Telepathology to Support Patient Care at Remote Facilities

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Telepathology to Support Patient Care at Remote
Facilities

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

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Conflict-of-interest statement

• Bruce E. Dunn, MD has no financial interest in
  any commercially-available telepathology system

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21 Veterans Integrated Service Networks
(VISNs)
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Hospitals and CBOCs in VISN 12
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Challenge Replace an On-Site Pathologist at Iron
Mountain with Off-Site Pathologists Located in
Milwaukee

• Notified late summer 1995 that part-time IM
  pathologist to retire in summer 1996
• Iron Mtn Chief of Staff requested that Milwaukee
  pathologists provide telepathology services
• Tele-Radiology and tele-nuclear medicine services
  implemented by Milwaukee Imaging Service

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Functions of On-Site Pathologist

• Surgical Pathology
• Support small, but active general surgery service
• Good, but limited on-site histology lab functions
• Frozen sections requested occasionally
• Nuclear Medicine case diagnosis
• Clinical Pathology
• Transfusion medicine
• Autopsy pathology
• Clinical consultation
• Administrative activities
• Laboratory oversight
• Medical Executive Committee

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Robotic Telepathology (TP) at Iron Mtn

• Late 1995 early 1996 Orientation/feasibility
  studies
• Summer 1996 Full implementation of commercial
  hybrid dynamic store/forward system operated by
  two senior pathologists in Milwaukee
• Feasibility study performed - published in 1997

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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 in VISN resulted in increased AP
  workload
• 5,841 cases available for TP
• Phase III 2005 present (through June 2007)
• One original senior pathologist and two new
  pathologists
• ASAP ImagingTM implemented
• 2,704 cases available for TP through June 2007

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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
• PA places slides onto stage in Iron Mtn
• Pathologist controls robotic microscope remotely
  from Milwaukee

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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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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
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Deferral to Light Microscopy

• Reasons for deferral case difficulty, need for
  consultation, special or immuno stains, short
  staffing
• If case referred to Milwaukee due to computer
  unavailability (malfunction or upgrade), or the
  assigned pathologist was not yet competent to use
  telepathology, then case not counted as a
  deferral

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Discordance Rates by Pathologist

• Deferred cases not included
• Major discordance
• Benign versus malignant
• Different patient outcome or therapy
• Report modified and clinician called

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Comparison by Phase (June 2007)

• Phase I II III
  Total
• Total opportunities 2,200 5,841
  2,704 10,745
• No. deferred 56 1,205 365
  1,626
• Deferral rate () 2.5 20.6
  13.5 15.1
• TP cases 2,144 4,636 2,339
  9,119
• Maj discord 7 21 5 33
• Discordance () 0.33 0.45 0.21
  0.36

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Summary

• Pathologist-specific discordance rates range from
  0.12 to 1.03, with median of 0.28 and overall
  rate of 0.36
• Despite extensive experience in use of
  telepathology occasional discordances occur
• Longer time required to read cases by TP than by
  LM
• All TP cases continue to be reviewed by LM in
  Milwaukee

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Telepathology and the Autopsy

• Send key images electronically to attending along
  with Preliminary Autopsy Diagnosis
• Submit tissue sections from a distance
• Documentation of sections
• Autopsy conference presentations
• Images stored in Computerized Patient Record
  System

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How Pathologist Functions are Covered from a
Distance Iron Mtn

• Surgical Pathology robotic telepathology
• Clinical Pathology
• Transfusion medicine phone calls
• Autopsy pathology pathologist travels
• Micro/peripheral smears - telepathology
• Clinical consultation phone calls
• Administrative activities
• Laboratory oversight delegation, phone calls
• Review CAP Proficiency Testing reviewed on site
• Medical Executive Committee pathologist
  travels, phone calls

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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
POP
POP
Interface to VistA
WAN
Westside
NRM
Hines Micro
Multi-site conferencing
N. Chicago
DR
POP
POP
Dedicated Server
NRM
NRM
Hines
North Chicago
GS
Hines
Chicago
GS
POP
POP
DR
KEY POP point of presence VistA VA
computerized patient record
VHA WAN Internet
VHA WAN Internet
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Consolidation of Microbiology Functions

• Specimens accessioned at primary labs, read by
  bar code at core labs
• Plate, incubate and send (portable incubators)
• Telepathology to view gram stains, early culture
  growth and show cultures to clinicians
• Core lab microbiology staff enter results
  directly into primary lab computer
• (Microbiology support in Iraq conflict)

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Ear KOH Prep
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North Chicago Tele-Infectious Disease Rounds

• Consolidation of NC Microbiology to Milwaukee
• No on-site Microbiology training for ID fellows
• Didactic/clinical sessions by Milwaukee
  Microbiology supervisor/pathologist
• ID staff and trainees - N. Chicago
• ID staff and trainees Milwaukee
• (GI, Pulmonary, Endocrine)

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Current and Future
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Gram Positive Cocci in Pairs
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VISN 12 Strategies to Improve Lab Cost
Effectiveness

• Lab network formed with centralized leadership
  and budget
• Consolidation
• Core (2) and primary (7) labs
• Single commercial reference lab
• Commercial courier system
• Standardization of major equipment/procedures
• Distant access via telepathology
• Three sites lack on-site pathologists Tomah,
  Iron Mtn, N. Chicago
• Medical technology training programs (2)

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Summary/Enabling Features for Telepathology

• In the right clinical environment, pathologists
  using robotic telepathology can substitute
  effectively for an onsite surgical pathologist
• Telepathology can be extended to all areas of
  anatomic and clinical pathology
• Must balance access, diagnostic accuracy and cost
• Pathologist attitude Users must be flexible, but
  do not have to be computer experts
• Strong technical support of the
  telecommunications network is essential