Informatics and the Future of Pathology (and Medicine):
Making a Case for The Need for Computational Pathologists
Michael J. Becich, MD PhD - becich@pitt.edu
Chairman, Department of Biomedical Informatics
http://www.dbmi.pitt.edu
University of Pittsburgh
School of Medicine
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)
Slide 2
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!!!
Digital Can Improve Quality of Care in Pathology
http://www.pathologyinformatics.org/R
esources/ldip2103.jpg
1850 Present
H&E
Lung
Today
Automated IHC
AQUATM
Modified with permission
From Montalto,
2007 CAP Futurescape
Lung
6/9/2007
Automated subcellular localization of RRM1
in 187 stage I NSC Lung Cancer patients,
stratifies patients following surgical treatment.
Advanced Diagnostics Enabled by Digital Pathology
Ginty F, The relative distribution of membranous and cytoplasmic Met is a prognostic Modified with permission
From Montalto,
indicator in stage I and II colon cancer , Clinical Cancer Research, June 15 2008
2007 CAP Futurescape
Diagnostic innovation/invention are key to our future
Circulating Tumor Cells
Clinical and Anatomic Pathology Convergence
Use of Imaging Tools
From Schwartz, CAP, 2009
Imaging
Digital Pathology Timeline
360-sec
20x scan
60-sec
20x scan
20-second
40x multi-angle scan
Multispectral imaging
Applications
Rapid
secondary
consultations
Subspecialist
work flow
triage
Computer-aided
detection
Storage
100 Terabytes
Computer-aided
diagnosis
Petabytes
100 Petabytes
Enterprise image management
Pathology PACS
2007
2012
• 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!!!
2017
Modified from: From Schwartz, CAP, 2009
Emerging Developments
Future
in Pathology
* Source:and
Sg2Your
T3 Virtual
Slide
Imaging
Industry recognizes the opportunity
Are diagnostics the
new wonder drug
on Wall Street?
From Schwartz, CAP, 2009
Perspective on the Future of Pathology
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!!!
Slide 16
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, 2009
Emerging 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
Modified from: From Schwartz, CAP, 2009
Emerging Developments and Your Future in Pathology
DISTRIBUTED HIGH-THROUGHPUT ANALYTICS
REVOLUTIONARY TECHNOLOGIES
As Medicine evolves from the treatment of illness to aggressive
promotion of wellness – genomics/informatics will be key!!!!
PERSONALIZED HEALTHCARE
Automated
systems
Lifetime Treatment
PrePre-symptomatic Treatment
CACA-diagnosis
TRANSITIONAL MEDICINE
Molecular Medicine
Information
Correlation
1st generation
diagnostics
Moving from the
Genetic Predisposition Testing
treatment of illness
HEALTHCARE
to the aggressive
TODAY
Clinical Genomics
Computational
Pathology
promotion
of
Digital Imaging
will be the key
enabler!!!
wellness
Episodic Treatment
Electronic Health
Record
Nonspecific
(treat symptoms)
Organized
(error-reduction)
EVOLUTIONARY PRACTICES
DATA & SYSTEMS INTEGRATION
SOURCE: IBM LIFE SCIENCES SOLUTIONS
Artificial Expert System
Personalized
(disease prevention)
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
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
http://apiii.upmc.edu
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…”
Slide 28
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!!!
Key Publications by Our Team –
NOTE: Please e-mail me at becich@pitt.edu if you want PDFs
•
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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: 10.4103/21533539.103013. 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.
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Slide 32
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.