Practical Applications of Robotic Telepathology

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Practical Applications of Robotic 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
• Bruce.Dunn_at_med.va.gov

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Disclosure

• No financial interest in nor support from any
  vendor

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21 Veterans Integrated Service Networks
(VISNs)
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Marquette
Houghton/ Hancock
Sault Ste. Marie
Iron Mt.
Chicago Metro VAs
Menomonie
Rhinelander
Wausau
Evanston
Chippewa Falls
Loyal
Appleton
Tomah
Chicago
Cleveland
Milwaukee
Hines
VISN 12 Hospitals Clinics
Oak Park
Woodlawn
Madison
Union Grove
Gurnee
North Chicago
Aurora
Rockford
Elgin
Chicago Heights
Crown Point
LaSalle
Joliet
Manteno
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Robotic Telepathology (TP) in VISN 12

• Iron Mountain is an active, rural DVA hospital
  with a general surgery program
• 1000 surgical pathology cases per year
• Part-time on-site Iron Mountain pathologist
  announced retirement in 1996
• Iron Mountain clinical and technical staff
  recommended robotic telepathology from Milwaukee
  (gt200 miles away)
• Feasibility study started late 1995
• Full implementation of commercial hybrid dynamic
  store/forward system in July 1996
• Two senior surgical telepathologists trained
• Feasibility study performed - published 1997

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Current and Future
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Current and Future
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Current and Future Non-Robotic
Telepathology System
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Technical Summary (published 1999)(first 2,200
cases)

• Same 2 experienced pathologists
• Deferral rate 2
• Major concordance on non-deferred cases 99.7
• Time per case 11.6 min (cases 1-200), reduced
  to 3.58 min (cases 2001-2200)
• Time per slide 4.25 min (cases 1-200), reduced
  to 1.13 min (cases 2001-2200)
• Case turn-around-time lt 1.5 days (vs gt 4 days)

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Factors influencing robotic TP in VISN 12since
1999

• Milwaukee became core AP lab for Tomah and N.
  Chicago in 1999 and Madison cytology in 2001
• One senior telepathologist retired from VA in
  late 1998
• Junior surgical pathologists (3) hired in 1999
  and 2000
• Several iterations of TP hardware and software
  implemented, but basic dynamic imaging remained
  unchanged through 2004

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Goals of this study

• Determine rates of case deferral and TP
  concordance with light microscopy (LM) among four
  pathologists during 1999-2004 to compare with
  previous results
• Three junior naïve telepathologists
• One senior experienced telepathologist
• Determine whether concordance rates improve
  and/or deferral rates decrease with experience

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Summary of cases (from 1999 study)

• 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

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Technical aspects of work flow

• Tissue grossed in Iron Mtn by experienced PA
  (tele-gross imaging available)
• Slides processed by Iron Mtn histotechnician
• Telepathology systems linked up
• PA puts slides individually onto stage in Iron
  Mtn
• Pathologist controls robotic microscope remotely
  from Milwaukee

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Robotic microscopy

• Commercial hybrid dynamic store/forward system
• Olympus microscope with motorized stage,
  objectives, lighting control
• CODEC used for gross microscopic imaging and
  videoconferencing
• 4x,10x, 20x 40x 100 (oil free) objectives
• Dynamic imaging 350 x 288 x 24-bit color
• Static imaging 1520 x 1144 x 24-bit color
• Images transmitted at 768 kbps over WAN

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Methods

• Each of 4 pathologists read cases by TP,
  completed reports where appropriate, then read
  same cases by LM
• Reasons for case deferral to LM documented
• Revised reports generated based on LM diagnosis,
  if necessary clinicians notified
• Rates of deferral, concordance and TAT determined
  by pathologist
• QA 30 of cases subjected to second read
• Notes
• TURP cases deferred automatically
• Gastric biopsies reviewed for H. pylori-like
  organisms by PA in Iron Mtn by LM

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Deferral to light microscopy (LM)

• If due to computer down-time during one of
  several upgrades, then not counted as a TP
  deferral
• Turn-around-time (days) calculated for all
  deferred and non-deferred cases

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Concordance rates by pathologist

• Deferred cases not included
• Major discordance
• Benign vs malignant
• Different patient outcome or therapy
• Report modified and clinician called
• Total discordance
• Any case including major and minor discordances
  in which a modified report was generated as a
  result of diagnostic differences between TP and LM

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Overall summary 1999-2004

• Pathologist A B C D Total
• Total cases 997 1031 2231 1582 5841
• No. deferred 326 270 319 290 1205
• Deferral rate () 32.7 26.2 14.3 18.3
  20.6
• TP cases 671 761 1912 1292 4636
• Ave TAT (days) 1.72 1.65 1.70 1.68 1.69

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Major discordance/concordance

• Pathologist A B C D Total
• Maj discord 1 8 7 5 21
• TP cases 671 761 1912 1292 4636
• Discordance 0.15 1.05 0.37 0.39 0.45
• Concordance 99.85 98.95 99.63 99.61 99.55

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Total discordance/concordance(modified reports)

• Pathologist A B C D Total
• Tot discord 7 36 28 76 147
• TP cases 671 761 1912 1292 4636
• Discordance 1.0 4.7 1.5 5.9 3.2
• Concordance 99.0 95.3 98.5 94.1 96.8

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Rates of Deferral by Pathologist
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Major Concordance Rate by Pathologist
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Pathologist C Major concordance rate (initial
2200 cases)
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Pathologist C Major concordance rate (N3012)
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Report Modification Rate by Pathologist
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Summary

• Deferral rates (14-33) were much higher in
  1999-2004 than in our previous report (1999)
• Reasons for deferral insufficient staffing, case
  difficulty, special stains not performed at Iron
  Mtn
• Deferral rates influenced more by perceived
  staffing levels than by TP experience
• Despite variable deferral rates, all pathologists
  had very similar average TAT
• Major concordance rate from 1999-2004 was 99.55
  compared with 99.67 in previous report (1999)
• Highest rate of concurrence (99.85) observed in
  pathologist with highest rate of deferral (32.6)

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Summary

• Most telepathology diagnoses made solely using
  the dynamic imaging mode
• Despite extensive experience, the quality of
  dynamic imaging used through 2004 still allowed
  occasional major errors, even by the most
  experienced pathologist
• All TP cases continue to be reviewed by LM
• Total TP primary diagnoses now gt 7,000
• Improved dynamic imaging installed in late 2004
• TP is one tool which has allowed reduction of
  pathologists from 32 (1996) to 16 in VISN 12

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VISN 12 Telepathology Network
NRM
Iron Mtn
RM
Tomah
Iron Mtn
Tomah
DR
GS
POP
POP
DR
NRM
Milwaukee
Madison
Milw
Madison
DR
Interface to VistA
POP
POP
WAN
Westside
NRM
Multi-site conferencing
Hines Micro
N. Chicago
DR
POP
POP
Dedicated Server
NRM
NRM
Hines
North Chicago
GS
Hines Path
Chicago
GS
POP
POP
DR
KEY POP point of presence VistA VA
computerized patient record system
VHA WAN Internet
VHA WAN Internet
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Licensure and credentialing in VHA

• One valid state license sufficient in VHA
• Pathology/telepathology credentialing required at
  each VA hospital at which the pathologist
  practices
• VISN-wide credentialing not available

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Acknowledgements

• Sarah Kerr, MD PGY1 Pathology U VA
• Ben Wagenma, MD - PGY1 Pathology U GA

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Related References

• Dunn, B.E., U.A. Almagro, H. Choi, N.K. Sheth,
  J.S. Arnold, D.L.Recla, E.A. Krupinski, A.R.
  Graham and R.S. Weinstein. 1997. Dynamic-robotic
  telepathology Department of Veterans Affairs
  feasibility study. Human Pathol. 288-1.
• Dunn, B.E., H. Choi, U.A. Almagro, D.L. Recla,
  and R.S. Weinstein. 1999. Routine surgical
  telepathology in the Department of Veterans
  Affairs Experience-related improvements in
  pathologist performance in 2200 cases. Telemed J.
  5323-337.