Integration of Pathology and Radiology Reports

Transkript

1 Integration of Pathology and Radiology Reports (Cancer Pathology and Radiology Reports) Franz-Tappeiner Hospital Merano Hematology and Oncology Italy Dominic Fong

2 Cancer Care Cycle Radiologist Radiologist or Surgeon Pathologist Surgeon Dx Imaging X-ray, U/S, MRI Biopsy Pathology Quantitative Histo, Molecular, Receptor status Surgery Lumpectomy Mastectomy Treatment Response Oncologist Radiologist Pathologist Treatment Chemo / hormone / Radiation therapy Tumor Board Treatment planning Staging PET/CT, MRI Rad oncologist Med oncologist Radiologist, Surgeon, Oncologist Radiologist

3 Paper or Electronic Reports Accurately convey the findings to the referring physician Reflect the competence of the reporting physician Timely communication for patient care Archived in the patient medical record Legal record of (imaging) exam Reporting physician s signature Support secondary uses Charge capture and billing Teaching and research Clinical data registries, clinical trials Process improvement

4 Benefits (+) and challenges (-) of Electronic Reports Accuracy + Drive for quality improvement with quantitative data, CAD and other measurements + Possible major benefit with attached key images and graphical analysis (picture = 1000 words) Will systems support graphical reports? Timely communication + Probable improvement Archived in the patient medical record /+ Where is the electronic medical record? (distributed, multiple copies) Legal record What is a valid electronic signature? Is an exact visual reproduction required, or only exact semantic content? Secondary uses + Huge potential improvement, especially with structured and coded data + More accurate billing (avoid undercoding) Use of reporting physician s time /+ Potential negative impact with transition from traditional dictation workflow

5 Planning for electronic reporting What are our goals? Efficient/structured reports Better capture of imaging measurements into report Add key images into reports Coding Ability to do research / data mining What kinds of reports do we need? Text only Text + image references Structured text Structured text + coded content Multimedia

6 (Oncological) Pathology Report (coding)

7 (Oncological) Pathology Report Minimal information: Personal (patient ID name, date of birth ) Clinical notes Tumour characteristics most valid basis of diagnosis topography, i.e. primary site morphology, i.e. histology behaviour source of information comprehensive coding of all sources code for each hospital, laboratory etc. code for type of source number of hospital or lab. record death certificate Optional information treatment outcome

8

9 WHO Family of Classifications RELATED Classifications REFERENCE Classifications DERIVED Classifications International Classification of Primary Care (ICPC) International Classification of External Causes of Injury (ICECI) The Anatomical, Therapeutic, Chemical (ATC) classification system with Defined Daily Doses (DDD) I nternational C lassification of D iseases I nternational C lassification of F unctioning, Disability & Health I nternational ICD-10 is the international C lassification standard of to report and monitor Neurology diseases H ealth and mortality. (ICD-10-NA) (ICD-10 based classifications I nterventions for reporting and surveillance) (under development) ISO 9999 Technical aids for persons with disabilities Classification and Terminology International Classification of Diseases for Oncology, Third Edition (ICD-O-3) The ICD-10 Classification of Mental and Behavioural Disorders Application of the International Classification of Diseases to Dentistry and Stomatology, Third Edition (ICD-DA) Application of the International Classification of Diseases to ICF, Children & Youth Version (ICF -CY)

10 ICD-9 CODE A - Category of code B - Etiology, anatomical site, and manifestation ICD-10 CODE A - Category of code B - Etiology, anatomical site, and/or severity C - Extension 7 th character for obstetrics, injuries, and external causes of injury A B A B C ICD-9-CM is out of date and running out of space for new codes. Lacks specificity and detail No longer reflects current medical practice

11 Current local practice: Merano (Italy) Bonvicini BZ Pathology BZ ICD-9!! ICD-10 ICD-9 Pathology Zams ICD-10 (retrospective Coding - TU-Register) [2015]

12 ICD-10 C C16.1 Malignant Neoplasm: Fundus of Stomach C16.2 Malignant Neoplasm: Body of Stomach Histology??? C81.1 Malignant Neoplasm: Hodgkin s Disease Nodular sclerosis Localisation??? Useful in Oncology???

13 Minimal information: Personal (patient ID name, date of birth ) Clinical notes Tumour characteristics most valid basis of diagnosis topography, i.e. primary site morphology, i.e. histology behaviour source of information ICD-O-3 comprehensive coding of all sources code for each hospital, laboratory etc. code for type of source number of hospital or lab. record death certificate Optional information treatment outcome

14 DIMDI - WHO Kapitel II: C00 D48 Neubildungen 4/385 SNOMED CT (2002) CAP/IHTSDO

15 Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT ) CPT ICD-9 and ICD-10 LOINC SNOMED CT ICD-O (morphology) NOC ICNP Omaha System PNDS CCC NANDA NIC Standardized Terminologies/Classifications Integrated within SNOMED CT

16 16

17 International Classification of Diseases for Oncology 3rd Edition (ICD-O-3) Topography Code Morphology Code = C section ICD-10 C00.0 C90.0 C. / Anatomic site [Histology] / [Behaviour] [Grading] C / 3 1 Breast.Upper-inner quadrant [Adeno-] / [carcinoma] [well diffentiated]

18 ICD-O C /3 Mucinous Adenocarzinoma Colon Transversum C /3 Diffuse large B-Cell Lymphoma Axillary Lymph Node C /3 AML with {t(8;21)(q22;q22)}; {AML 1(CBF-alpha)/ETO} C /0 Neoplasm of Cortex of Adrenal Gland, Clear Cell Adenoma Multiple tissue specimens 1. Biopsy diagnosis: Supraclavicular lymph node, metastatic signet ring cell adenocarcinoma, most likely from stomach. C /6 2. Primary site: Fundus of stomach, signet ring cell ademonarcinoma C /3* Metastatic site: Upper lobe bronchus, metastatic signet ring cell adenocarcinoma. C /6 * Codes for this case as recorded in registry

19 ICD-10?? (ICD-9) TNM Classification ICD-10/ICD-O??

20 (Oncological) Radiology Report (tumor measurement)

21 (Oncological) Radiology Report part of the patient s medico-legal record provides a comparison with previous or later examinations develop a consistent search pattern provides a record if radiographs are lost resume of contraindications or indications reports should contain the following items heading (date of exam, date of report, patient information ) clinical information *(debatable) findings diagnosis/differential diagnosis/conclusions recommendations signature

22 Standardizing the Methodology of Tumor Measurement Rationale Establish a standardized methodology for tumor measurement to facilitate comparison with prior exams Reliably and reproducibly determine tumor growth or regression so our colleagues can make appropriate treatment decisions

23 Objectives Define variables How many lesions to measure How to compare current and prior studies How many lesions to count Standardize how measurements are made Are measurements saved on PACS? Availability of prior images Inconsistency of measurements Time consuming Obstructions

24 Tumor Measurement Criteria TUMOR RESPONSE CRITERIA WORLD HEALTH ORGANIZATION (WHO) WHO Handbook for Reporting Results of Cancer Treatment World Health Organization Offset Publication No. 48 Geneva, Switzerland, 1979 Reporting Results of Cancer Treatment AB Miller, B Hogestraeten, M Staquet, A Winkler Cancer 47:207 14, 1981 RESPONSE EVALUATION CRITERIA IN SOLID TUMORS (RECIST) New Guidelines to Evaluate the Response to Treatment in Solid Tumors P Therasse, SG Arbuck, EA Eisenhauer, J Wanders, RS Kaplan, L Rubinstein, J Verweij, M Van Glabbeke, AT van Oosterom, MC Christian, SG Gwyther Journal of the National Cancer Institute 92: , 2000 Eisenhauer et al. Eur J Cancer 2009 (RECIST 1.1)

25 RECIST - Target Lesions Target lesions must be measurable [10mm CT/MRT; 10mm clinical exam; 20mm chest X-ray]; malignant lymph nodes: >15mm in short axis Target lesions must be reproducibly measurable - Consistency across time points [stable position, same phase ] Target lesions should represent distribution of disease [lesions from disparate areas; nodes from different nodal stations - lymphoma]; 5 lesions total (2 per organ) Quantitative Assessment The SLD is the quantitative assessment Strict rules and definitions of: Complete response = No measurable disease Partial Response = Greater than 30% decrease in score Stable Disease = Between 30% decrease and 20% increase Progression = Greater than 20% increase in score

26 RECIST - Non Target Lesions (Qualitative Assessment) All aspects of disease not chosen as Target Lesions All non-measurable lesions Measurable lesions that were not chosen as target lesions Lesions that may be (but not definitely) metastases Non- measurable lesions Not suitable for accurate repeated measurements Ascites Leptomeningeal disease Pleural effusions Inflammatory breast disease Cystic lesions Lymphangitis cutis/pulmonis Bone lesions Brain lesions Irradiated lesions Ground glass lung lesions

27 Limitations of RECIST guidelines No criteria for non-solid tumors Tumor morphology Confluent, Irregular borders Unusual configuration; Circumferential (eg. mesothelioma) Discordant results due to RECIST technique Uni-dimensional measurement Shape changes may confound results Tumor size: Sub-centimeter tumors Choosing representative tumor burden (Non-spherical, asymmetric tumors) Problematic when tumor burden is substantial Differential tumor response Updated imaging technology not considered (3D/volumetric measurement, PET, automated TU detection) Not adapted to evaluate cytostatic rather than cytotoxic treatments (progressive disease remains progressive disease even if tumor growth is slowed) Criteria for tumors treated by Non-drugs? (eg: Radiofrequency ablation)

28 Lesion Confluence and Relationship to Normal Anatomical Structures Future? Unusual Lesion Configuration Volumetric Differential tumor behavior Functional Wahl et al. J Nucl Med 2009

29 Cheson Criteria Based on International Working Group Recommendations Standardized repeatable method for measuring response to therapy for NHL Response is assessed on 3 criteria: 1 Radiological Lymph nodes/ Quantitative masses 2 Clinical Physical Exam Qualitative Spleen/Liver Biochemical 3 Pathological Bone Marrow Semi-quantitative Copyright 2008 TIMC, Matthew A. Barish M.D. All rights reserved. 29 Cheson et al. J Clin Oncol

30 Befundet von Untersuchungen CT Hals und CT Thorax: Restaging bei Parotis-TU. TC collo (senza e con), TC torace (senza e con) Es liegt zum Vergleich eine Voraufnahme vom vor. CT Hals: Am tiefen Anteil der li. Parotis zeigt sich der bekannte Parotis-TU mit einer Ausdehnung in der Voraufnahme von 4,7 x 1,8 cm und aktuell 4 x 1.5 cm, somit größenregredient. Im Vergleich zur VA zeigt der Tumor in der aktuellen Aufnahme eine deutlich geringere Vaskularisierung, als Zeichen für ein gutes Therapieansprechen. Die pathologischen LK am li. Kieferwinkel, im Level 2 a, zeigen auch ein deutliches Ansprechen auf Therapie mit Größenregredienz von in der Voraufnahme 1.6 x 1.2 auf aktuell 0.7 x 0.5 cm. Auch die pathologischen LK li.seitig im Level 3 sind deutlich größenregredient. Keine neu hinzugekommenen pathologischen LK. CT Thorax: Keine vergrößerten axillären, supra- oder infraklavikulären LK. Keine mediastinale Lymphadenopathie. Lediglich einzelne kleinere paraaortale LK sowie ein LK am aortopulmonalen Fenster von 1.1 x 0.7 cm. Reguläre Herzgröße. Diskreter Perikarderguss. Im Lungenfenster zeigt sich zu Lasten des re. OL im Segment 2, adhärent zum großen Interlob des re UL, eine noduläre Formation von zirka 6 x 7 mm, DD: Metastase, DD: postentzündliche Veränderung. Zu Lasten des re. UL im apikalen Segment intrapulmonaler Lungenrundherd von 4 x 6 mm, DD: intrapulmonalen Metastase. Auch zu Lasten des li. UL basolateral, mit schwieligen Veränderungen zum Interlob, zeigt sich eine spikulaartige Verdichtung von 9 x 5 mm, am ehesten postentzündlicher Veränderung entsprechend, jedoch wird auch hier eine Verlaufskontrolle empfohlen. In den mitabgebildeten OB-Schichten altersentsprechender CT- Abdomen-Befund. Im Knochenfenster kein osteodestruktiver Knochenprozess. Befundet von Untersuchungen TC torace (senza e con), TC addome sup.e inf. (senza e con), TC collo (senza e con) Ct HalsThorax Abdomen mit KM Klinische Fragestellung: Lymphadenomegalie unklarer Genese zervikal mediastinal retroperitoneal Lymphom? Andere NPL? Modus: CT Hals Thorax Abdomen in helicaler Schichtführung unter Kontrastmittelverabreichung von 130 ml Xenetix i.v.. Befund: Keine Vergleichsbilder im PACS-System abrufbar. Hals: Schleimhautschwellung im rechten Sinus maxillaris. Die großen Kopfspeicheldrüsen sind seitensymmetrisch. Massiv vergrößerten Lymphknoten zervikal beidseits in sämtlichen LK-Levels mit Aussparung der submentalen/submandibulären und nuchalen LKs. Seitensymmetrische Darstellung von Pharynx und Larynx. Regelrechte Kontrastierung des zervicalen Gefäßbandes. Thorax: Ausgeprägte LAP bds. axillär und paraklavikulär. Auch mediastinal kommen, etwas weniger ausgeprägt, pathologisch vergrößerte Lymphknoten in Level I/II/III/IV/V zur Darstellung und bds. hilär. Im übrigen mediastinale Strukturen unauffällig. Pulmonalen kein suspekter RF. Geringe Emphysemzeichen. Kein pneumonisches Infiltrat. Kein Pleuraerguss. Abdomen: Hepatomegalie. Keine fokalen hepatischen Läsionen. Die intra und extrahepatischen Gallenwege sind nicht dilatiert. Pankreas o.b.. Milzgröße 11,5 cm. Nebennieren o.b. Zeitsynchrones Nephrogramm. Keine Harnabflußstörung. Ausgeprägte retroperitoneale Lymphadenopathie betont paraaortalen und iliacal. Kein Aszites. Im Knochenfenster keine agressiven Osteolysen. Ergebnis: Bild vereinbar mit Lymphom, ausgeprägte Lymphadenopathie zervikal / axillär und retroperitoneal sowie iliacal bds.

31 The issues An electronic report is created using computer based techniques (workflow), includes some amount of structured and coded content, and may include multi-media (e.g. images) How do we bridge the gap between the imaging side and the reporting side? Annotations, key images, and measurements How do we include these enhanced features in reports?

32 The CDA Iceberg Pathologist/clinician sees Machine sees

33 The clinician sees

34 <ClinicalDocument xmlns='urn:hl7-org:v3'> <typeid extension="pocd_hd000040" root=" "/> <!-- conformance to a generic APSR content module --> <templateid root=' '/> <!-- conformance to a cancer APSR content module --> <templateid root=' '/> <!-- conformance to a breast cancer content module --> <templateid root=' '/>...remainder of the header not shown... <component> <structuredbody> <component> <section> <templateid root=' '/> <code code=' ' displayname= Pathology report relevant history' codesystem=' ' 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=' '/> <code code=' ' displayname= Reason for referral codesystem=' ' codesystemname='loinc'/> <title>reason for anatomic pathology procedure</title> <text>breast mass - left breast</text> <entry>... </entry> </section> </component> <component> <templateid root=' '/> <code code=' ' displayname= Pathology report relevant history' codesystem=' ' codesystemname='loinc'/> <title>relevant information provided by the ordering physician</title> <text> Tissue submitted: left breast biopsy and apical axillary tissue The machine sees

35 Is this an electronic report? MSH ^~\& RIS GOOD HOSPITAL ORU^O01^ORU_O01 P 2.6 <cr> PID 1 PATID1234^5^M11^ADT1^MR^GOOD HOSPITAL~ ^^^USSSA^SS EVERYMAN^ADAM^A^III M C 2222 HOME STREET^^GREENSBORO^NC^ GL (555) S PATID ^2^M10^ADT1^AN^A ^NC <cr> PV1 1 I 2000^2012^ ^ATTEND^AARON^A SUR ADM A0 <cr> OBR 1 P8754^OE XR1501^XR ^CXR PA+LAT^LN ^INTERN^IRVING^I^^^MD^L...<cr> OBX 1 TX ^CXR PA+LAT^LN Infiltrate probably representing bronchopneumonia in the right lower lobe. Also pulmonary venous congestion cardiomegaly and cephalization, indicating early congestive heart failure. Followup CXR 1 month....<cr>

36 Terms to Know HIS (KIS) Hospital Information System RIS Radiology Information System APIS Anatomic Pathology Information System PACS Picture Archiving and Communication System IHE - Integrating the Healthcare Enterprise (IHE Anatomic Pathology WG) (IHE Radiology WG ) HL7 Medical text communication protocol. (Health Level 7) HL7 Anatomic Pathology WG; HL7 Radiology WG CDA Clinical Document Architecture standards DICOM Digital Imaging and COmmunication in Medicine PERT/PERC (Pathology Electronic Reporting Task Force)... WG=Working Group

37 users developers interoperability international standards

38 IHE Organizational Structure Domains ASTRO AAPM ACR AROI CARO CSRO ESTRO JASTRO SIEMENS PHILIPS

39 IHE Mission IHE is an initiative promoting and supporting the integration of systems in the healthcare enterprise. IHE Integration Goals Improve the efficiency and effectiveness of clinical practice: Improve Workflow Improve Information Accuracy Improve Information Availability Enable Cross-System Functionality A Proven Standards Adoption Process IHE Technical Framework Product With IHE Easy to Integrate Products Standards IHE Integration IHE Integration Profiles B Profile A IHE Connectathon IHE Demonstration User Site RFP

40 HL7 CDA (Clinical Document Architecture) A CDA document consists of a header and a body Header Structured Body Header is consistent across all clinical documents - identifies and classifies the document, provides information on patient, provider, encounter, and authentication Body contains narrative text / multimedia content (level 1), optionally augmented by coded equivalents (levels 2 & 3) Section DICOM Section Text Section Findings Object Catalog Section Text Section Impressions Section Recommendations Entries (Annotated) Image References Entry Coded statement Entry Coded statement ICD-10/ICD-O Section Key Images Measurements (RECIST/Cheson)

41 CDA Document Content Module IHE APSR HL7 CDA standards Any APSR CDA document content module is composed of a header and a structured body. 20 organ-specific cancer APSR Daniel C et al. Stud Health Technol Inform 2012

42 Standardized (e)reports Automatic Classification of Reports into Codes Narrative Report Synoptic Report with discrete Data Fields/ Coded Entry enter search: Ki67 ICD-10(GM) ICD-O TNM stage/ann Arbor.? Tumor grade IHC markers Response (RECIST)

43 Synergies with Electronic Reports Pathologists want access to diagnostic image data Radiologists have interest in pathologic data and access to summary data Clinicians have interest in clear/comprehensive report bronchoscopy

44 CD LAB User Passwort OncoNet KIS Rezepte User Passwort TaoNet User Passwort CFO User Passwort User Passwort User Passwort Repview User Passwort Concerto User Passwort Spartito User Passwort AIFA etc. User Passwort >10 Programme

45 Vielen Dank!