Pathologist Opinions about EPIC Beaker AP: a Multi-Institutional Survey of Early Adopters.

EPIC Systems Corporation provides a widely used electronic medical record. Beaker Anatomic Pathology is a newly developed laboratory information system (LIS) that has been implemented at a small number of academic pathology departments. Pathologist opinions of EPIC Beaker AP have not been well described in the literature. A 37-question survey was administered to pathologists and pathology trainees to assess overall satisfaction and efficiency of report generation using Beaker AP. Data about experience in pathology, signout responsibilities, Beaker AP usage, and the legacy LIS was also collected. Seventy-four pathologists (51 faculty, 23 residents) responded to the survey (overall response rate 29.7%). Overall pathologist satisfaction with Beaker AP showed high inter-institutional variability; institutions with legacy LISs with a graphical interface had a generally neutral to negative assessment of Beaker AP. The majority of respondents disagreed with the statement "Beaker AP is easy to use and designed for my needs". Pathologists felt that Beaker AP was useful for reviewing clinical information and billing; areas of weakness included searching for prior cases and grossing efficiency. Overall, pathologists had a neutral opinion of whether generating and signing out a complete report was faster in Beaker AP, with marked inter-institutional variation. This variability was likely due to a combination of the efficacy of the legacy LIS, familiarity with Beaker AP at the time of the survey, and institution-specific optimization efforts.

Data warehouse strategies and the modern anatomic pathology laboratory: Quality management, patient safety, and pathology productivity issues and opportunities.

Application of lean process management strategies to process improvement in clinical and anatomic pathology laboratories afford opportunities to enhance workflow process to lower costs and simultaneously to improve patient safety. Bar-codes are now employed in most modern anatomic pathology laboratories to track specimens from the clinicians' office or the operating room all through the continuum of service to specimen disposal. In order to enhance patient safety and workload optimization strategies, novel computer hardware and software assets are being developed to enable monitoring, analysis, and improvement of specimen workflow and diagnostic accuracy. More recently, data warehouse technologies from the retail industry have been optimized to permit high-throughput analysis of granular data in the laboratory arena. These optimize mass-data analysis in real time in the information technology space. In this review we describe the application of an in-house designed data warehouse to the anatomic pathology assets of a large regional reference laboratory.

Evaluating the benefits of digital pathology implementation: time savings in laboratory logistics.

BACKGROUND: The benefits of digital pathology for workflow improvement and thereby cost savings in pathology, at least partly outweighing investment costs, are being increasingly recognised. Successful implementations in a variety of scenarios have started to demonstrate the cost benefits of digital pathology for both research and routine diagnosis, contributing to a sound business case encouraging further adoption. To further support new adopters, there is still a need for detailed assessment of the impact that this technology has on the relevant pathology workflows, with an emphasis on time-saving. AIMS: To assess the impact of digital pathology adoption on logistic laboratory tasks (i.e. not including pathologists' time for diagnosis-making) in the Laboratorium Pathologie Oost Nederland, a large regional pathology laboratory in The Netherlands. METHODS AND RESULTS: To quantify the benefits of digitisation, we analysed the differences between the traditional analogue and new digital workflows, carried out detailed measurements of all relevant steps in key analogue and digital processes, and compared the time spent. We modelled and assessed the logistic savings in five workflows: (i) routine diagnosis; (ii) multidisciplinary meeting; (iii) external revision requests; (iv) extra stainings; and (v) external consultation. On average, >19 working hours were saved on a typical day by working digitally, with the highest savings in routine diagnosis and multidisciplinary meeting workflows. CONCLUSIONS: By working digitally, a significant amount of time could be saved in a large regional pathology laboratory with a typical case mix. We also present the data in each workflow per task and concrete logistic steps to allow extrapolation to the context and case mix of other laboratories.

Consolidation of pathology services in England: have savings been achieved?

BACKGROUND: During the last decade, pathology services in England have undergone profound changes with an extensive consolidation of laboratories. This has been driven by some national reviews forecasting a national reduction of costs by £250-£500 million ($315-$630 million) a year as a result. The main aim of this paper is to describe the financial impact of such consolidation, with a specific focus on the forecasted savings. A secondary aim is to describe the development of private sector involvement in laboratory services in a traditionally publicly funded healthcare system and the development of pathology staff size. METHODS: In the English scenario, the majority of hospitals and laboratories are publicly funded and a survey was sent as Freedom of Information request to all directors of pathology. A descriptive comparison of savings among consolidated and non-consolidated pathology services was made by using the pathology budgets in two different periods (2015 versus 2010), adjusted by inflation and increased activity. RESULTS: The hub-and-spoke model has been implemented as part of the consolidation process of pathology services in England. Consolidated pathology networks have achieved higher savings compared to non-consolidated single laboratories. There has been an increased role of private providers and savings were achieved with negligible personnel redundancies. CONCLUSIONS: Consolidated units have on average achieved larger cost savings than non-consolidated units but further analysis with stronger research design is required to independently evaluate the impact of pathology consolidation on both savings and quality.

Better resource utilisation and quality of care for ovarian cancer patients using internet-based pathology review.

BACKGROUND: The current literature indicates that a considerable number of patients in ovarian carcinoma clinical trials have histopathological diagnoses in conflict with inclusion criteria. It has been suggested that specialised pathology review prior to randomisation should become the standard procedure in study protocols. We hypothesised that our new, internet-based high-throughput infrastructure would be capable of providing specialised pathology review within 10 working days (w.d.). METHODS: Patients scheduled for the AGO OVAR17 ovarian carcinoma chemotherapy trial were registered for expert pathologic case review using a new internet-based central pathology review platform prior to randomisation. All original slides were requested from local pathologists. Slides were scanned and uploaded to a secured internet server. A network of experienced gynaecological pathologists was connected to the server through a custom-designed software platform. If deemed necessary by the expert pathologists, immunohistochemistry was available through a collaborating pathology lab. RESULTS: A total of 880 patients with an original diagnosis of ovarian epithelial carcinoma were registered for expert pathology review from October 2011 to July 2013. For case review, five gynaecopathologists from Austria, Switzerland and Germany were available online. Median number of w.d. required to complete the whole process from patient registration to transmission of final review diagnoses was 4 (range 2-31) (w.d.), and in 848 out of 880 (97.5%) cases, it amounted to ⩽10 w.d. In 2.5% (n=22) of cases, a major diagnostic discrepancy of potential clinical relevance was found leading to exclusion from the chemotherapy trial. CONCLUSIONS: Our results show that the use of a new internet-based infrastructure makes timely specialised case review, prior to patient randomisation feasible within ⩽10 w.d. Our new approach helped to protect against overtreatment with chemotherapy of patients with ovarian borderline tumours and inadequate treatment of patients with ovarian metastases, as a result of their inappropriate entry into a clinical trial designed for patients with primary ovarian carcinoma.

[What do our clients want? : Is speed all that matters?] / Was wünschen unsere Einsender : Ist Geschwindigkeit alles?

The pathology department of the University Hospital Bonn conducted a survey among all its clients in order to evaluate their expectations concerning the diagnostics and service from a university department of pathology. A questionnaire including 30 topics was sent by mail to all senders. The questions could be answered using a scale ranging from "0" ("not important at all") to "10" ("very important"). Most important for the clients were "speed of communication of the diagnosis", "personal availability of the responsible pathologist by telephone" and "friendliness of contact". Less important were "autopsy diagnostics", "24 h on-call duty" and "service on Saturdays". A critical analysis of the results made us realize that pathology is threatened to be seen exclusively as a service discipline and that we should convey its methods and possibilities and also its requirements better to clinicians.

Impact of centralized evaluation of bone marrow histology in systemic mastocytosis.

BACKGROUND: Bone marrow (BM) histology/immunohistochemistry, KIT D816V mutation analysis and serum tryptase measurements are mandatory tools for diagnosis of systemic mastocytosis (SM). MATERIALS AND METHODS: Within the 'German Registry of Disorders on Eosinophils and Mast Cells', we identified 65 patients with SM who had two consecutive BM biopsies. The first biopsy was evaluated by a local pathologist (LP) and the second biopsy by a reference pathologist (RP) of the 'European Competence Network on Mastocytosis (ECNM)'. RESULTS: Final diagnoses by RP were SM (n = 27), SM or aggressive SM (ASM) with associated clonal haematological non-mast cell lineage disease [(A)SM-AHNMD, n = 34)] or mast cell leukaemia ± AHNMD (n = 4). In 15 of 65 patients (23%), initial diagnoses by LP were incorrect (by overlooking SM), for example primary myelofibrosis (n = 3), myelodysplastic/myeloproliferative neoplasm unclassified (n = 3) or B-cell lymphoma (n = 2). Fourteen of 15 patients (93%) with incorrect diagnosis had an advanced SM, mostly (A)SM-AHNMD. In the 50 concordantly diagnosed patients, immunohistochemical markers for quantitative assessment of mast cell infiltration, for example CD117 (KIT) or CD25, were applied by LP in only 34 of 50 patients (68%), and mutational analysis for KIT D816V was performed or recommended in only 13 of 50 patients (26%). Finally, the subclassification of SM was discordant because LP did not diagnose AHNMD in nine of 50 (18%) patients. CONCLUSIONS: In summary, adequate diagnosis and subclassification of SM requires an in-depth evaluation of the BM by experienced haematopathologists (preferably in a reference centre) in combination with molecular genetics, serum tryptase level and clinical parameters.

Histopathology practice and training in Nigeria ­ a model.

Objectives: Contemporary histopathology practice and training in Nigeria have been plagued by the fundamental issue of inadequate exposure to surgical pathology material by both trainees and trainers. This paper critically examines the factors that affect the discipline and profers practical solutions to aid its advancement. Materials and Method: This review is based on the authors experience and observations of histopathology practice in Nigeria. Results: The Nigerian health sector is plagued by many ills including poor funding, weak policies, dilapidated structures, disgruntled and frustrated practitioners, amongst others - and pathologists are not immune to all these. In recent times, there has been a proliferation of accredited training centres as well as medical graduates interested in the specialty of histopathology. The busiest histopathology laboratories in the country ascession between 2200 and 5500 surgical samples yearly. Thus there is inadequate exposure by histopathologists and trainee pathologists to surgical materials with the attendant consequences. Many centres still rely principally on routine haematoxylineosin stains. There are no nationally agreed standard reporting formats for most diseases. Conclusion: The development of a deanery or regional system of accredited histopathology laboratories may form the fulcrum for improving the overall quality of histopathological services and training in Nigeria. This will help develop local expertise and ensure adequate exposure to teaching aids and surgical materials. We hope that the proffered solutions will help encourage local pathologists to continue and increase their efforts to raise the profession up to enviable heights.

[Analysis of death certificates in postmortem examination waivers]. / Halottvizsgálati bizonyítványok adatainak elemzése nem boncolt elhunytak esetén.

INTRODUCTION AND AIM: The practices of autopsies and waivers in three Hungarian counties subject to the same statutory framework in a 5-year interval have been examined, with special attention to cases of non-natural death. METHOD: The summary data included in the post mortem examination certificates, for the years between 2006 and 2010, in a breakdown according to counties, covering all cases of death were analysed. The work was assisted by a Java-based software programme. RESULTS: In terms of the waiving of autopsies, a comparison of the three counties revealed significant differences. The persons who issue waivers from the performance of autopsies also vary across the counties. In case of deaths caused by accidents, no autopsy was performed in 844 cases. Similar situation was found in case of various identified and non-identified injuries, which were entered as the direct cause of death in 28 cases, as well as road traffic accidents entered in 32 cases and the unidentified consequences of road traffic accidents, which we found in 26 cases. No autopsy was performed in 25 cases of deaths assumed to be suicides and in one homicide. CONCLUSIONS: The Hungarian laws follow the recommendation of the Committee of Ministers to Member States of the Council of Europe, and provide that in all cases where the death is due to non-natural causes or the possibility of non-natural causes is raised, an autopsy should be performed. In this given legal context it is unclear how autopsies in the cases of death due to homicides, suicides and accidents as detailed above could possibly be dispensed with. The purpose of this paper was to provide a baseline study on the current practice of certification. The findings could be used in the course of governmental reviews for the purpose of drawing up recommendations. Orv. Hetil., 2016, 157(52), 2082-2087.

[Methods and methodology of pathology]. / Metody i metodologiya patologicheskoi anatomii.

The lecture gives the state-of-the-art of the methodology of human pathology that is an area of the scientific and practice activity of specialists to produce and systematize objective knowledge of pathology and to use the knowledge in clinical medicine. It considers the objects and subjects of an investigation, materials and methods of a pathologist, and the results of his/her work.

Polish forensic medicine A.D. 2016 - report of the National Consultant.

The aim of the study was to present the current state and basis of functioning of an academic model of forensic expert activities in Poland and perspectives of their further development. The study material included information obtained from a preliminary survey among regional consultants within the ongoing activities of the national consultant team. The recently completed period of research infrastructure support within the policy of coherence of the European Union contributed to significant advances in scientific-educational potential of the majority of university forensic medicine centres. However, the improved educational base and purchases of new diagnostic devices were not associated with a considerable increase in staff resources of individual units, which finally decides about the renown of the entire discipline. It is necessary to undertake initiatives to highlight the importance of forensic medicine as a separate medical field and to increase the number of physicians starting specialist trainings. A highly profiled nature of the speciality necessitates cooperation with other centres and receptiveness to clinical fields. The establishment of various forms of cooperation is a measure of optimal use of equipment and stimulation of multi-centre research.

Customizing Laboratory Information Systems: Closing the Functionality Gap.

Highly customizable laboratory information systems help to address great variations in laboratory workflows, typical in Pathology. Often, however, built-in customization tools are not sufficient to add all of the desired functionality and improve systems interoperability. Emerging technologies and advances in medicine often create a void in functionality that we call a functionality gap. These gaps have distinct characteristics­a persuasive need to change the way a pathology group operates, the general availability of technology to address the missing functionality, the absence of this technology from your laboratory information system, and inability of built-in customization tools to address it. We emphasize the pervasive nature of these gaps, the role of pathology informatics in closing them, and suggest methods on how to achieve that. We found that a large number of the papers in the Journal of Pathology Informatics are concerned with these functionality gaps, and an even larger proportion of electronic posters and abstracts presented at the Pathology Informatics Summit conference each year deal directly with these unmet needs in pathology practice. A rapid, continuous, and sustainable approach to closing these gaps is critical for Pathology to provide the highest quality of care, adopt new technologies, and meet regulatory and financial challenges. The key element of successfully addressing functionality gaps is gap ownership­the ability to control the entire pathology information infrastructure with access to complementary systems and components. In addition, software developers with detailed domain expertise, equipped with right tools and methodology can effectively address these needs as they emerge.

[How should cytopathology be taught?]. / Wie soll Zytopathologie gelehrt werden?

Cytopathology is not excessively employed in the whole faculty of pathology in Germany, in contrast to some neighboring countries. Cytopathology also suffers from a lack of next generation cytologists, because experienced and interested specialists as well as assistants actively engaged in cytology (ZTA, cytological technical assistant and MTLA medical laboratory technical assistant) are only available in limited numbers. However, cytopathological expertise is urgently needed, not only in the diagnostics of gynecological cancer screening but also for assessment of many non-gynecological preparations, which have nowadays become more demanding and more complex particularly due to the technical developments in internal medicine. In addition, adjuvant methods have become incorporated into cytopathology, the interpretation of which must be carried out within this specialty.This article gives a review of the status quo of cytopathology in Germany and sketches how training and advanced education opportunities are organized and if necessary could be improved. The course of specialist medical training as well as the ZTA and MTLA training are described, also as a teaching concept (e.g. microscopy of current cases, microscopy of case collections and online microscopy). In order to provide cytopathology in Germany with a wider perspective, a paradigm shift in the internal approach to cytology is suggested so that the next generation can perceive this specialty not as a burden but as a chance.

[What place and what future for the pathology of infectious and tropical diseases in France?]. / Quelle place et quel avenir pour l'anatomo-cyto-pathologie des maladies infectieuses et tropicales en France?

The management of tissues and cellular samples by the pathologists in the infectious and tropical diseases pathology field in 2014 needs a strong knowledge of both morphological and molecular domains which includes the good control: (i) of the taxonomy of infectious and tropical diseases pathology leading to the pathogens identification and (ii) of the ancillary methods which can be used in fixed samples in order to detect or better identify these pathogens. There is a recent paradox in France concerning the frequency of infectious diseases to be diagnosed in pathology laboratories and the progressive loss of pathologist's expertise in this domain. Different reasons could explain this statement including the omnipresence of the tumour lesions to be managed in a pathology laboratory as well as the recent constraints associated with the different biomarkers that are mandatory to be detected by immunohistochemistry and/or by molecular biology. Even if the microbiologists play a pivotal role for identifying the different pathogens as well as for the assessment of their sensitivity to the anti-microbial drugs, a large number of infectious diseases can be diagnosed only on fixed tissue and/or cells by the pathologists. The purpose of this review is to describe the current and future issues of infectious and tropical diseases diagnoses in pathology laboratories, in particular in France.

[Japanese Association of Clinical Laborato Physicians--What We Are Doing Now and How We Should Develop in the Future as Competent Members of Team Medicine].

No clinical laboratory would admit they do not practice team medicine, at least conceptually. However, true team medicine is more than an aspiration--it is an intentional care structure built, led, and delivered by a diverse, multidisciplinary team of physicians, medical technologists, nurses, pharmacists, and dozens of other professionals. We clinical laboratory physicians are able to fulfill an important role as competent members of the team medicine. Because we can look at the results of clinical examinations of patients earlier than anyone else, we can interpret the patient's condition by analyzing that results, and provide useful information to facilitate team medicine. I have conducted a questionnaire survey on team medicine targeting clinical laboratory physicians to clarify the tasks we are performing. In this paper, I describe what clinical laboratory physicians are currently doing, and how should we develop in the future.

Building a pathology laboratory in Malawi.

Until recently, the Malawian capital of Lilongwe was without diagnostic pathology services, which left many patients with cancer facing serious diagnostic delays. Through collaboration with the University of North Carolina and other partners, a pathology laboratory was successfully established at Kamuzu Central Hospital in July, 2011, providing an essential foundation for cancer diagnosis and research in the country's largest city.

[Tissue repositories for research at Sheba Medical Center(SMC].

INTRODUCTION: Cancer is the number one cause of death in both genders. Breakthroughs in the understanding of cancer biology, the identification of prognostic factors, and the development of new treatments are increasingly dependent on access to human cancer tissues with linked clinicopathological data. Access to human tumor samples and a large investment in translational research are needed to advance this research. The SMC tissue repositories provide researchers with biological materials, which are essential tools for cancer research. GOALS: SMC tissue repositories for research aim to collect, document and preserve human biospecimens from patients with cancerous diseases. This is in order to provide the highest quality and well annotated biological biospecimens, used as essential tools to achieve the growing demands of scientific research needs. Such repositories are partners in acceLerating biomedical research and medical product development through clinical resources, in order to apply best options to the patients. METHODS: Following Institutional Review Board approval and signing an Informed Consent Form, the tumor and tumor-free specimens are coLLected by a designated pathologist at the operating room only when there is a sufficient amount of the tumor, in excess of the routine needs. Blood samples are collected prior to the procedure. Other types of specimens collected include ascites fluid, pleural effusion, tissues for Optimal Cutting Temperature [OCT] and primary culture etc. Demographic, clinical, pathologicaL, and follow-up data are collected in a designated database. SMC has already established several organ or disease-specific tissue repositories within different departments. SUMMARY: The foundation of tissue repositories requires the concentrated effort of a multidisciplinary team composed of paramedical, medical and scientific professionals. Research projects using these specimens facilitate the development of 'targeted therapy', accelerate basic research aimed at clarifying molecular mechanisms involved in cancer, and support the development of novel diagnostic tools.

Expectations towards forensic professionals conducting external examinations of dead bodies on the crime scene--results of a questionnaire distributed among public prosecutors in the Mazovian Voivodeship / Oczekiwania wobec uczestnictwa medyków sadowych w ogledzinach zwlok na miejscu ich ujawnienia--wyniki ankiety przeprowadzonej wsród prokuratorów w województwie mazowieckim.

UNLABELLED: The purpose of this study was to determine expectations of public prosecutors towards forensic professionals participating in external examinations of dead bodies performed at the site of finding the corpses. The presence of forensic physicians on the crime scene was recognized as advantageous by all prosecutors; however, expectations associated with corpse inspection did not correspond to capabilities of modern medicine or necessitated repeating activities performed during autopsies. Homicides (99%), deaths of children (86%) and "media" deaths (73%) were indicated as cases when the presence of forensic professional was especially important. Definition of injuries with indication of the causative object made by forensic physicians on the crime scene was the advantage most often chosen by respondents (82%). Almost one third of respondents expected forensic physicians to evaluate the length and direction of wound tracts, more than half of them--to provide a detailed description of injuries, one fifth wanted physicians to determine the exact time of death. Description of post mortem changes was not indicated as the most important benefit by any prosecutor. CONCLUSIONS: Public prosecutors recognized the presence of forensic professionals on the crime scene as advantageous, but their expectations associated with dead body examinations did not correspond to capabilities of forensic medicine or forced physicians to perform activities normally made during autopsy. An algorithm of dead body examination on the crime scene including aims and advantages of such a examination should be developed jointly by prosecutors and forensic medicine specialists.

Improving international research with clinical specimens: 5 achievable objectives.

Our increased interest in translational research has created a large demand for blood, tissue, and other clinical samples, which find use in a broad variety of research including genomics, proteomics, and metabolomics. Hundreds of millions of dollars have been invested internationally on the collection, storage, and distribution of samples. Nevertheless, many researchers complain in frustration about their inability to obtain relevant and/or useful samples for their research. Lack of access to samples, poor condition of samples, and unavailability of appropriate control samples have slowed our progress in the study of diseases and biomarkers. In this perspective, I focus on five major challenges that thwart clinical sample use for translational research and propose near term objectives to address them. They include: (1) defining our biobanking needs; (2) increasing the use of and access to standard operating procedures; (3) mapping interobserver differences for use in normalizing diagnoses; (4) identifying natural internal protein controls; and (5) redefining the clinical sample paradigm by building partnerships with the public. In each case, I believe that we have the tools at hand required to achieve the objective within 5 years. Potential paths to achieve these objectives are explored. However we solve these problems, the future of proteomics depends on access to high quality clinical samples, collected under standardized conditions, accurately annotated and shared under conditions that promote the research we need to do.