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Title: Teleneuropathology at UPMC: a fiveyear report


1
Teleneuropathology at UPMC a five-year report
Craig Horbinski, MD, PhD UPMC Neuropathology Octob
er 25, 2006
2
History
  • 1973 Washington, DC pathologists diagnosed
    lymphosarcoma/leukemia via satellite in a patient
    on a ship docked in Brazil
  • 1986 telepathology coined by Weinstein
  • 1993 first teleneuropathology paper
  • Intraoperative consults
  • Static nonrobotic system
  • High intraop-final discrepancy rate (27)
  • 2001 Szymas et al.
  • 83 neuropathology cases (not intraoperative
    consults)
  • Dynamic robotic system
  • 95 concordance with conventional microscopy

3
Our situation
  • Neuropathology CoE _at_ Presbyterian (PUH)
  • Neurosurgery _at_ PUH, Childrens, and Shadyside
    (SYS)
  • 18 city blocks between PUH and SYS
  • 1 hour total transit time

4
What happens when a neurosurgeon at Shadyside
needs an intraoperative consult from
neuropathology?
5
2001 VTEL
  • VTEL teleconferencing between pathologists at SYS
    and PUH
  • Poor image quality
  • No remote control
  • Required 2 pathologists
  • Frequent technical glitches, also required
    presence of IT techs to assist

6
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7
2002 Nikon DN100
  • High-resolution imaging
  • Broadcast every 2 seconds
  • No remote control
  • No whole-slide image available

8
http//www.microscopyu.com/articles/digitalimaging
/dn100/index.html
9
2003 Nikon CoolscopeTM
  • High resolution
  • Whole slide imaging
  • Full remote control by the neuropathologist
  • Internet website

10
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11
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12
Image quality via telepathology
13
Workflow
  • Surgeon at SYS calls SYS pathology
  • Trained PA at SYS receives tissue, prepares
    slides, loads the slides into Coolscope (1 at a
    time)
  • Neuropathologist is contacted at PUH
  • Opens the website examines the slide
  • Calls the surgeon directly to render the
    diagnosis
  • Calls the PA, who then records the diagnosis on
    the requisition
  • Material sent to PUH for permanents

14
Our study
  • Compared PUH and SYS intraoperative consults from
    2001-2006
  • 1,629 total consults on adult patients
  • 1,227 conventional consults
  • 402 telepathology consults
  • Deferral, discrepant, exact concordant,
    essentially concordant, overall concordant
  • Scorers blinded to year, site (PUH vs SYS)

15
Criteria
  • Deferral no intraoperative diagnosis rendered
  • Discrepant significant mismatch between
    intraoperative and final diagnoses
  • neoplasm/non-neoplasm
  • type of neoplasm (e.g. meningioma vs
    schwannoma)
  • grade
  • Exact concordant intraoperative diagnosis
    equivalent to final diagnosis
  • Essentially concordant intraoperative not
    exactly identical to the final diagnosis, but
    close
  • glioma without grade
  • diagnostic material present on CT-guided
    stereotactic biopsy
  • Overall concordant Exact Essentially

16
Intraoperative cases, 2002-2006
17
Diagnostic classes
18
Deferral rates

19
Deferral rates by class
20
Discrepancy rates
21
Discrepancy rates by class
22
Exact concordant rates


23
Exact concordant by class
24
Overall concordant rates

25
Overall concordant by class
26
Discrepancies and inexact diagnoses, subclassified
27
Conventional benign/reactive subclassified
28
Telepathology benign/reactive subclassified
29
Conclusions
  • Similar discrepant rates
  • Similar overall concordant rates
  • More exact concordant diagnoses via
    conventional
  • Similar types of problem cases
  • Longer turnaround time for diagnoses (anecdotal)
  • Validated method for cost-effective expansion of
    neuropathology coverage

30
Advice from the man who owns one
  • The technology is sufficient for routine use
  • Make sure the infrastructure/workflow is
    well-organized and well-defined
  • Proper training of PAs
  • Clear designation of responsibilities
  • Rapid lines of communication
  • Establish backups in the rare event of system
    failure

31
Acknowlegements
  • Clayton Wiley, M.D., Ph.D
  • Jeffrey Fine, M.D.
  • Rafael Medina-Flores, M.D., Ph.D.
  • Yukako Yagi, Ph.D.
  • Karen Weber

32
References
  • Becker RL et al. Human Pathology 24(8) 909-911,
    1993.
  • Dunn BE et al. Telemedicine Journal 5(4)
    323-337, 1999.
  • Horbinski C et al. JNEN in press
  • Riggs RS et al. JAMA 228(5) 600-602, 1974.
  • Szymas J et al. Human Pathology 32(12)
    1304-1308, 2001.
  • Weinstein RS. Human Pathology 17(5) 433-434,
    1986.

33
http//blog.everydayscientist.com/wp-content/uploa
ds/brain_reader_cartoon.jpg
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