The rush to deliver integrated reporting in pathology

Important in making these things happen are interoperability and data standards. Data standards are not sexy—we can talk about the cloud, cybersecurity, but underlying it all is interoperability. If cybersecurity is the house, interoperability and standards are the bricks, and bricks aren’t sexy. But without those bricks your house might fall.

We need to continue to lead in the conversation about the need for interoperability and, more specifically, making sure the standards are supported and built out so we can create interoperable systems that will allow complex reporting systems—LISs and EHRs—to maximize what’s possible.

Dayna and Ed, tell me how you’re poised with your new release to address some of the issues around data standards, interoperability, and making it easier on pathologists to get the work accomplished.
Ed Youssef (NovoPath): AP labs have been redefined to include a lot more than AP-specific testing. And vendors are consolidating, through mergers, acquisitions, or partnerships, and with that comes the interoperability. The problem is, how do we interface with other systems? How do we make use of strong partnerships with other vendors that provide the components, whether it’s AI or machine learning, that might be needed for the future?

One of the components in NovoPath 360 is an interface engine that is responsible for communicating and making connections with third-party systems and external systems that the lab can work on—for example, a specialty lab that has third-party applications they need to integrate with NovoPath. Or if a lab has external systems and partners that are specialized in a certain solution they’re providing to the lab, we can come together to quickly and easily hook up the two systems. With that, we provide the lab not only the best of breed in the AP system or an LIS, but also a best of breed of partners that can come together and provide a comprehensive solution to the client.

Dayna, would you like to add to that?
Dayna Carlin (NovoPath): We spent a lot of time with our existing clients looking at how we can make it easier for them to use the system. The pathologists and lab managers we talked to said to reduce clicks, reduce clicks, reduce clicks. And that’s what we’ve done. We’ve redesigned the interface to the system and made it easier to order stains, add images, and release reports within a second, one click. We’ve also made it easier to train. With the staffing shortages, clients are asking: How do we make it easy to bring people onboard without having to go through a 100-page document? It should be intuitive enough that the user can jump on, understand where they need to go, and complete their work. And we’ve done that.

Suren, are you hearing the same from your clients and potential clients about minimizing clicks and time on task at a keyboard?
Suren Avunjian (LigoLab): Absolutely. Our entire development philosophy revolves around streamlining and adding market differentiation for our partner laboratories. It’s important to consider the pathologist and every other role that interacts with the platform. Throughout the years we have invested a lot of time and effort into making these interactions as intuitive and fast as possible.

Everything can be programmed with keyboard shortcuts, which translates to voice dictation. With all the different voice dictation systems, you can fully control the software just by sitting back and using a microphone. We’ve extended the system to where there is zero need for some pathologists to click.

Curt, you have an interesting customer base. You have very large laboratories, smaller laboratories, pathology groups, and pathology groups embedded in health systems. Are you hearing from your customers and potential customers the same things you’re hearing from your colleagues here?
Curt Johnson (Orchard): We are, and one of the things Dr. de Baca brought up was that when we talk about interoperability and standards, the standards never seem to be in front of where the market is going. They seem to be where we were five years ago, which can make it difficult if you’re trying to come up with a standard to use for interoperability. We’re still talking LOINC codes, object reporting, HL7 2.3. We need to move on. We need to move to application programming interfaces and determine the best way to integrate with digital pathology. What is needed in the document and in the transfer of information, and what is needed for the doctor’s use and the pathologist’s use? If we wait for people to bring us a standard, it’s too late because it’s archaic and out of date.

The future of integration and interoperability involves moving toward APIs that we understand, and then we set the standard for what these things are going to look like in conjunction with the pathology community. You will see over the next couple of years a shift from HL7 integration to APIs, and that conversion to APIs will open the door for better interoperability and should assist us in meeting a lot of the pathologists’ needs.

Joe, comment on this, because there is a kind of a paradox here. Monica is right, no one loves standards. But do you think APIs may offer a more universal solution, as Curt suggested?
Joe Nollar (Xifin): Absolutely. It is about having APIs and making it easy—providing the toolsets to our customers to easily access, extract, and share the data. APIs are an easy way to do that. APIs allow them not only to access the data but also to do their own interfacing if they have an IT team that can support it. It’s a great option for our customers.

We have a standard XML output so that we can provide an easy way to populate third-party data warehouses and provide that dataset to our customers. But it’s the APIs our customers gravitate to. They want to write their own interfaces. They want to get an easy standard output and be able to select which output they want—will it be an HL7, an XML, or JSON [JavaScript Object Notation], or whatever they require. It’s having the flexibility within those APIs to be able to provide that data and those web hooks. It’s a great way to go.

Monica, give us a general definition of an API and then talk about standards.
Dr. de Baca (MDPath): APIs are functions or procedures that allow applications to access features in other places.

I don’t think that shifting the words from standards to API is a move out of the current Venn diagram. I think there is a union there because data standards are still needed for the data that cross an API, and agreeing that we’re going to do things with APIs is also a kind of standard. Data standards are generally documented agreements on how data is going to be managed, represented, formatted, defined, structured, tagged, transmitted, et cetera. I see APIs as part of a continuum of this series of circles in the Venn diagram and not something completely outside it.

Ed, can I go to an Apple store or a Best Buy to buy an API? That is, is there an API flavor that is NovoPath, Xifin, or Epic, and as a result we still have a pileup at the intersection needing a data standard?
Ed Youssef (NovoPath): We all have APIs, they all look a lot different from one another, and it takes a considerable amount of time for us to connect the systems. It is an effort that will need to be led by some of the members on this team here today. There may continue to be a dependency on HL7 standards, so there could be a reliance on that as we build the API, at least in the message structure.

Once the move on the cloud is stronger and more companies and customers are living on the cloud, you will probably start to see more of us leaning toward sharing and exchanging our APIs and partnering to create that standard.

Nick, would you like to make a comment?
Nick Trentadue (Epic): We have probably tens of thousands of APIs, and we’re trying to be transparent. Any customer or vendor can go to open.Epic.com, and all of our public APIs are there. I agree with Monica that standards have to be part of it. A pretty standard API is: get patient sex. Is that sex assigned at birth, is that legal sex, is that sex the person identifies with? It sounds easy but it’s not.

Where we have the cross-section of standards and APIs as more technology or groups want to do one, two, or six things—there are tons of APIs out there—but if you don’t intersect them with standards, our customers or the lab community will be spinning their heads trying to piece together these different applications with these APIs that might not be grabbing the same thing.

Joe, do we have adequate resources in the world of pathology to enable and make progress toward these important goals? Or is pathology underfunded?
Joe Nollar (Xifin): It is probably underfunded, though this past year has seen a great level of investment in new technologies. We’re seeing more AP labs expanding into molecular testing, a lot of it initiated by COVID.

We’ve seen investments in digital pathology and we’re doing more digital pathology integrations than ever before. This past year we’ve seen a huge uptick in artificial intelligence algorithms being applied to digital pathology platforms. It’s exciting to see that level of investment. To Dr. de Baca’s point about investing in the future and trying to be ahead of the industry, that is where the market is going—support of digital pathology and artificial intelligence and giving pathologists the toolsets they need to be successful for the future.

Nick, as you look at pathology, are the resources there adequate to accomplish what we’ve been talking about in terms of desirable outcomes for technology and the pathology lab?
Nick Trentadue (Epic): I’m going to say yes, because hopefully the pathology groups will have to think less about it as their vendors take care of it for them. Whether you’re going to offer an on-site deployment, a cloud deployment, a combination deployment, or host in a public cloud like Amazon Web Services or Microsoft Azure, the vendor you work with, whether it’s Epic or NovoPath, has it figured out for you and you’ll have a secure solution. You’ll go through your SOC 1 or SOC 2 or all of your different security analyses—you can control what you have on site and how you access that deployment.

We spend a considerable amount of time at Epic in our hosting operation focused on cybersecurity. Customers, the pathology community, should be able to sleep better at night if they can count on their vendor—especially if they choose one that is holistic for the laboratories and they don’t have a seven, eight, or nine different best-of-breed approach—to deliver it securely, assuming the customer does the things it can control on its end for secure access.

Curt, we know there has been an infusion of funds due to COVID. But are there adequate resources for all the IT needs and goals we have?
Curt Johnson (Orchard): I believe there are adequate resources out there, and as the vendors take on more of that responsibility, it benefits the overall end users and the facilities. The uniqueness of the lab is that it is still a business unit within health care. If everyone were to close their eyes, they would have different views of what a pathology lab is. Are we talking about an independent group of pathologists? A hospital? A teaching university with a large pathology and research arm? A big urology clinic that has several pathologists onboard? Depending on what you call pathology, it changes the conversation as far as resources go. But the move to the cloud, the assistance of cybersecurity by the vendors, working as partners and in cooperation with their customers, is allowing for more to be done in a faster timeline. And as I said earlier, with COVID, the molecular explosion is going to make a big difference for all customers and all of health care.

Dr. Auerbach, what’s your reaction to this discussion of resources and desires?
Dr. Auerbach (Joint Pathology Center): I think your average pathologist works in a place where they have real hope that their AP solutions will do a lot of the things we talked about. They hope they’ll have solutions that have digital pathology, will work more with AI products, and will do more integrative reporting. That may not always be part of a small, community hospital-based practice.

My organization is looking at resourcing at higher levels, with the hope of leading with some of these different issues. I don’t know if that trickles down to the smaller practices. But pathologists are a hopeful group, so we’re looking forward to these innovations in the future.

Monica, share your final thoughts on and reactions to the resources and needs we’ve talked about.
Dr. de Baca (MDPath): The idea that there is a gamut of possibility or need out there is a crucial comment. If I were at a major institution with a pathology department doing research in AI or in digital pathology, during the pandemic I would have been at home looking at cases, thanks to the work the CAP did to get waivers. I work at an institution that uses CoPath M. It’s still functional but basic; it nicely serves the institution for which I work, but I can’t do any of the complex things we’ve talked about today. There are other places with the intermediate functionality we’ve discussed. So until we bridge these gaps, then when we talk about pathology, what are we actually talking about? We’re talking about a lot of different things, where some people are driving Teslas and some are trying to pound the last mile out of an old mule.

The question “Is there enough money?” also depends on which of those participating paradigms you are discussing. It will be a bigger lift for some institutions to join the 21st century because they haven’t invested in pathology systems over time—the dollar delta is big. Others who have been investing in their pathology services have smaller deltas, and those shifts to up-to-date systems are small for them.

We know there are ever-increasing needs for pathology services, and we have a host of positions in the country that are unfilled. We just don’t have enough pathologists. Part of that is because of the way residency programs are structured, because of visa issues and decisions about how many medical school slots to fill, and because many medical schools have not been teaching pathology as a separate discipline. Whatever the cause, pathologists need systems that allow them to increase efficiency to meet growing case loads.

I am hoping the pandemic will help people understand that although pathology is only a small part of the medical dollar, between two and three percent, without pathology and the results pathologists bring to the house of medicine, very little medical action can be taken. Perhaps people in the C-suites will realize that for what is a small investment for them—pathology is one tiny column in their big spreadsheet—the return is not just large but actually sweeping. Pathology—and the data it produces—is a good place to spend money.

As we think about interoperability and APIs and the possibility to transfer data, then the better the data, the stronger the data, the more the data, therefore the stronger the pathology departments and the better the position in which the C-suites find themselves. I’m a pathologist so that’s my hammer, but I’ve also not been a pathologist in the past and I know that were I still a clinician I still would be pounding this hammer. It just makes logical sense. I hope others see this too.

The views expressed by Dr. Aaron Auerbach are his and do not reflect the policy of the Department of Army/Navy/Air Force, Department of Defense, or U.S. Government.