Implementation and Validation of Telepathology

1. Implementation and Validation of Telepathology Bruce E. Dunn, M.D. Chief Pathologist Veterans Integrated Service Network (VISN) 12 Professor and Vice-Chair, Dept of Pathology, Medical College of Wisconsin

2. 21 Veterans Integrated Service Networks (VISNs)

3. Hospitals and CBOCs in VISN 12

4. Robotic Telepathology (TP) at Iron MountainVAMC: Background • Iron Mountain is an active, rural DVA hospital with a general surgery program • 1000 - 1500 surgical pathology cases per year • Occasional frozen sections requested • 1995: Directors of Iron Mountain and Milwaukee VAMCs requested that Milwaukee pathologists provide primary diagnostic TP • 1996: Part-time Iron Mountain pathologist retired • 1997: Feasibility study published

5. Key Features of Apollo Software Robotic TP • Allows real time and static imaging of gross specimens • Distant pathologist can direct specimen grossing • Annotation of static images • Searchable image archiving system • Slides viewed in dynamic or static imaging modes • On-site PA and distant pathologist must be available at the same time • Communication critical

9. Three Phases of Robotic TP at Iron Mtn • Phase I: mid-1996 – early 1999 • Two senior surgical pathologists exclusively read cases with extensive documentation • 2,200 cases available for TP • Summary published in 1999 • Phase II: early 1999 – end of 2004 • One senior pathologist retired; three junior pathologists hired • Consolidation resulted in increased pathologist workload • 5,841 cases available for TP • Phase III: 2005 – present • One original senior pathologist and two new pathologists • ASAP ImagingTM implemented • 3,512 cases available for TP

10. Objectives • Compare rates of case deferral and major TP discordance with light microscopy (LM) among seven pathologists during three phases of robotic telepathology • Compare rates of major discordance before and after implementing the ASAP ImagingTM system

11. Case Mix (1999) Organ/system Percent of total Gastrointestinal 42.9 Skin 27.5 Prostate 10.2 Hernia sac 3.8 Urinary bladder 2.6 Bone/synovium/tendon 2.1 Penis/testis/spermatic cord 1.9 Gallbladder 1.3 Extremity amputation 1.1 Appendix 0.5 Gynecologic 0.5 Breast 0.3 Miscellaneous 5.2

12. Technical Aspects of Workflow • Tissue grossed in Iron Mtn by experienced PA (tele-gross imaging available) • Slides processed by Iron Mtn histotechnician • Telepathology systems “linked up” – live connection • PA places slides onto stage in Iron Mtn • Pathologist controls robotic microscope remotely from Milwaukee

13. Robotic Microscopy • Apollo hybrid dynamic store/forward system • Nikon microscope with motorized stage, objectives, lighting control • 1996: CODEC used for gross and microscopic imaging and videoconferencing • 2005: ASAP ImagingTM enables remote access with live streaming imaging (Motion JPEG) • 4x, 10x, 20x, 40x, and 100x (oil free) objectives • Dynamic imaging: 704 x 480 x 24-bit color @ 30 fps • Static imaging: 1280 x 960 x 24-bit color • Images transmitted at 500 kbps – 8 mbps over WAN controllable by user

14. Current and Future

15. Methods • Each pathologist reads cases by TP, completes reports where appropriate, then reads same cases by LM • Revised reports generated based on LM diagnosis, if necessary, and clinician notified • Reasons for case deferral to LM documented • QA: >40% of cases read by additional pathologist by LM • Pathologist-specific rates of deferral and discordance determined

16. Deferral to Light Microscopy • Case difficulty - need for consultation • Special or immunohistochemical stains not performed in Iron Mountain required • “Short staffing”

17. Major Discordance Rates by Pathologist • Benign versus malignant • Different patient outcome or therapy • Report modified and clinician called

18. Overall Comparison by Phase Phase I II III (ASAP) Total Total opportunities 2,200 5,841 3,512 11,553 Deferral rate (%) 2.5 20.6 16.3 15.9 Discordance (%) 0.33 0.45 0.20 0.35

19. Overall Pathologist-Specific Discordance Rates

20. Major Discordance Rate (%) by Technology Pathologist Technology B E F G All Pre-ASAP 0.30 0.15 ND ND 0.41* ASAP 0.18 0 0.20 0.33 0.20 *0.33 excluding pathologist D

21. Pathologist B: Major concordance rate (N=4,123)

22. Surgical Pathology TAT for Iron Mountain VA before and after Robotic Telepathology TP used only to cover on-site pathologist absence Histotech/PA both involved in TP PA only involved in TP PA begins on-line transcription and correction TP implemented completely; dictations streamlined Iron Mtn. Transcriptionist retires

23. Summary • Iron Mountain clinicians have expressed great satisfaction with remote telepathology service • Despite extensive experience in use of telepathology, occasional major discordances occur • Longer time required to read cases by TP than by LM • All TP cases continue to be reviewed by LM in Milwaukee

24. Expanded Uses of Telepathology • Pathologists or technologists at a distance can review peripheral blood smears, body fluids or gram stains • Microbiology education at North Chicago VAMC which has an ID fellowship training program • Clinical conferences in GI, Endocrine and Pulmonary Medicine at North Chicago • Autopsy Rounds at Iron Mountain VAMC

25. Take Home Lessons • In the right clinical environment, pathologists using robotic telepathology can substitute effectively for an onsite surgical pathologist • Support by a strong Pathologist Assistant is critical • Ability to view live and static images of gross specimens is essential for tele-surgical pathology • Telepathology can be extended to many areas of anatomic and clinical pathology • Must balance access, diagnostic accuracy and cost • Pathologist attitude is critical for success