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

21 Veterans Integrated Service Networks (VISNs)

Hospitals and CBOCs in VISN 12

Robotic Telepathology (TP) at Iron Mountain VAMC: Background Iron Mountain is an active, rural DVA hospital with a general surgery program 1000 - 1500 surgical pathology cases per year Occasional frozen sections requested 1995: Directors of Iron Mountain and Milwaukee VAMCs requested that Milwaukee pathologists provide primary diagnostic TP 1996: Part-time Iron Mountain pathologist retired 1997: Feasibility study published

Key Features of Apollo Software Robotic TP Allows real time and static imaging of gross specimens Distant pathologist can direct specimen grossing Annotation of static images Searchable image archiving system Slides viewed in dynamic or static imaging modes On-site PA and distant pathologist must be available at the same time Communication critical

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 resulted in increased pathologist workload 5,841 cases available for TP Phase III: 2005 – present One original senior pathologist and two new pathologists ASAP ImagingTM implemented 3,512 cases available for TP

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

Case Mix (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

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” – live connection PA places slides onto stage in Iron Mtn Pathologist controls robotic microscope remotely from Milwaukee

Robotic Microscopy Apollo hybrid dynamic store/forward system Nikon microscope with motorized stage, objectives, lighting control 1996: CODEC used for gross and microscopic imaging and videoconferencing 2005: ASAP ImagingTM enables remote access with live streaming imaging (Motion JPEG) 4x, 10x, 20x, 40x, and 100x (oil free) objectives Dynamic imaging: 704 x 480 x 24-bit color @ 30 fps Static imaging: 1280 x 960 x 24-bit color Images transmitted at 500 kbps – 8 mbps over WAN controllable by user

Current and Future

Methods Each pathologist reads cases by TP, completes reports where appropriate, then reads same cases by LM Revised reports generated based on LM diagnosis, if necessary, and clinician notified Reasons for case deferral to LM documented QA: >40% of cases read by additional pathologist by LM Pathologist-specific rates of deferral and discordance determined

Deferral to Light Microscopy Case difficulty - need for consultation Special or immunohistochemical stains not performed in Iron Mountain required “Short staffing”

Major Discordance Rates by Pathologist Benign versus malignant Different patient outcome or therapy Report modified and clinician called

Overall Comparison by Phase Phase I II III (ASAP) Total Total opportunities 2,200 5,841 3,512 11,553 Deferral rate (%) 2.5 20.6 16.3 15.9 Discordance (%) 0.33 0.45 0.20 0.35

Overall Pathologist-Specific Discordance Rates

Major Discordance Rate (%) by Technology Pathologist Technology B E F G All Pre-ASAP 0.30 0.15 ND ND 0.41* ASAP 0.18 0 0.20 0.33 0.20 *0.33 excluding pathologist D

Pathologist B: Major concordance rate (N=4,123)

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

Summary Iron Mountain clinicians have expressed great satisfaction with remote telepathology service Despite extensive experience in use of telepathology, occasional major discordances occur Longer time required to read cases by TP than by LM All TP cases continue to be reviewed by LM in Milwaukee

Expanded Uses of Telepathology Pathologists or technologists at a distance can review peripheral blood smears, body fluids or gram stains Microbiology education at North Chicago VAMC which has an ID fellowship training program Clinical conferences in GI, Endocrine and Pulmonary Medicine at North Chicago Autopsy Rounds at Iron Mountain VAMC

Take Home Lessons In the right clinical environment, pathologists using robotic telepathology can substitute effectively for an onsite surgical pathologist Support by a strong Pathologist Assistant is critical Ability to view live and static images of gross specimens is essential for tele-surgical pathology Telepathology can be extended to many areas of anatomic and clinical pathology Must balance access, diagnostic accuracy and cost Pathologist attitude is critical for success