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The rush to deliver integrated reporting in pathology

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February 2022—Oracle’s purchase of Cerner, cloud computing, and integrated reporting were up for discussion when CAP TODAY publisher Bob McGonnagle convened a virtual roundtable Jan. 6 on anatomic pathology computer systems. Hematopathologist Monica E. de Baca, MD, said on the call she was encouraged by what she heard about integrated reporting from the AP LIS vendor reps on the call. But she said: “We should also be thinking about what is next; we don’t want to be talking about things 10 years after they were needed.”

She and seven others answered McGonnagle’s questions, among them: Are the resources in pathology adequate to make progress toward and enable the necessary IT outcomes?

Joining Dr. de Baca and McGonnagle were Aaron Auerbach, MD, Joint Pathology Center; Suren Avunjian, LigoLab; Curt Johnson, Orchard; Nick Trentadue, Epic; Joe Nollar, Xifin; and Ed Youssef and Dayna Carlin, NovoPath.

CAP TODAY‘s guide to AP computer systems begins here.

What is your reaction, Nick Trentadue, to the news of Oracle taking over Cerner?
Nick Trentadue, product manager, Beaker, Epic: It was expected. Cerner had been propping up the balance sheet, making business decisions. It was Cerner’s goal to sell the company, whether it was to Oracle, Amazon, Microsoft, Facebook, one of the big tech players.

Monica de Baca, what’s your reaction?
Monica E. de Baca, MD, founder of MDPath and hematopathologist, Pacific Pathology Partners, Seattle: Oracle was trying to get into the space and Cerner was trying to sell. What that means for those of us in pathology will be determined as we go forward.

Joe Nollar, perhaps this will clarify Cerner’s role in anatomic pathology and open opportunity for vendors.
Joe Nollar, associate VP, product development, Xifin: The acquisition gives Cerner the opportunity to modernize using Oracle’s new investment, and they need to. If they’re going to remain relevant in our space, that’s the next step for them. It’s a great marriage because Cerner’s assets and the health care data are valuable. That’s exactly what Oracle was looking for.

Suren Avunjian, what’s your reaction to this news?
Suren Avunjian, founder and CEO, LigoLab: Overall, the news was great for the industry and good for vendors. It will accelerate more of the information systems going to the cloud, which will be good for customers. It’s a good combination.

Aaron Auerbach, do you have a reaction to Oracle’s acquisition of Cerner and what it might mean for the AP space?
Aaron Auerbach, MD, senior pathologist in hematopathology, Joint Pathology Center, Silver Spring, Md.: My first thought is how the existing Cerner products will be affected. Parts of the government have been shifting to CoPathPlus and this acquisition may have big consequences for us.

Curt Johnson, let’s hear from you.
Curt Johnson, chief commercial officer, Orchard Software: It could be exciting for the industry. It’s always a positive when new technology is moving in the direction the industry needs to go to benefit our clients, such as moving to the cloud.

I am not sure, with the size of Cerner, if laboratory is its main focus anymore, let alone anatomic pathology. In the big picture, if you’re sitting in the corporate strategic room at Cerner, how often does anatomic pathology come up and where are they going with it? We’ll have to wait and see. Overall, anything moving to the cloud, any new technology investment coming in, should benefit their clients as long as it’s done with a customer focus.

Nollar

Is there now unanimity of opinion that cloud-based solutions are indisputably the future for laboratory and AP LIS computing? Joe, do you think that’s a settled issue?
Joe Nollar (Xifin): We believe it is the future and have for the past 20 years. We built all our products as web-based products from our inception. We believe it’s the fastest way to deliver new product to our customers and keep them on the latest and most updated platforms month to month and keep their costs under control.

Ed Youssef and Dayna Carlin, you have a lot of movement into the cloud at NovoPath, including new versioning. Ed, can you outline what this new release will be like?
Ed Youssef, VP of operations, NovoPath: We’ve been working on our cloud platform for a few years; it has already been live at a few clients. Our official launch of the platform is January 2022, so we’re excited to present the market with a fully web solution that is completely cloud—based on cloud architecture and technologies. The new platform addresses all the aspects used in the lab, including all the workflows; it’s a flexible system, able to adapt to the environment for our clients. We’re looking at it as a new market player that can shift the market toward the cloud.

Anatomic pathology computer systems product guide

We have done a lot of reporting on the disruption of cybersecurity in health care and particularly in laboratories. Monica, does the cloud offer more security in your mind?
Dr. de Baca (MDPath): Theoretically yes; however, there are also many regulatory issues that remain unclear in terms of data transmission, which makes a definitive yes or no outright almost impossible. From a computational point of view, if data are split up and shared in many places, it’s more difficult to pirate complete documentation of any one topic/patient, which is definitely more secure. HIPAA guidelines speak more to a paper-based world than to a digital world. Trying to thread the needle of what our regulatory environment requires of us and what our ever-evolving digital possibilities grant us is, to use two metaphors in one sentence, a dance that we’re trying to figure out the steps to.

Avunjian

Some people in labs are saying, given the staffing problems and the cybersecurity needs, that budgets will be devoted to these two big problems. Suren, do you have a feeling about cloud- versus web-based solutions?
Suren Avunjian (LigoLab): There’s still relevance to hosted solutions, especially with larger laboratory organizations that do high-throughput testing, to having the data close to them. Typically this is how we deploy to laboratories that have daily volumes of a few thousand and up with a lot of instrumentation. You don’t want to have the cloud lag between your instruments and the data needed in real time. We deploy local appliances where the rest of the software and the application layer live in the cloud and the instrument communication happens locally. This is our hybrid deployment strategy. Larger organizations typically have their own server environment, and if they want, we give them the flexibility to have the data closer to them. For smaller customers, cloud is a no-brainer.

There is higher-level security compliance that could be done via the cloud, just because cloud hosting is becoming more of a commodity. The hosting vendors themselves have invested a lot in the security layer; however, LIS vendors also have to go through SOC [service organization control] 2 type one and type two security compliance just so we can have our internal security practices in place. Those two things together will improve security and mitigate risk for laboratories.

We partner with a vendor that helps laboratories with security because that’s not a service we provide. This company helps with ransomware and provides insurance against it.

Suren comments on two issues. One, the anatomic pathology laboratory is a complex place compared with what it was 20 years ago. There’s a lot of instrumentation and middleware, all of which need to be handled in some kind of sync, and security is always an issue. At the same time, we see a trend toward the consolidation of work in anatomic pathology. I realize there are areas where smaller startup AP labs are getting traction, but by and large would you agree with me, Curt, that we’re seeing more consolidation of pathology activities and groups?
Curt Johnson (Orchard): From an anatomic pathology point of view, we are continuing to see consolidation. COVID testing has been such a catalyst for molecular technologies that these technologies are going to continue to explode and we will see growth that we haven’t seen in past decades. That change will affect anatomic pathology as well.

Moving into the future we’re going to see a combination of instrumentation in the anatomic pathology laboratory designed to work with digital pathology, the pathologists, and molecular testing. That’s going to be the next big change that takes place and moves cancer diagnostics further along. A lot of the testing we’re doing now will be immensely more accurate, and diagnoses will be faster.

The move to the cloud is going to be important, and you will have to have a way to integrate localized instrumentation. You will need the flexibility of a system that can be all-inclusive. You have to be looking to the future—what will it look like five, 10 years from now in terms of cybersecurity, the cloud, and personnel? You have to be able to make best judgments on where the market is going, have opportunities for each of those, and how you’re going to address them.

Aaron, as you look at it from the perspective of the Joint Pathology Center, this is a pretty tall order in terms of what needs to be in place for you to optimize your work and efficiency. Does this ring true with you as you think about the future of computing?
Dr. Auerbach (Joint Pathology Center): Absolutely. We’re looking at cloud-based solutions, but being part of the government, cybersecurity is our primary concern. With our IT-based platforms, we focus on the highest level of security.

Within the AP LIS world, as we traditionally know it, there is a lot of buildout of AP systems. In CAP TODAY product guides we have AP companies in the LIS guide and LIS companies in the AP guide. There’s been a blurring to some degree.

Dayna, if you were to envision what a pathology department will look like in five years, has it integrated clinical, molecular, and anatomic pathology, along with the other bells and whistles, like digital pathology, all under one system? Or is there still a lot of division?
Dayna Carlin (NovoPath): I think pathology labs are going to consolidate, make it easier for themselves. Having one platform that does it all would have benefits from a maintenance standpoint, for example. I foresee labs consolidating their IT footprint and having one vendor or one system in place. That would also help with the security of going to the cloud. Instead of having your IT team focus on workarounds and looking at the different infrastructures, you’d shift them from infrastructure to security.

Nick, what are your impressions about this notion of an integration of the work of pathology and of the various subspecialty areas?
Nick Trentadue (Epic): When Beaker launched in 2006 it was clinical pathology only. Anatomic pathology came in 2009. We’ve never had different systems, so it’s always built as one on top of that integrated patient record. As we offer more features, it’s on our one integrated lab product. Whether it’s molecular, whether it’s a COVID test, or cytology, an autopsy, a basic chemistry test—it’s all done in one system.

As labs consolidate and as we go more into diagnostic management teams or do more on an integrated disease level, having all the data on top of the clinical data has proved to be beneficial for pathologists who do hematopathology reports or complex oncology cases, where they can bring outside testing from a specialty lab into their tissue-based reports or a tumor report and have all that data in one platform. It has also been a benefit to academic medical center groups.

Joe, tell me your thoughts about this.
Joe Nollar (Xifin): Having a single integrated platform for CP, AP, and molecular is where the market is going. The ability of our systems to provide that is important, because when the pathologist is looking at, say, heme path, they’re doing comprehensive bone marrow morphologies and looking at several testing modalities including clinical, FISH, flow, cytogenetics, and molecular. The pathologist needs to be able to easily view and assess these results.

Ultimately they need to create comprehensive summary reports that take all those diagnostics and communicate them in a consolidated, cohesive way to the treating oncologist. It’s about having a system that breaks down those silos and provides consolidated reporting.

Dr. de Baca

Monica, can you comment on this pursuit of the holy grail? The other side of this coin is kind of a best-of-breed tissue system, and the integration of a lot of pathology information has been a headache almost as long as I’ve been in the field.
Dr. de Baca (MDPath): Integrated reporting has been my main goal since joining pathology. I was a patient-facing physician before, so in the beginning of my career I was reading those reports. To Joe Nollar’s point, the real goal is for the person who is treating a patient to get a report that tells them everything they need to know. Pathologists have been trying to do that for the past 20 years in an ever-increasingly complex series of systems required to inform all the new testing modalities we have.

In a past roundtable, the conversations revolved around things we were aspiring to; now it’s good to hear that the vendors are aligned with those needs. It’s uplifting to think that perhaps by the time I retire, we’ll be at a place we envisioned at the beginning.

The things we are discussing today as up-and-coming are what we need right now. I’m glad vendors are already considering these things. We should also be thinking about what is next; we don’t want to be talking about things 10 years after they were needed. We must think proactively: How are things changing? Are these systems considering how AI and machine learning products are going to be included? Are we talking about the transparency of those products—how product methods will be shared, how patients will be affected, how patient safety will be assured?

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