from going further until the information is acquired?
• For non-CPOE systems, does the system allow a user to attach an order to a generic “non” physician in the ordering provider field? If it does, is there some sort of reminder to the user at a later time to update the information when possible so that the specimen can be processed in the immediate term but still reminds them to get the correct provider in a timely manner? For communication about critical or unexpected results, it is imperative to know with whom to communicate.
• For interfaced systems, what are the limitations of the interface? What results are not crossing and cause medical staff to have to search for results on paper rather than in the LIS or EMR?
• Do providers (including pathologists) have access to all retrospective data on all patients and not just a small subset of laboratory or other history?

These are just a few things that a well-designed proficiency testing program could objectively evaluate and grade. Grading and accrediting these systems according to best practices, regulations and standards (HIPAA, HL7, barcoding, etc.) could provide impetus for vendors to improve their software products to gain certification/accreditation that could then be used for marketing while improving the tools that laboratorians and others have to use to provide needed care to patients in an efficient and meaningful manner.

By the way, the opinions expressed in this blog post are my own. Completely. Entirely. No exceptions. They certainly do not represent the opinions of anyone other than myself or any entity, including any organization in which I hold membership, for whom I work or with whom I have had the opportunity to conduct business.

I would also recommend looking at some of their other videos, here, as they are all impressively well done and deal with topics from S. pneumo to immune-mediated tumor responses.

Enjoy…

Click here to view the embedded video.

A screenshot of the slide viewer in action.

A team at the NYU School of Medicine’s Division of Educational Informatics has created a brilliant implementation of a virtual slide viewer using the Google Maps API. They are using their viewer to view digital slides acquired using Bacus and Aperio slide scanners.  In my opinion, this is superior in some ways to the viewers I’ve used from commercial vendors. Check out the NYU system here.

As a side note:  One concern I have about existing whole slide imaging technologies is the proprietary nature of the associated software platforms, and the resulting reliance on a certain vendor’s product for access to archival materials.  At present, Bacus / Olympus and Aperio make their viewing software, but not their source code, freely available for download (though Aperio is a contributor to open-source initiatives, e.g. their contributions to the libtiff project, which I applaud). As far as I know, industry standards for whole slide imaging are still evolving, particularly with regard to their relationship to new and existing software patents. I am hoping we can look forward to a totally transparent and open standard–one that will encourage innovation and, in the long run, result in better technologies and better patient care.