Toronto’s Michener Institute adding digital slide images to EHR

The Michener Institute is adding digital laboratory slide images to the EHR
By Jerry Zeidenberg 

Toronto’s Michener Institute, an educational centre for applied health sciences, has started integrating digitized microscopy images into an Electronic Health Record system. It’s one of the first sites in the country to do this.

“Typically, you do not see digital microscopy in the health record,” commented Dr. Karim Bandali, vice provost of the Michener.

Digital slide technology has the potential of becoming a very important tool for pathologists who analyze patient samples for the presence – or absence – of serious diseases, including cancer and blood disorders. “Digital microscopy is a major piece, and integrating it into the electronic record is a major development,” said Dr. Bandali.

The incorporation of slide images into the EHR has many benefits, both for Michener as a school and for hospitals and health regions.

“It will have real value for rural areas,” said Dr. Bandali. He explained that small hospitals collect samples, but usually send them out to larger centres for analysis. Unfortunately, this can be a slow process and it can take up to a week before they receive results.

By contrast, if their lab technologists prepare slides and digitize them, using special equipment, they can be sent electronically to pathologists for viewing and analysis. “You could receive a diagnosis in 24 hours,” commented Dr. Bandali.

What’s more, just as Picture Archiving and Communication Systems (PACS) for radiological images have powerful tool sets for analyzing images, so do newly emerging computerized applications for digital microscopy.

Pathologists can make use of powerful, software-based tools such as cell counters and colour analyzers, thereby improving the accuracy of their analyses.

Another major benefit: with digital microscopy, you can display several slides on the same computer screen for comparison. That is a big improvement over traditional practice, where pathologists can view only one slide at a time.

Finally, just as with images in a PACS, physicians using digital microscopy can share images for second opinions and group consultations. Once the images are stored in an archiving system and become part of the patient’s electronic record, the images can be sent to specialists and referring physicians.

Michener’s own solution arose as part of its project to create an integrated EHR, one that consolidates lab, radiology, radiotherapy, and traditional components of a health information system so that all the parts can be easily accessed.

“We’re teaching our students how to work in the hospital of the future, so we are producing a better student,” said Dr. Bandali, adding that it mitigates the amount of time that clinicians must spend educating students once they’ve joined the healthcare workforce.

He noted that most hospitals and health regions are building EHRs right now to solve real-world problems, such as patient safety. “For example, we know that medical error in the health system usually stems from a lack of communication between care-givers, especially at the time of patient hand-offs. There is not enough collaboration.”

To combat these problems, “inter-professional collaboration is now an important theme in most hospitals,” said Dr. Bandali, who asserted that the integrated, electronic health record is critical for making sure that all healthcare professionals have quick and easy access to the information they need, when they need it.

Brad Niblett, director of information management, notes that the Michener’s EHR contains the components needed for making quick, accurate clinical decisions. Major components include a Siemens PACS and RIS, as well as a HIS, LIS and radiotherapy systems from IMPAC of Sunnyvale, Calif., a division of Swedish-based Elekta. “We’re not just building an EHR,” said Niblett. “It’s an inter-professional driven EHR that’s designed to support collaboration.”

To help start building this technological vision, Michener brought together several key partners, including Unis Lumin, a systems integrator located in Oakville, Ont., Cisco Systems, which specializes in communications, and for the digital microscopy component, Quorum Technologies Inc., of Guelph, Ont., which is a Canadian distributor for Aperio Inc., of San Diego.

Niblett said “the incorporation of digital microscopy into the curriculum and EHR represents a successful public-private-partnership opportunity between multiple organizations.”

He added that when it comes to the EHR, there are three primary objectives:

• advancing the level of integration between traditional EHR information systems;

• incorporating non-traditional systems into the EHR framework;

• and incorporating relevant emerging technologies into the overall EHR.

In order to support EHR innovation, beefing up the foundational technology (network and storage infrastructure) was essential.

The main network router was replaced with a dual core unit to facilitate effective data flow and security. In addition, the installation of a SAN (storage area network) provided not only critical data capacity, but essential security and quality of service to data residing on all systems, including digital pathology, the radiology information system, radio-therapy information system, laboratory information system, and overall hospital information system.

As well, the solution employs high-powered pipes –- fibre-optic cables link servers across the network, and data is delivered to the user’s desktop at gigabit speeds. That reduces the time required to send very large image files.

The importance of a high-capacity becomes clear when we find out just how large the images can be. A single slide can take up 1 gigabyte of space, and between five minutes to one hour to scan a single slide by the specialized Aperio scanner.

An area of interest on the slide can be reduced to 100K for transmission, but if a pathologist wants a better look, he or she may very well return to the original 1GB slide image. “The 100K image isn’t diagnostic quality, but it will identify problems,” commented Niblett. “You can then go back to the original.”

Not only will clinicians benefit from digital pathology, so will students and instructors.

By using the new system, an entire class can view and discuss the same slides, at the same time. This makes it easier for the instructor, who must otherwise work with each individual student, viewing through a microscope and pointing out various structures and problems.

“Now, if you have a unique slide, perhaps a slide that is rare and specific to one clinical site, we can share this educational experience with all our students using digital slide technology,” said Dr. Bandali, who noted that most of Michener’s laboratory classes have 16 to 25 students. He commented that a professor can display the slide in high-resolution at every workstation, and discuss the case while every student sees the same image.

Digital pathology also allows the school to create its own collection of slides, which can be accessed by students and faculty at any hour. That has already happened with the Michener’s digitized collection of over 1,000 slides.

Niblett noted that plans are afoot to work with other educational institutions to share online libraries of ‘unique cases’, thereby increasing the scope of and depth of the education they can offer.

It might be added that digital slides reduce the nervousness of students and instructors who handle traditional glass slides. “Glass slides may contain rare cases, and if they are dropped or misplaced, they are lost to us forever,” commented Dr. Bandali. That is why professors in medical laboratory science and diagnostic cytology have closely supervised their students in the past,
making sure that nothing is mishandled. Going digital, however, eliminates this concern – with computerized images, there’s nothing to break. “And everyone can access them, 24/7,” said Dr. Bandali.

Niblett estimates that fewer than 1 percent of labs in Canada and the United States have implemented digital microscopy systems, and quotes a recent 2006 study by the Gartner Group, a technology market research company headquartered on the U.S.

However, given all of the benefits of this relatively new solution for diagnostic labs, especially when integrated with the EHR, many observers say the issue is when, rather than if, digital microscopy will take off.

For its part, the Michener Institute is ready for this to happen. It’s already training students to use this solution, along with many others. “It’s all part of our simulation strategy,” said Dr. Bandali. “We put students through a wide variety of simulations here before they go into clinical settings.

“So when students get into the clinical environment, we are hoping it results in a seamless transition to their clinical placements. As a result of our new curriculum and the technologies we have invested in, we hope our students are prepared to hit the ground running.”  •