Robotic Telepathology: Practical Applications

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Robotic Telepathology Practical Applications

• 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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Robotic Telepathology (TP) at Iron Mtn

• Iron Mountain is an active, rural DVA hospital
  with a general surgery program
• 1000 - 1500 surgical pathology cases per year
• Occasional frozen sections requested
• 1996 part-time Iron Mountain pathologist retired
• 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 July 2006)
• One original senior pathologist and two new
  pathologists
• ASAP ImagingTM implemented
• 2,015 cases available for TP through July 2006

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Objectives

• Compare rates of case deferral and major TP
  discordance with light microscopy (LM) among
  seven pathologists during three phases of robotic
  telepathology
• Compare rates of major discordance before and
  after implementing the ASAP ImagingTM system

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Summary of Cases (1999)

• 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 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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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
• 2005 ASAP ImagingTM enables remote access with
  live streaming imaging

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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 HIS
POP
POP
WAN
Westside
NRM
Multi-site conferencing
Hines Micro
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 system
VHA WAN Internet
VHA WAN Internet
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Current and Future
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Methods

• Each of 7 pathologists read cases by TP,
  completed reports where appropriate, then read
  same cases by LM
• Over 50 of cases read by second pathologist by
  LM
• Revised reports generated based on LM diagnosis,
  if necessary, and clinician notified
• Reasons for case deferral to LM documented
• Pathologist-specific rates of deferral and
  discordance determined
• Notes
• TURP and bone marrow cases deferred automatically
• Gastric biopsies reviewed for H. pylori-like
  organisms by PA in Iron Mtn by LM

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Current and Future Non-Robotic
Telepathology System
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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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Phase I Individual Summaries

• Pathologist A B Total
• Total opportunities 1121 1079 2200
• No. deferred 34 22
  56
• Deferral rate () 3.0 2.0
  2.5
• TP cases 1087 1057 2144
• Maj discord 5 2 7
• Discordance () 0.46 0.19 0.33

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Phase II Individual Summaries

• Pathologist B C D E Total
• Total opportunities 2231 1582 1031 997 5841
• No. deferred 319 290 270 326
  1205
• Defer rate () 14.3 18.3 26.2 32.7
  20.6
• TP cases 1912 1292 761 671 4636
• Maj discord 7 5 8 1
  21
• Discordance () 0.37 0.39 1.05 0.15 0.45

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Phase III Individual Summaries (ASAP) (July 2006)

• Pathologist B D E F G Total
• Total opportunities 795 17 185 683
  335 2015
• No. deferred 40 0 12 78
  65 195
• Deferral rate () 5.0 0 6.5
  11.4 19.4 9.7
• TP cases 755 17 173 605
  270 1820
• Maj discord 1 0 0 2 1 4
• Discordance () 0.13 0 0
  0.33 0.37 0.22

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Comparison by Phase (July 2006)

• Phase I II III
  Total
• Total opportunities 2,200 5,841
  2,015 10,056
• No. deferred 56 1,205 195
  1,456
• Deferral rate () 2.5 20.6 9.7
  14.5
• TP cases 2,144 4,636 1,820
  8,600
• Maj discord 7 21 4 32
• Discordance () 0.33 0.45 0.22
  0.37

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Pathologist B Major concordance rate
(N3,724)(July 2006)
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Pathologist-Specific Discordance Rates
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Major Discordance Rate by Technology (July 2006)

• Pathologist
• Technology B E All
• Pre-ASAP 0.30 0.15 0.41
• ASAP 0.13 0 0.22
• 0.33 excluding pathologist D

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Summary

• Pathologist-specific discordance rates ranged
  from 0.12 to 1.03, with median of 0.37 and
  overall rate of 0.37
• Despite extensive experience of one senior
  pathologist, occasional discordances continue to
  occur
• The rates of discordance using ASAP ImagingTM are
  lower that those observed previously
• All TP cases continue to be reviewed by LM

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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.