Milwaukee Pathology Hub and Spoke Model

1
Milwaukee Pathology Hub and Spoke Model

• Bruce E. Dunn, M.D.
• Milwaukee VA Medical Center
• E-mail Bruce.Dunn_at_med.va.gov

2
Milwaukee Pathology Hub and Spoke Model
Iron Mountain VAMC
Tomah VAMC
220 mi
170 mi
Milwaukee VAMC
60 mi
North Chicago VAMC
3
Overview

• Since 1998, 4.7 Milwaukee pathologist FTEE have
  provided service in anatomic, clinical and
  administrative pathology to the Milwaukee VAMC
  hub and to the spoke sites at Iron Mountain,
  Tomah and North Chicago VAMCs
• Prior to 1996, a total of 11 pathologist FTEE
  served these four sites

4
Clinical Activity Summary

• Iron Mountain
• In- and outpatient general surgery
• Tomah
• No surgery. Skin biopsies and resections only
• North Chicago
• Outpatient surgery only
• Milwaukee (Diagnostic and educational hub)
• In- and outpatient general and specialty surgery
• Tertiary VA referral center
• All sites
• Anatomic pathology, clinical laboratory, blood
  transfusion

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Total Anatomic Pathology Workload Summary FY01

• Surgical pathology 5950 cases (2.38 FTEE)
• Cytology/FNA 2910 cases (0.83 FTEE)
• Bone marrows 150 cases (0.30 FTEE)
• Autopsies 70 cases (0.28 FTEE)
• Neuropathology (0.125 FTEE)
• Total Pathologist FTEE (3.915 FTEE)

6
Additional Pathologist Activities at Hub and
Spoke Sites

• Clinical Pathology
• Resident Training (2 slots at Milwaukee only)
• Administrative Functions
• Medical Executive Committees
• Blood Product Utilization Review
• Surgical Case Review
• Laboratory Proficiency Testing Review
• Laboratory Procedure Review

7
Need for Pathologist Consolidation

• Increased cost-effectiveness
• Retirement of pathologists at Iron Mountain,
  Tomah and North Chicago VA Medical Centers
  between 1996 and 1998

8
Strategies for Consolidation of Pathologist
Functions

• Telepathology hybrid dynamic/store forward
  system
• Milwaukee pathologists travel to spoke sites for
  selected clinical, administrative and educational
  functions
• Increased oversight role by lab managers
• Voice-activated dictation by pathologists

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Telepathology Hub and Spoke Model
NRM
RM
Tomah
Iron Mtn
DR
GS
POP
POP
DR
NRM
Milwaukee
Voice-Activated Dictation
GS
POP
DR
Interface to VistA
Scanner
WAN
Printer
KEY RM - Robotic microscope NRM - Non-robotic
microscope GS - Grossing station DR - Document
reader POP - Point of presence WAN - Wide area
network VistA -VHA info system
Multi-site conferencing
NRM
North Chicago
GS
POP
VHA WAN Internet
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Telepathology Equipment Summary

• Iron Mountain
• Robotic microscope with grossing station and
  document reader
• Tomah
• Non-robotic microscope with document reader
• North Chicago
• Non-robotic microscope with grossing station
• Milwaukee (Diagnostic and educational hub)
• Non-robotic microscope with grossing station,
  document reader, scanner and printer.
  Voice-activated dictation
• All sites
• VistA Imaging and multi-site conferencing
  (mid-2002)

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Applications of Telepathology at Iron Mountain
VAMC

• Surgical pathology
• Primary diagnosis including frozen sections
• Documentation of gross and histopathology
• Consultation with clinicians
• Autopsy pathology
• Clinico-pathologic correlation conferences
• Clinical pathology
• Microbiology consultations (smears and cultures)
• Hematology
• Review of peripheral blood smears
• Continuing education

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Applications of Telepathology at Tomah VAMC

• Clinical pathology
• Microbiology consultations (smears and cultures)
• Hematology
• Review of peripheral blood smears
• Continuing education

13
Applications of Telepathology at North Chicago
VAMC

• Surgical pathology
• Documentation of gross and histopathology
• Consultation with clinicians
• Clinical pathology
• Microbiology consultations (smears and cultures)
• Infectious diseases conferences and consultations
• Hematology
• Review of peripheral blood smears
• Continuing education

14
Applications of Digital Imaging at Milwaukee VAMC

• Surgical pathology
• Documentation of gross and histopathology
• Autopsy pathology
• Documentation of gross and histopathology
• Clinical pathology
• Documentation of interesting cases
• Hematology
• Documentation of interesting cases
• Continuing education

15
Spoke Site Autopsy Performance

• Iron Mountain Milwaukee pathologist travels
• Tomah autopsies performed at Madison (by
  Madison pathologists)
• North Chicago Milwaukee pathologist travels

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Summary of Pathology Networking Activities in
VISN 12

• Standardization of equipment and procedures
• Consolidation of batched/esoteric testing
• Telepathology
• Provide access to distant pathologists and
  technologists
• Provide a single diagnostic standard of care
• Reduced personnel and all other expenses
• Focus resource sharing rather than independent
  labs and employees (interdependence)