Corporate innovation as an engine for change: panel discussion.
Article Type: Discussion
Subject: Diagnostic services (Innovations)
Diagnostic services (Economic aspects)
Diagnostic services (Conferences, meetings and seminars)
Medical equipment and supplies industry (Officials and employees)
Medical equipment and supplies industry (Services)
Medical test kit industry (Officials and employees)
Medical test kit industry (Services)
Wellness programs (Evaluation)
Wellness programs (Conferences, meetings and seminars)
Pub Date: 04/01/2009
Publication: Name: Archives of Pathology & Laboratory Medicine Publisher: College of American Pathologists Audience: Academic; Professional Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2009 College of American Pathologists ISSN: 1543-2165
Issue: Date: April, 2009 Source Volume: 133 Source Issue: 4
Topic: Event Code: 540 Executive changes & profiles; 360 Services information
Product: Product Code: 3840000 Medical Instruments & Supplies NAICS Code: 3391 Medical Equipment and Supplies Manufacturing
Organization: Company Name: General Electric Co. GE Healthcare; General Electric Co. GE Healthcare
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 230246987
Full Text: FRIEDMAN: We have the luxury of having time for conversation with 4 of the leading experts in the country in 2 different areas, digital pathology and integrated diagnostics. I am going to start with a question to both Gene Cartwright and David Okrongly. This question pertains to a program that has been launched by Siemens and GE. GE calls it "Early Health Model" and Siemens calls it "Early Detection and Treatment." I have been fascinated by this concept as I think it represents a totally new paradigm in the health care process. I do not want to put too fine a point on this, but early health model can be defined as preclinical, presymptomatic diagnosis. If a patient is diagnosed in a preclinical, presymptomatic state, this essentially brings the diagnostic enterprise to the center stage. We are all used to the current model where the physician takes a history from the patient and asks, "What is bothering you?" With the current disease model, if the patient says "nothing," the physician says, "I will see you next year," or perhaps some subsequent time. With the early health model, it is the diagnosticians who are going to essentially pin a diagnosis on the patient in a presymptomatic state. There are a lot of participants in the current health care delivery process who will be agitated and perhaps disturbed by this new approach. Payers will be bothered for sure and probably Big Pharma, because all of the clinical trials have been based on treatment of symptomatic patients. I would like to ask Gene and David to share with us their perceptions of this early health model, early detection and treatment. How was this idea hatched and what will be the future implications of this new paradigm for the pathologist and the lab medicine specialist?

CARTWRIGHT: I will try to answer that in a relatively simple way. The largest overview at GE for early health was mentioned earlier in the meeting: taking about 10% of the money that is now spent on therapy and moving that to diagnostics. If we do that, we believe that we can significantly lower the total cost of health care. From a diagnostic standpoint and from a pathology standpoint we see that there will be great things in our future. I think also at the same time that it accomplishes a reduction in overall health care costs.

OKRONGLY: I fully agree, Gene, that we have got to focus on how to move money out of silos and be able to find a way to bring more value to diagnostics. That is going to be key in implementing an early detection strategy. We are going to have to start focusing as much on health economics as we do on the technology and the development of our clinical plans for these new tests. In fact, reimbursement is going to also play a big role here, because we've obviously got to be able to get a return on the investment for those clinical trials and those health economic studies. The current practices right now within CMS, which are basically cross walking a new diagnostic test from an existing diagnostic test from the 1980s, make it difficult to really think about how new molecular diagnostic tests are going to be reimbursed. Advamed is working very diligently now. There is both a House and a Senate version of a bill to create a demonstration program for a more logical, transparent process for setting reimbursements for these new diagnostics tests. Part of that would be health economics that would help to drive changes of behavior and how we fund these things, and also to make it a little bit easier for a diagnostic company to know exactly what it is going to get in terms of a return out of a significant investment in new biomarkers.

FRIEDMAN: Moving money out of silos sounds like a wonderful idea. David just said there are political ramifications to this approach. Does the promotion of the idea go beyond the politics? I know many of the GE press releases that refer to the early health model suggest that the early health model may reduce costs. Intuitively, I believe that is a correct assumption. But can we put some numbers behind this idea or do we have to wait until it is more of a reality and we are deeper into the early health model to better understand the possible cost savings?

CARTWRIGHT: I do not think we have numbers that we have a lot of confidence in quoting, but I would say that I would agree with David that there will be a lot more emphasis on health care economics in order to get to those numbers. I think Mara Aspinall showed a couple of numbers where it typically was the savings on the drug costs and not only on a total-per-patient basis, but on the number of patients who were successfully treated. There's a lot of work to get to those numbers and to answer your question appropriately. That is where the health care economics work has got to be done.

FRIEDMAN: I need to push back on this idea because a previous speaker showed that the yearly costs of some of these new biotech drugs can be astronomical. Is it correct to say that pathology and laboratory medicine will be competing with Big Pharma for resources? We are trying to drive down the cost of diagnosis but they are trying to maximize their revenue to quickly cover their development costs of these new biotech drugs. Is there not, then, a tension in terms of driving down the costs with the early health model?

CARTWRIGHT: To a degree there is, but I would say that if you look at the Pharma model and from a Pharma standpoint, I would not be surprised if the major push for change comes from their finance guy, meaning that he will be the one to stand up and say, "This model is not working; this blockbuster model is not working." We need to hit some singles and we need much higher likelihood of success and those 2 things are also accomplished with biomarkers, so they are not necessarily competing.

OKRONGLY: I agree. We saw the chart quoting 50% of new drugs failing at phase III. To kill a drug at a phase III level is a disaster from a financial perspective for a pharmaceutical company. It is going to be more and more imperative to develop the right selection model for patients along the way and that is going to be done with a combination of in vitro and in vivo diagnostic technologies.

FRIEDMAN: So David and Gene, are pathology and pathologists ready for the early health model? Are they ready to step up to the plate and take on this added burden of not only making diagnoses but also developing therapeutic recommendations? And if not, what do we need to do to get them and other laboratory professionals to this spot?

CARTWRIGHT: Our job is to prove to our customers, the pathology base, that we have a solution that does make sense. A lot of work has to be done on our part and it's a challenge. Physician education is a challenge. It is probably a challenge for the CAP pathology community; it is certainly a challenge from a corporate standpoint. We must come up with new effective ways to educate people about new ideas so that they can learn a lot more about them within their busy days and without necessarily making sales calls.

OKRONGLY: I think we are talking about a 5-to 10-year process here. This is not going to be an overnight phenomenon and I think there will be enough success stories along the way that will give the pathology practice time to adopt and change. But I think it starts with a vision for the future and then starting to take steps along the way to enable your practice to be ready for that future.

FRIEDMAN: Five to 10 years and this conference is a good start in that journey. Picking up on this same physician education theme, I want to turn to the topic of digital pathology with Dirk Soenksen and Mark Newburger. Dirk mentioned this very briefly, but I want to commend him in the sense that in the digital pathology world, Dirk and Mark, not only have you had to create a new product category but you have also been required to educate potential clients, the pathologists, who will derive the most benefit from this technology. I saw this same theme represented in their presentation--they have developed tech nology but are also educating at the same time. I am also interested in the fact that Aperio has created its own conference, the Visions conference. I cannot think of any other precedents where a company offers a very sophisticated yearly conference. I think this engagement in physician education is to their credit. I would like to know how Dirk and Mark react to this comment. Did you get into this business knowing that you would have to not only create the product but also create the market as well? Perhaps Dirk first and then Mark.

SOENKSEN: I have been involved in getting new technologies launched and one of the key ways in which you start is to create awareness of the possibility. For those of you who may have gotten to know Aperio 7 to 8 years ago, we had a lot of vision about where this field would go. We would go around the country and essentially talk about the vision and then as we were able to add some reality into it, the mix of vision versus reality has changed to where it is today. We have mostly reality. We are a leader in a very exciting market. Our biggest challenge 2 years ago was lack of awareness and so we made a deliberate effort to raise the level of awareness. Awareness just meant you had to be aware of digital pathology. It did not have to be from Aperio or any other vendor; we just wanted to create awareness in the space. I would say today we are at a point where a large number of people are aware of digital pathology. A lot of people still have fear, a lot of people do not see the value, and there certainly is not full acceptance yet along the lines of what we heard earlier today. Today, I think the next step is all around proof sources. This is all around educating again because people are generally aware ... some people have a good impression of the technology, others say it is not for me, but we now need to fill in the blank with real proof sources, with data, clinical studies that have been done, pilot studies that are conducted and then say, here are exactly the results we got. Here is where it was before, here is what it was after, to provide something more tangible to people who are not aware of the technology. This is all part of an educational campaign. Our view of our Visions is that, 5 years from now, Visions may not be an Aperio-sponsored conference. It could be turned over to another group and it could turn into its own industry conference. There is no real excitement I have for spending hundreds of thousands of dollars on Visions every year, but we think in general that we have to grow the market for the businesses to become successful. At some point it will get turned over to a steering committee and it will take on its own character and we would love that. At this point that is not the case so we will continue to hold the reins. But if you fast forward, that is how Visions is going to be. It is going to be a digital pathology conference and the fact that Aperio got it off the ground may be something that not many people even remember.

NEWBURGER: I've been promoting digital pathology in one form or another for 2 decades now and it is refreshing that people are starting to be focused on what it can do within the laboratory environment. I think it is important, however, that while we have a lot of technologies to bring into play, we need to be focused on the strategy of the business of pathology and the diagnostic operations of pathology and what the key is to making all that work. There are a lot of tools to help with diagnostics, but it is the pathologist who brings it altogether and makes the work flow go. What we are focused on is understanding the business that you are in and what your strategic needs are, and then helping you develop a strategic plan to get that forward utilizing whichever technologies make sense both today and in the long term. I agree with the rest of the panel that in 5 to 10 years it will be a whole different world, but we need to get to that and we can talk a lot about the technologies and need to talk about the technologies, but we also need to know how we get from here to there and not just imagine us popping into there. We have to have a road to get there.

FRIEDMAN: I am going to ask one more question and then open the floor to questions. Dirk, in your presentation I was reminded of "the dog that did not bark" from the Sherlock Holmes's stories in the sense that you made hardly any reference to whole slide imaging. It seems to me that your approach in this area was a more go-slow one when you talked about mature applications and yet, Gene, in your press releases for Omnyx, you discussed a 2-to 3-year horizon for the evolution of the mature technology. I now turn to Dirk and Gene to discuss the future of whole slide imaging, to comment on when you think it will be a practical reality, and how we ramp up into the broader application of the evolution of the digital pathology department.

CARTWRIGHT: I am speaking a little bit for GE as well as Omnyx. It is our job, the size company we are, to address big problems. That is our focus. I do not think there is a big disagreement between Dirk and myself on this, but we are squarely focused on how to make digital pathology make a solution for the clinical environment and make it work in hospital-based systems and reference laboratories in a very positive way for everyone. I am certain that we will also have an ability to sell into the research environment as well, but we are focusing on what we consider arguably the hardest problem, the biggest problem, and feel that is the kind of problem we should be focused on.

SOENKSEN: The question really highlights how we started the morning, which was to talk about the innovator's dilemma, and I think what Gene just basically said is that for a company like GE to move the needle, they would have to focus on the big problem that is going to give them the big return. They probably could not think about applications for tumor boards and secondary consults and frozen sections and quality assurance because that is where we are. I think it is an interesting question about what the strategy is, whether a niche adoption strategy will lead you long term to be successful. In other words, will Aperio by doing the niche adoption be the long-term winner or will somebody like a GE that focuses on the long-term problem turn out to be first across the finish line. I think that is very interesting and I look forward to seeing how that develops in the market.

With respect to the question about whole slide imaging, when we started this company back in my garage in 1999, we had to build a scanner. It was clear that the hours per slide to scan a slide in that day were not practical. It had to be minutes a slide, so we had to come up with a way to rapidly digitize a slide. The second we did that, we focused on the development of software and the back end because at the end of the day nobody wakes up in the morning saying, "I want to scan a slide in 30 seconds." That is just not something that you wake up and say I need to do. What you wake up to do is you say, "I want to be more efficient. I do not want to have to spend 3 hours doing this. I want this to be done in 1 hour," which is what Gene was talking about: the integration into the workflow and really solving problems. I would say the scanner is going to be the first part of this that is going to become a commodity. It will be the first part where you want to have scanners from a variety of vendors and you want them to be interoperable, so we're making good progress on DICOM standards and I would expect in the next year or two that you will be able to buy scanners that should interoperate. Just like in radiology where you kind of have the modality, which is the hardware, you have the PACS, which is the software, and you have the CAD, which is the analytics; you are seeing the same thing in pathology, so you have the modality in pathology, which are the scanners, then you have the software, which is the PACS and the image management, and then you have the analytics and certainly there is more opportunity for analytics in pathology than there is in radiology. I think that is what is exciting certainly from Aperio's perspective.

FRIEDMAN: I have found myself somewhat embarrassed by the asymmetry between the field of radiology and pathology regarding the adoption of digital technology, with radiology all digital and with us still working almost exclusively with our glass slides. I think is possible for us to accelerate our adoption of digital technology such that we can achieve almost equal parity with our colleagues in radiology.

Let us now open to the audience for any questions.

JARED SCHWARTZ: I have a question that relates to thinking about the digitalizing of pathology slides from experiences in radiology. We have obviously discussed this significantly in our department and I have talked with pathologists. We have about 50 radiologists. We have gotten to see them during the last 20 years go from film to digitized images. You go into their darkroom and there are just zillions of images all over the place and a lot of them are whining to us, "There are so many images." In the old days we only had a few things we had to look at and now we have the capability of looking at a limitless number of images. The pathologists are saying, "What is this going to mean for us?" Right now we make a decision to put on a slide 1 section, 3 sections, 10 sections; but what is going to happen when it is digitized and what about the legal liability issues, and so forth? Right now we talk about cutting through the block or cutting in deeper. You are always anxious; oh, my God, if we cut 3 more microns we might find the cancer or whatever. What are your thoughts about how that is going to affect productivity and efficiency and are any lessons to be learned from radiology for pathology?

CARTWRIGHT: For our venture, Omnyx, we have a partner. The University of Pittsburgh Medical Center (UPMC) and the pathologists at UPMC are a 50% partner in our company. In effect, we will be designing it with pathologists every step of the way, not to say that it will easy, but certainly that was one of the main reasons we decided to partner with them. Second, something that Dirk mentioned, his fourth quadrant. Really what you are talking about is how to make that viewing experience both richer and nonconfusing and those sound like they are at opposite ends of the spectrum. Richer sounds like a lot more stuff; nonconfusing is just the opposite. It is not a simple task to put those together. Hopefully we will learn from what mistakes have been made in radiology.

SCHWARTZ: What we have observed in radiology is that during the last few years to continue to sort of drive the revenue curve, the manufacturers of these devices have made them more sophisticated. So instead of getting a CT or an MRI that has 16 slices, now you have 32 and 64 and, of course, now you can have a radiologist looking at all the different slices and looking for something abnormal so then the need for a computer to highlight where you should look is much higher. I think radiology is just giving more data and it is probably overwhelming the radiologists and there are not tools available to allow them to manage this. In concurring with what Gene said, the vision here is to have a pathologist's cockpit that provides all the information you need at your fingertips. People always ask me, "Do you really think it is going to be faster to read out a slide on a monitor than on a microscope?" You might be surprised at the answer, but I do not think that is the case. I would say if you give a pathologist a glass slide and you give him a microscope and then you say, "Read it under the microscope versus reading that digital slide on a monitor," he is going to be more efficient reading that glass slide under a microscope. You know what? That does not defeat the purpose of digital pathology because in digital pathology the goal is not to read 1 slide; the goal is to read out a case and to get a report out. If I say, "Hey, you know what? I can make it more efficient for you to read out 4 or 5 slides, maybe to synchronize them in a way that you cannot do under the microscope. I can bring up a previous case history, I can integrate flow, and I can integrate cytogenetics and molecular data and I can put it all on one screen." Now if I ask the question, "Is digital pathology going to be more efficient than the way you do it today?" I will take that bet and I think the answer will be yes, we will have to prove it. One on one, just slide versus slide, you cannot beat the microscope and you cannot beat the glass slide. But in an integrated environment where you are trying to do things very quickly and efficiently and to address the needs of an aging population and the number of tests, I think digital pathology will address that problem particularly well.

ROGER SMITH: All the panelists are personal innovators and the companies are really corporate innovators. They are really trying to do things and transform pathology practice, but not all the innovation in the world goes on inside companies or inside your companies even. Can you give us some sort of insight into corporate strategy for evaluating innovations that occur elsewhere? How you decide whether to partner or to try to bring them in-house or to establish some sort of relationship. Is it something big enough to move the needle, which in the case of GE takes a lot more than some other companies?

SOENKSEN: There are 2 ways to really tackle that problem in terms of partnering with folks who are not in companies. In the early days we got a ton of feedback from pathologists. We would listen to them and many of the pathologists in this audience here were some of the folks who gave us feedback early on about what worked and what did not work. Fundamentally, in terms of scalability, if you think about the sorts of real value that could be added by academic institutions, you really want to have academic institutions have the freedom to take the bits and pieces you have built and to add on top of that. So I think this goes back to the need for having open standards and having an open system that others can attach value to. In the case of Aperio we have a large number of investigators who are using our development tools to develop their own algorithms, to develop their own user interfaces, to integrate with their own LIS systems, with their own EMR systems, so we have built something and we have documented all the interfaces and so many of our customers are really excited that they have tremendous flexibility in terms of how to leverage that, so that was how we planned to address that kind of question.

OKRONGLY: From a diagnostic perspective on the in vitro side, a really key factor for us is being able to access not only outstanding investigators but also biobanks, plasma, serum, and tissue that are going to be associated with long-term outcomes that will allow us to do a lot of the testing in a retrospective mode, at least in the finding mode where we're trying to develop an algorithm and be able to sort out from that algorithm what is the right way to differentiate the patient groups we are looking at. In our long-term strategy we come up with the areas that are of greatest interest and, no surprise, it is things like cardiovascular disease, neurology, infectious diseases, and cancer. That is how we look for the partnerships that are going to drive our programs: either things that start out in the universities that are tested in their own biobanks that we bring internally or the other way around. We have got an idea and we want to go and do some work. We will partner around the availability. The validation burden for these tests is really, really large. You have to have solid data to be able to convince pathologists or oncologists that there is a different way to start looking at a disease.

CARTWRIGHT: I think I would separate discovery from development. What companies are good at is more development. What the academic community, in my experience anyway, is better at is discovery and so I always try to remind our own people of that. Even if you look at as large a company as GE or Siemens is and you look at the amount of money that we spend on discovery and add it up, multiply it by I do not know what number, it is still a tiny number to spend on discovery compared to government funding, venture capital funding, academia, and pharma. That is where the money is on discovery. What we need is very smart people internally who really focus on what is going on and are fully knowledgeable of what is going on in discovery in the market and then when they see something good to bring it in and develop it.

NEWBURGER: From our perspective, we are focused just on PACS and that component in software. We focus primarily on development, not on discovery at all. All of our discovery happens by the relationships that we build with the academic institutions, people mostly out in this audience or some people that were not able to attend and then we get into a licensing scheme with the capabilities that we add onto or we build relationships with the devices that we are hooking into like all the guys on the panel with me, so it depends also on corporate strategy as to how you approach it. A group like GE, which has discovery, but also a lot of development, or a group like Apollo, which is primarily about development.

JAFFE: It strikes me from a National Institutes of Health standpoint that one of the things that is not going to move the field forward very rapidly is the issue of simply transferring images and making them do the same thing by subjective analysis. The cutting edge for us in radiology really is the issue of computer-aided diagnostics because that is going to solve some of the problems of how do you deal with viewing a whole block. The key element to that from what we consider our major investment is open databases of collections that are annotated. If the community here can do anything at all, it is to move beyond ... once they get their things digitized ... what they have to do is make their contribution of ontologies and markup so that then the imaging processing groups can take the next step. You must have massive databases to do this because you need to look at the statistical properties of the spectrum of disease. It is not going to be possible to do it with a few other investigators. It is got to be the whole society that does it. We are doing that a little bit with radiology, I think, rather successfully on a number of things because it is opening up new windows particularly on issues of quantification and I see that as being a very important investment that everyone in the community can make and only the community can make that, once you get beyond the issue of pure digitization and common resources for sharing images are possible. Perhaps someone may comment on the issue of where they think computer-aided diagnostics can go, but we see that as the frontier.

SOENKSEN: I completely agree with what you said, but a challenge from the corporate standpoint is how fast to run and we want to be running fast, but always at the direction of the pathologist and we do not want to outrun the pathologist on computer-aided diagnostics. That is really the challenge that we have. We just want to keep a very open dialogue so that we do not outrun how fast the pathologists want to run here.

JAFFE: But this is the point that Allen Kaye makes about inventing the future. The burden is not on industry; the burden is on the community because if they are going to go farther than where they have been, than substituting simply a digital view of what they could have done on a slide is not going to be enough. In order for them to create their own future, it should not be the burden of industry. We at the National Institutes of Health want to have this moved forward. We are happy to meet on some communications basis with the community here if they are ready to advance that, but the key issue is not simply digitization. It is the subjective value add of annotation and ontologies that go with that.

UNIDENTIFIED: I agree with that. I think that the way that we get to there both from a partnership between industry and the community is by the development and finalization of standards, and DICOM is an important standard. Unfortunately, it is still not done for pathology yet. It has taken years to get to where we are now. We were all part of the CAP initial meetings back in the 1990s, but as those standards become enforced within DICOM the same way for pathology that they have become in radiology, I think there will be a real opportunity to build those community repositories for imaging so that computer-aided diagnostics can get further along. I agree. I think CAD is an important part, but I think it is also important to realize that the pathology community for its entire existence (hundreds of years) has been choosing what they are going to look at and not being overwhelmed by the amount of information. I do not think that moving to digital pathology will slow that down. I think that it will actually enhance their ability to look at more because it will free up from a commercial basis unreimbursable time to be used for reimbursable time, which will drive what you are talking about.

UNIDENTIFIED: I'm a second-year resident in pathology and since the conference is about the future of pathology I have a question from a future pathologist. I see the corporate world entering the practice of pathology. We will see if it is for good or for bad. But what is your message, your take-home message for us, the residents, regarding the changes that we should expect in the practice of pathologists during the next 5 to 10 years? Do you want us to acquire toolkits that will help us adapt to what you are bringing in the future or do you want us to look forward to changes from your side and with us to adapt? What is your message for us, the residents?

SOENKSEN: The reason we have conferences like this and the reason that Visions exists is to maximize the feedback that we get from the pathologist. I think the path of how we get there is not entirely clear to any of us, but the worst path to take would be to say, we will design it and then we will show it to you when we're ready; that would be kind of silly. I think in many cases what we would love from the pathology community in general is the maximum amount of feedback about the way they see the value, some suggestions about where the pain is the biggest. We do market research just to get those kind of answers, so if people were more forthcoming about suggestions, that would be very helpful to all of industry because largely our goal is to address your needs and if we fail, it is because we didn't do our homework. I think it is done in collaboration so I think from the perspective of being a resident, this is a very, very exciting time and I think the residents in pathology have an opportunity to really shape what the tools look like that you are going to be using for the rest of your careers most likely.

UNIDENTIFIED: My question was prompted by the comment about the open source and development of algorithms and extracting value from public databases. This sounds wonderful but the concern from a commercial perspective is what happens to the discoveries. There are potentially serious IP ownership issues, which can impede the actual commercialization because if everyone owns it, no one owns it and it may be hard to commercialize and actually make it available to the greater community.

CARTWRIGHT: It is certainly an issue in gene discovery and gene-associated algorithms for differential diagnosis. I think there are a few areas that you have got to pick in your portfolio that you say we are going to work really hard to drive our own IP in that area and then it is going to be pooled at some point with other intellectual property, but I think the delivery at the end of the day is going to be how well you validate it, how well you can implement it, and how well you can integrate it into existing clinical workflow. The intellectual property certainly is clearly important and likely you will see every company is going to focus on a couple of key areas. But at the end of the day there is a lot more value added than just the test itself. There is going to be the workflow component and how you get your message out to the oncologist, to the cardiologist, whomever you are targeting with that new diagnostic modality that will really bring value.

SOENKSEN: (response to question from unidentified individual) If I understand your question, we are talking about searching images and the application of algorithms. One of the ways we think about that is if you want to develop your own algorithms and you have your own digital slide repositories, you have the opportunity to create tremendous IP for yourself. I think then as a community the pathologists can get together ... it is all related to how valuable the data is. Companies like ours do not have access to a lot of pathology data and it is not our business, so I think there is tremendous IP that could be generated in the community if people saw the value of doing that and I think industry would support that. We would give you the tools and we would help you as much as we can, but having IP in that area is not something, I do not want to speak for these guys, but that is not something that is our business at all.

SCHWARTZ: I want to answer the resident's question. When he asked it, I saw some squirming up there, and I thought maybe this was a more appropriate question for one of the pathologists to answer. I think it is fascinating. Again, this goes back to the issue of human nature. As I have been going around to all these different medical centers, university training centers, one of the first questions I ask is, "Do any of your medical students have microscopes any more?" I would say more than 90% respond, "No, we do not use microscopes any more in medical school." All the histology they learn and their pathology, everything is done using digital images. You say, "How about your tumor conferences? How is that done?" Again, they may not be using a specific digital system, but they are using digital technology for the conferences. The radiologists are observing; the radiologist is totally digital. I have been accused at a few meetings of hating microscopes. Actually, I do not hate microscopes; microscopes are wonderful. Every day when I am home I use my microscope. It is a tool. I think that what we are seeing now is the medical schools are using a new tool to show images. We look at images and again it is hard for me to understand why this is not moving up into the residency training programs; it is at some places. There definitely are places where it is current, but in general it is not. I think that the speed at which it will happen is going to be very fast because for the new group moving up into the training programs, that is all they are used to; they are already used to video games and everything else that is digital and the acceptance is very rapid. I am very optimistic that getting the customer, as we say, to adopt this will come very fast. I think we saw it with Smartphones; we saw it with a lot of others in my particular group. A couple of people get the technology. Everyone else says they will never have it and then a month later everybody has got a Blackberry. I think we should be very positive and optimistic about it. It will take education, but we are going to do it and that is part of the reason the CAP is here today.

FRIEDMAN: I can't let this panel terminate without having an information technology (IT) question and a number of speakers and the panel members have talked about IT. You guys are all about IT. I think a lot about the issue of the explosion of science and technology in pathology and in radiology. I am continuously frustrated by what I would call fairly slow progress in terms of the EMR and using the EMR as the "sole reporting vehicle" for this explosion of images and signs in pathology and laboratory medicine. There are some political implications (I don't even want to get into that), but I just want to ask all of you for a future scenario in hospitals for information technology given what we have learned today. What is your vision? How are we going to report to our customers using images, using the sophisticated genomics and proteomics now at our disposal and that we have in our LISs? How do we talk, how do we communicate with them digitally and electronically? I would like to address those questions to the entire panel.

CARTWRIGHT: At GE we have a very big effort underway at Intermountain Healthcare in Utah. We have about 250 engineers out there working on an electronic medical record just to address the point you made. Secondly, I think the way I envision this (and this is my personal opinion) after we get that done, eventually it will evolve to where a patient comes in, they have their family history, their genetic information, they will have their image information, they will have prior stuff and so forth, and that will just be one very big pattern of data. Just image it is like a little universe of data. Then that pattern will be compared to 10 million other patterns that are stored on a computer. You will display other patterns of that 10 million that are very similar to the pattern you generated of your 1000, 10 000 or so data points, and then each of those 10 million cases will have an outcome associated with it and that will be your confidence level for your diagnosis.

FRIEDMAN: Gene, where does this data reside? Right now the health systems view the data as proprietary. There is an emergence of PHRs. There is a kind of fragmentation of this data and it is hard for me to understand. There are ID problems; I do not even want to get into that. Where does the impetus come for the integration of these heterogeneous islands of data?

CARTWRIGHT: I do not think I am capable of answering that question to be honest with you. It is a big question, a good question, but I do not have the background to deal with it.

OKRONGLY: I think an interesting development is the announcement of Google to be looking at ways of putting together medical information. I think that could be a really significant driver of change. I see this in the future as a very Web-enabled approach to how we get at health care records. When companies like Google and Microsoft start to show an interest in this area, we could be in for some really interesting developments in the next few years.

SOENKSEN: Why wouldn't we get to the state where you have your electronic medical record on your iPod? It is proprietary, nobody else can look at it, but you can have it yourself. So why wouldn't you be in a position where you have an iPod with a terabyte of data and you carry it around and wherever you go, it gets plugged in and whatever is needed gets uploaded and you own it?

FRIEDMAN: The problem has always been updating that information and with the health systems, there is no reimbursement for them to keep that fresh. The reimbursement is for their own purposes.

NEWBURGER: One of the things that the information technologies that we are all working on bring about is a kind of transparency from the various specialty departments to the patient. While we are not there yet, I agree with everybody else that the Google and Microsoft focus on the health care record is an important indicator and not necessarily the answer, but an important indicator that information technology is going to help us get to division of this transparency. It has been done in several other different industries for the sharing of proprietary data. Finance comes to mind. There are several different methodologies that could work. It is just which one can we get to politically, technologically, and cost-effectively. As long as we all keep working on our piece of it with long-term possible visions we can get there.

FRIEDMAN: One other factor is that we are not totally cognizant of is Health 2.0 and the empowered health care consumer who will not be passive and not tolerate this sort of paternalistic attitude toward health care. That is another thing in the mix. One more question then we will terminate.

UNIDENTIFIED: This isn't a question but I feel like Jared, I have a responsibility to speak up and answer the young resident's question. I am one of the pathologists from UPMC who is working with Omnyx to build this solution, but I want to make sure that we get the message across that this tool that we help build is specifically for us and specifically for the pathologists out in the audience. This is for your workflow. I totally feel your pain. We have been looking for this sort of opportunity for a long time where we can have kind of a creative hand, a guiding hand, in how to design the software and how to design the hardware to fit into our workflow. We have about 20 hospitals and 120 anatomic pathologists who pump out lots and lots of glass every day. So my personal goal and the goal of all the other pathologists who are working on this project is to make our workflow better with digital glass not just for one bench, but for all the benches. We feel happy enough that Omnyx has written good software and good hardware. When we feel okay that we can deploy it here, then we can put our name on it and others will be able to use it to enhance their workflow. You can think of it as a super tool, a super microscope, something to give you turbo boost in your practice rather than being told this is another corporate piece of software that you guys have to use. That is not the way we want this project to come out. You will move from your microscope to your new sign-out station and you will just feel right at home, so we really have been lucky and blessed that the new company has given us a little bit of creative control over the design process and like I said, it is something that we have been looking for. So I wanted to answer that question in that, do not ask yourself, should we be afraid of this? Tell yourself that this is something that you need to get a hold of and that you need to not prepare for, but look forward to in the next few years.

UNIDENTIFIED: I think the technology already exists. If you are creative, you can integrate already in terms of digital practice. I do a lot of it myself. The big question is, not so much the vision of what we can do, but how do you get paid to do it? That is the big challenge with the digital integration. If you cannot get on the insurance panels what does it matter if you can do it, if you cannot get paid to do it because then you cannot pay you guys for the technology to do it.

SOENKSEN: I agree. We will pay for it. We are all in business so the onus is really on us as vendors to demonstrate the value of this. Reimbursement may play into this. There are CPT codes in place for reading slides. They do not have to be glass for you to use that CPT code. If there is value in adopting the technology for other applications, it has to be demonstrable. If we are saving you 10 hours a week, what is that worth? If saving you 10 hours a week to do something saves you enough money to be able to buy one of these types of systems, that is great and if not, then we have got to make it 20 or 30 or 40 hours. I think the value comes out of the productivity and that is how we view it. Getting CPT codes and other things is certainly on the horizon, but it is a long slog. We have embarked on that, but I think in the short term it just has to be driven out of the productivity and efficiency benefits that you get and there are some. The reason that there was such a long list of niche applications I talked about is because each of them has a slightly different value proposition for a specific user.

Accepted October 1, 2008.

Presented at the College of American Pathologists Futurescape of Pathology Conference, Rosemont, Illinois, June 7-8, 2008.

Reprints: Bruce A. Friedman, MD, Department of Pathology, University of Michigan Medical School, M5228/0602 Medical Science I, 1301 Catherine St, Ann Arbor, MI 48109-0602 (e-mail: bfriedma@med. umich.edu).

The moderator for the panel discussion was Bruce A. Friedman, MD, University of Michigan Medical School, Ann Arbor, Michigan. Panel participants were Gene Cartwright, PhD, Omnyx LLC, Pittsburgh, Pennsylvania; David Okrongly, PhD, Siemens, Tarrytown, New York; Dirk Soenksen, Aperio, Vista, California; and Mark Newburger, CEO, Apollo (PACS), Falls Church, Virginia.
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