Title: Digital Imaging in Education and Distributed Pathology Practice
1Digital Imaging in Education andDistributed
Pathology Practice
- Elizabeth H Hammond MD
- Professor of Pathology
- University of Utah and Intermountain Healthcare
- Executive Editor for Pathology
- Amirsys, Inc.
2 Is Digital Imaging Critical or Is it Just
a New Toy?
- Value in Pathologist Education
- Value in Pathology Practice
3 Pathology Education Deficiencies
- Teaching methods limited in teaching certain
disciplines and skills - Some skills cannot be taught by current methods
- Some skills not examined by self assessment, a
requirement of MOC. - Pathologists accessibility requires better
electronic tools
4 Skills Required in Diagnostic Pathology
- Searching
- Identification
- Classification
- Comparison with previous experience by observer
5 Searching Skill
- Searching
- Finding areas of interest
- Skill developed by experience
- Strategies are not taught but are learned
- Time to diagnosis less for skilled versus
unskilled observers - Can be detected by evaluating and comparing eye
movements of novices and experts - Not taught or glossed over because of limits of
time
6Whole Slide Imaging is Highly Valuable in
Searching
- Static images are often poor at low magnification
where searching occurs. - Since static images include the lesion, the
searching skill is bypassed. - Observation of skillful observer by a novice
promotes learning of searching skills
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9 Whole Slide Image Heart Transplant Biopsy
10Identification Skill
- Skills needed to identify areas of interest using
low power visual clues - Visual clues may not be obvious without training
- Areas on IHC exam to select for HER2 FISH
- Vascular lesions in transplant biopsies
- Areas of lobular carcinoma in breast
11Value in Identification
- Skilled observer can be instructed to define in
words how the identification occurs while the
less skilled observer is watching - Areas of confusion or misidentification can be
carefully reviewed and discussed - Artifacts can be defined
- Limited preselected images do not fill this need
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13 Whole Slide Image HER2 Stained Slide
14Classification Skill
- Ability to compare test object with correctly
classified objects reproducibly - Can be combined with identification skill in
learning - Requires many high quality images of variously
classified objects
15Value in Classification
- Combination of identification and classification
skills is enabled - Based on interaction with learners, various
classification clues can be focused on - Quality of static imaging is improved for
documentation or teaching - Number of images that can be easily obtained is
high.
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18 Whole Slide Image HER2 Stained Slide
19How Can Such New Technology Be Deployed
Effectively?
- Video microscopy sessions at meetings
- Use unknowns to enhance conversation
- Describe process while doing it
- Webcasts with other members of department as
intradepartmental consults - Sessions with resident and staff at time of
diagnosis.
20Accessibility
- Digital Imaging allows pathologist to practice
skills - Any place
- Any time
- Method can be incorporated for self assessment to
help pathologist define their areas of deficiency
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23 Whole Slide Image Heart Transplant Biopsy
24Distributed Practice Issues
- Consistent interpretation required because
Intermountain is a quality healthcare system - Variable skill and knowledge by group members
- Variable availability of expert resources
- Occasional manpower issues
- Wide geographic separation
25Practice Demographics
- 5 pathology groups
- Distributed over 450 miles
- Group sizes
- 17 most specialties (4 hospitals)
- 4 Dermpath, Hematopath (2 hospitals)
- 3 (x2) Hematopath
- 2 None
26Process
- Pathology groups are separate entities
- Intermittent consultation
- Sharing of expert resources for technical
functions and some professional functions - Sharing during manpower shortages
- Communication via phone and courier
- Collegial environment
27Potential Utilities of Whole Slide Microscopy
- Intragroup consultation of specialists
- Intergroup consultation between sites and for
double read situations - Intergroup consultation for frozen sections
- Professional sign out of immunohistochemistry
with or without expert consultation - Tumor board presentations to clinicians
- Education sessions to improve consistency of
interpretation and speed of integration on new
members
28Specialty Consultations
- Faster turn around time because couriers not
involved - More common consultation because of increased
availability - Opportunity for learning of others because of
multiple viewing options
29Intragroup Consultation
- Requirement for double reading in many cases
- New diagnosis of cancer
- Prostate needle biopsies
- Difficult cases which might benefit from
consultation - Difficult with multisite groups so that
appropriate second reader might not be used
30Frozen Section Consultation
- Difficult frozens benefit from second opinions
- If no other pathologist on site, this is not
utilized - Diagnoses could be improved by having this
capacity at each hospital
31Sign Out of IHC
- Currently, all IHC done in three sites and slides
shipped to other sites - Turn around time 24 hours for off site locations
- Could consolidate technical functions if virtual
microscopy was available - No option for dual viewing in difficult cases
- No option to educate new members of group
32Tumor Boards And Clinical Conferences
- One or two each day in largest group
- Slides that need to be included may not be
available - Lost in pathologist office
- Only at another hospital
- In process of filing
- Significant time required by pathologist to take
required static images or drag photoscope to
conference room
33Education of Group Pathologists
- Intermountain operates by developing standards
which are transmitted throughout the system using
data on provider behavior - Pathologists expected to be consistent and
complete in reports (data system) - Education of pathologists required
- Nottingham Score
- HER2 scoring
34 Summary
- Digital imaging has great value in improving
pathology education - Improving diagnostic skills
- Improving accessibility
- Digital imaging has great value in practice
- Allowing flexibility in sign out and consultation
- Allowing distributed conference functions
- Decreasing courier related process delays