Title: Teleneuropathology at UPMC: a fiveyear report
1Teleneuropathology at UPMC a five-year report
Craig Horbinski, MD, PhD UPMC Neuropathology Octob
er 25, 2006
2History
- 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
3Our 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
4What happens when a neurosurgeon at Shadyside
needs an intraoperative consult from
neuropathology?
52001 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
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72002 Nikon DN100
- High-resolution imaging
- Broadcast every 2 seconds
- No remote control
- No whole-slide image available
8http//www.microscopyu.com/articles/digitalimaging
/dn100/index.html
92003 Nikon CoolscopeTM
- High resolution
- Whole slide imaging
- Full remote control by the neuropathologist
- Internet website
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12Image quality via telepathology
13Workflow
- 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
14Our 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)
15Criteria
- 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
16Intraoperative cases, 2002-2006
17Diagnostic classes
18Deferral rates
19Deferral rates by class
20Discrepancy rates
21Discrepancy rates by class
22Exact concordant rates
23Exact concordant by class
24Overall concordant rates
25Overall concordant by class
26Discrepancies and inexact diagnoses, subclassified
27Conventional benign/reactive subclassified
28Telepathology benign/reactive subclassified
29Conclusions
- 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
30Advice 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
31Acknowlegements
- Clayton Wiley, M.D., Ph.D
- Jeffrey Fine, M.D.
- Rafael Medina-Flores, M.D., Ph.D.
- Yukako Yagi, Ph.D.
- Karen Weber
32References
- 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.
33http//blog.everydayscientist.com/wp-content/uploa
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