IHE Anatomic Pathology
DICOM WG26
Dr Christel DANIEL
IHE Anatomic Pathology co-chair
IHE Anatomic Pathology - San Diego 2011
Agenda



Results of recent IHE efforts
PathLex
Better use of DICOM in Anatomic
Pathology workflow
–
DICOM Modality Work list
IHE Anatomic Pathology - San Diego 2011
Overview

Intra hospital integration profiles
–
Anatomic Pathology Workflow (APW)


Ordering and performing anatomic pathology
examinations
Community
–
Anatomic Reporting for Public Health (ARPH)

–
Sending anatomic pathology reports to public health
organizations
Anatomic Pathology Structured Report (APSR)

Sharing/exchanging structured anatomic pathology
reports as CDA documents
IHE Anatomic Pathology - San Diego 2011
Organization of Anatomic Pathology
Technical Framework
2010
Revision 2.0 July 23, 2010
Draft for Trial Implementation
2011
2010 & 2011 Supplements for Trial
Implementation
IHE Anatomic Pathology - San Diego 2011
Anatomic Pathology Workflow (APW)


Establishes the integrity of basic
pathology data acquired for examinations
being ordered for an identified patient
Defines the actors and transactions
involved in
–
Ordering and reporting aspects of the workflow

–
Order entry, report creation and transmission.
Imaging aspects of the workflow

Image acquisition, storage and distribution among
multiple systems.
IHE Anatomic Pathology - San Diego 2011
Anatomic Pathology Workflow (APW)
Hospital
Care Ward
Anatomic Pathology
Laboratory
Image Mgmt
Image Archive/
Image Manager
(PACS)
Order
Mgmt
Order Placer
Acquisition Modality
Report Mgmt
Order Filler
Order result
tracker
IHE Anatomic Pathology - San Diego 2011
APW actors & transactions
IHE Anatomic Pathology - San Diego 2011
Standards used

HL7 v2.5
–
–

OML^O21/ORL^O22 (PAT-1, 2 &4)
ORU^R01 + report (PAT-3)
DICOM
–
–
–
–
–
–
DICOM 2003 PS 3.4: Modality Worklist SOP Class (PAT-5 & 6)
DICOM 2007 PS 3.4: Storage Service Class
DICOM 2007 PS 3.4: Storage Commitment Push Model SOP
Class
DICOM 2007 PS 3.4: Query/Retrieve Service Class
Supplement 122 : Specimen Identification Module and Revised
Pathology SOP Classes
Supplement 145 : Whole Slide Image Information Object
Definition (WSI IOD)
IHE Anatomic Pathology - San Diego 2011
Test cases

Different « subspecialties »
–
–
–
–
–

Surgical pathology (4 cases)
Biopsies (2 cases)
Cytopathology (2 cases)
Autopsy (1 case)
TMA (1 case)
Complex relationships
specimen/container
–
–
1 specimen per container
Several specimen per container
IHE Anatomic Pathology - San Diego 2011
Test cases
Specimen model : Usual situation
Specimen can be identified by
containers’ ID
Gross imaging
Virtual slide
IHE Anatomic Pathology - San Diego 2011
Test cases
Unusual situation: Tissue Micro Array
More than one derived
specimen on slide
coming from the different
blocks coming from
different parts and from
different patients
IHE Anatomic Pathology - San Diego 2011
Anatomic Pathology Reporting to
Public Health (ARPH)



Joint initiative : IHE AP, HL7 AP, NAACCR (North
American Association of Central Cancer
Registries), CDC (Centers for Disease Control).
Defines the actors and transactions involved in
anatomic pathology reporting to public health
organizations.
Global Perspective of Cancer Surveillance
–
International Association of Cancer Registries

–
241 Registries (Voting Member) from all 6 continents
North American Association of Central Cancer Registries



All Canadian Provinces
All US States
All US Territories and Jurisdictions
IHE Anatomic Pathology - San Diego 2011
Anatomic Pathology Reporting to Public
Health (ARPH)
Hospital
Care Ward
Anatomic Pathology
Laboratory
Healthcare
community
Report
Receiver
Order Filler
Report Sender
Public Health
Report Mgmt
Clinics
Report Sender
Anatomic Pathology
Laboratory
ARPH actors & transactions
IHE Anatomic Pathology - San Diego 2011
Standards used

HL7 v2.5
–



LOINC
SNOMED CT
NAACCR*
–
–

ORU^R01 message (PAT-10)
Standards for Cancer Registries Volume V: Pathology
Laboratory Electronic Reporting v3.0
Search Term List
International Classification of Diseases, 10th
rev (and 9th rev)
*NAACCR - North American Association of Central Cancer Registries (www.naaccr.org)
IHE Anatomic Pathology - San Diego 2011
Anatomic Pathology Structured Report
(APSR)


Joint IHE and HL7 anatomic pathology initiative
Content integration profile standardizing
Anatomic Pathology Structured Report (APSR)
using HL7 CDA
–
–

APSR as CDA documents including Anatomic Pathology
observations bound to images or regions of interest
Shared or exchanged within a community of care providers
using existing integration profiles defined by IHE Information
Technology Infrastructure
Unique opportunity to share/exchange Anatomic
Pathology Structured Reports that are
semantically interoperable at an international
level
IHE Anatomic Pathology - San Diego 2011
Scope

APSR for surgical pathology
–
21 CDA templates

Generic APSR template
–

–

All fields of anatomic pathology (inflammatory, vascular, traumatic,
metabolic diseases as well as cancer)
20 organ-specific cancer APSR templates
“Traditional” anatomic pathology observation using light
microscopy (including immunohistochemistry, FISH, etc)
Further cycles
–
–
–
Forensic (autopsy, toxicology)
Special ancillary techniques (flow cytometry, cytogenetics,
electronic microscopy)
Research (TMA, etc)
IHE Anatomic Pathology - San Diego 2011
Background
From clinical document models…


Recent recommendations for required, preferred,
and optional elements for any APR of surgical
pathology, regardless of report types [Goldsmith 08]
National initiatives
–
–
Anatomic Pathology SR (Netherlands, Germany, Australasia)
Cancer APSR

US - CAP (College of American Pathologists)
–

France - SFP (French society of pathology) – INCa (French National
Cancer Institute)
–

Minimum data sets for cancer APSR in 20 locations (85% of new cancers in
France) (required by accrediting bodies)
Australasia
–

67 cancer checklists and protocols (October 2009)
6 templates for cancer APSR
UK Royal college
Goldsmith, J.D., et al., Reporting guidelines for clinical laboratory reports in surgical pathology. Arch
Pathol Lab Med, 2008. 132(10): p. 1608-16.
Background
… to IT templates

Non healthcare IT standard
–

CAP electronic Cancer Checklist
Healthcare IT standard
–
CEN archetypes

–
Australia
HL7 CDA


Most reliable standard for clinical document templates
Existing implementation guides for the APSR ?
–
Netherlands, Germany
IHE Anatomic Pathology - San Diego 2011
Anatomic Pathology Structured
Report (APSR)
Hospital
Care Ward
Anatomic Pathology
Laboratory
Healthcare
community
Document
Repository
Order Filler
Document
Source
Document
sharing
Clinics
Anatomic Pathology
Laboratory
Document
Source
APSR actors & transactions

Content (Anatomic Pathology Structured Report)
is created by a Content Creator consumed by a
Content Consumer.

Sharing or transmission of content from one
actor to the other
–
XDS, XDM and XDR Integration Profiles, described in
Volume 3 of the Anatomic Pathology Technical
Framework.
IHE Anatomic Pathology - San Diego 2011
CDA Document Content Module (n=21)
Any APSR CDA document content
module is composed of a header and a
structured body.
2 types of CDA Document Content Modules
Generic APSR
(1.3.6.1.4.1.19376.1.8.1.1.1)
20 organ-specific cancer APSR
IHE Anatomic Pathology - San Diego 2011
CDA Section Content Modules (n=6)
CDA Entry Content Module (n=5)
e.g Diagnosis entry
Diagnoses on all specimens that
are delivered to the pathology
reported separatly
Additional pathologic finding(s),
results of ancillary studi(es) &
images
In case of cancer, this
section includes the
cancer checklists
Anatomic Pathology Observation
[0..*] <value> (zero to many response)
coded (code, coding system, version, display
name)
[0..*] <qualifier> (post coordinated
expression)
numeric (integer or real, unit)
textual
The CDA Iceberg
Pathologist/clinician
sees
Machine
sees
IHE Anatomic Pathology - San Diego 2011
The pathologist/clinician sees…
IHE Anatomic Pathology - San Diego 2011
The pathologist/clinician sees…
IHE Anatomic Pathology - San Diego 2011
The machine sees…
<ClinicalDocument xmlns='urn:hl7-org:v3'>
<typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
<!-- conformance to a generic APSR content module -->
<templateId root='1.3.6.1.4.1.19376.1.8.1.1.1'/>
<!-- conformance to a cancer APSR content module -->
<templateId root='1.3.6.1.4.1.19376.1.8.1.1.2'/>
<!-- conformance to a breast cancer content module -->
<templateId root='1.3.6.1.4.1.19376.1.8.1.1.2.1'/>
...remainder of the header not shown ...
<component>
<structuredBody>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.8.1.2.1'/>
<code code='22636-5' displayName=’Pathology report relevant history'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<title>Relevant information provided by the ordering physician</title>
<text>
Tissue submitted: left breast biopsy and apical axillary tissue
</text>
<entry> ... </entry>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.8.1.2.1'/>
<code code='42349-1' displayName= ‘Reason for referral’
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<title>Reason for anatomic pathology procedure</title>
<text>Breast mass - left breast</text>
<entry> ... </entry>
</section>
</component>
<component>
IHE Anatomic Pathology - San Diego 2011
Better use of DICOM in Anatomic
Pathology workflow
DICOM Modality Work list
IHE Anatomic Pathology - San Diego 2011
What is anatomic pathology?
It is not radiology

Order
=> report
Imaging procedure
step is optional

–

Specimen-driven
–
–
One study = one or
more specimen (one
or more patients)
Slides always
available
Order
–

=> imaging
procedure => report
Patient driven
–
One study = one
patient
IHE Anatomic Pathology - San Diego 2011
Modality Work list: Requested
procedure, accession number & Study

Order & Requested procedure
–

The Order Filler translates the received Orders into Requested
Procedure(s) identified by Order Filler Numbers and
automatically assigns Study Accession Numbers
Accession number <-> Order Filler Number
–
–
–
The unique identifier assigned by the Pathology Information
System of an Anatomic Pathology laboratory to an imaging
Study.
As expressed in DICOM Supplement 122: The concept of
“accession” in Anatomic Pathology has been determined to be
sufficiently equivalent to an “accession” in Radiology so that
the existing Accession Number at the Study level may be
reused for the same purpose and with essentially the existing
definition.
For Anatomic Pathology, like in Radiology, the Accession
Number may correspond to the Order Filler Number, as
specified in HL7 v2.x.
IHE Anatomic Pathology - San Diego 2011
Modality Work list
Procedure step & Series

Procedure Step
–
A Procedure Step (“Work Order Step”) is an atomic
operation belonging to Requested Procedure, to be
performed on one specimen by a single type of device (e.g.
immune-histo-chemistry automaton, staining automaton,
image acquisition modality).


Some Procedure Steps are dedicated to image acquisition
Series
–
–
–
A subset of an imaging Study acquired from a single
specimen by a single acquisition modality.
Whenever an image is acquired from a new specimen
or involves a new acquisition modality a new Series is
created.
A new series is also created when an image is acquired for
an existing study after the original order has been fulfilled.
IHE Anatomic Pathology - San Diego 2011
Modality Work list
Requested procedures & procedure steps

OR123: Lungectomy
–
Order
DP07110: Lungectomy

DP07110-A: Left upper lobe (gross image)
–
Study
“Case”
OrderFiller ID
Accession
Number
=
One
Requested
procedure
–
DP07110-A-1: Frozen section, mass
 DP07110-A-1-1: FS
 DP07110-A-1-2: H&E
DP07110-A-2: Entire mass
 DP07110-A-2-1: H&E (WSI)
Series
Two
Two “ (imaging)
“procedure
procedure
steps”
steps”
IHE Anatomic Pathology - San Diego 2011
Modality Work list
Requested procedures & procedure steps

Order : “AP
examination of Breast
biopsy”
–
Requested procedure :
“Imaging of AP
examination of Breast
biopsy” (at the patient
level)
= ACCESSION NUMBER =
OrderFiller ID
 (Imaging) procedure
step: “scanning Slide
DP07110-A-5-1”
(at the specimen/derived
specimen level)

Order :
“Mammography”
Requested (imaging)
procedure :
“mammography”
(at the patient level)
–
= ACCESSION
NUMBER =
OrderFiller ID
IHE Anatomic Pathology - San Diego 2011
Modality Work list
–
–
–
A mechanism defined to support the imaging workflow, by
which the Patthology Information System provides the
attributes of the imaging subject to modalities.
In anatomic pathology, the imaging subject is a specimen
derived from the patient.
Query Modality Worklist: “Based on a query entered at
the Acquisition Modality, a modality worklist is generated
listing all the items that satisfy the query. This list of
Scheduled Procedure Steps with selected demographic
information and information about specimen is returned
to the Acquisition Modality.”


The Modality Worklist provides patient, order (study) and
specimen identification and description to be included in the
acquired images.
The attributes of the Specimen Module have been defined in a
‘Macro’ construct, and added to the Scheduled Procedure Step
Module of Modality Worklist.
IHE Anatomic Pathology - San Diego 2011
Modality Work list
Requested procedures & procedure steps

Order : “AP
examination of Breast
biopsy”
–
Procedure step:
“scanning Slide
DP07110-A-5-1”
Worklist (attributes of
the imaging subject)
– List of requested
procedures
(patient/study level)
– List of procedure steps
(specimen/series level)
Order :
“Mammography”
–
Requested procedure




Requested (imaging)
procedure :
“mammography”
Worklist (attributes of
the imaging subjec )
– List of requested
procedures
(patient/study level)
IHE Anatomic Pathology - San Diego 2011
Modality Work list
Specimen description
DICOM Supp 122 : “Robust new Specimen
Module at image level of hierarchy”
 Specimen short/detailed textual description
Including specimen ancestry description in case of
derived specimen

–
–
In conformance with DICOM supp122, the short textual
description of a specimen retrieved from the Order Filler is a
concatenation of the short description of the specimen and
all the short descriptions of the specimen ancestry
Example : Whole Slide Image of DP07110-A-5-1

DP07110-A: Left upper lobe
–
DP07110-A-5: Left upper lobe/Tumor
 DP07110-A-5-1:H&E
 DP07110-A-5-1: Left upper lobe/Tumor/H&E
IHE Anatomic Pathology - San Diego 2011
More information


Googlegroup : ihe-anatomic-pathologycommittee@googlegroups.com
Road map
–
http://wiki.ihe.net/index.php?title=Anatomic_Patho
logy
IHE Anatomic Pathology - San Diego 2011