Using Digital Pathology in a Multi-Site, Geographically Distributed Integrated Delivery Network Paul M Urie MD PhD The Digital Pathology Experience at Intermountain Healthcare

Hospitals – 20 in Utah and 1 in Idaho 13 Urban sites and 8 rural sites 2,584 licensed beds Medical Group - employed physicians 500 physicians in 150 clinics Affiliated Physicians – 2,800 physicians SelectHealth – 390,000 insured members Highly integrated Information systems and data network Intermountain Healthcare Profile

Intermountain Healthcare Hospitals in the State of Utah Alta View American Fork Bear River Delta Community Dixie Regional Fillmore Community Garfield Memorial Heber Valley Intermountain Medical Center LDS Hospital Logan Regional McKay-Dee Hospital Orem Community TOSH Primary Children’s Sanpete Valley Sevier Valley Utah Valley Regional Valley View

Urban North – Cassia, Logan, McKay-Dee 5 pathologists, 22,000 surgical cases Urban Central – LDS, IMC, Alta View, PCMC 23 pathologists, 52,000 surgical cases, molecular pathology and flow cytometry Central clinical laboratory Urban South – UVRMC, AFH, OCH, Rurals 5 pathologists, 22,000 surgical cases Southwest – Dixie and Valley View 5 pathologists, 16,000 surgical cases Pathologist Distribution and Volumes

Pathology Service Problems Cases reviewed by the sub-specialty trained pathologists – consultations Peer reviews for quality assurance Frozen section interpretations at remote locations Tumor board and conference presentations Review of immunohistochemistry slides from the central lab Image analysis to quantify IHC slides

Digital Pathology Test Hypotheses Pathology presentations at Tumor boards and other conferences Frozen section consultations Remote interpretation of immunohistochemistry slides performed at the central lab Remote consultations by pathologists within Intermountain Healthcare Remote consultations by Stanford Surgical Pathology Consultants Impact on IT resources and network

Digital Pathology Pilot Project at Intermountain Healthcare Aperio ScanScopes and Spectrum software Duration of 90 days IMC Central lab – ScanScope XT and satellite server AFH – ScanScope CS and satellite server Dixie – ScanScope CS and satellite server Lake Park Data Center – Spectrum Server WAN with 100 MB links 4 pathologists – sponsor and study directors 11 participating pathologists Approximately 12 Intermountain support personnel

Standard questionnaires – quantitative ratings and comments Pathologists Tumor conference participants Support personnel Quantitative timings of functions IT monitors of network usage Digital Pathology Pilot Project at Intermountain Healthcare Data Collection

Digital Pathology Project Pilot Sites Intermountain Medical Center American Fork Dixie Regional

Findings of the pilot: Overview Tumor conferences – overwhelmingly positive results in three sites Frozen sections – 6 pathologists, 127 cases and 2 sites demonstrated % concordance with glass slides Remote interpretation of IHC slides – excellent scans with at least 24 hr improvement in turnaround time Remote consultations – inadequate testing with mixed results though interest remains high Digital pathology can solve or at least ameliorate some distance- related problems in a geographically distributed health care system

Tumor Conference: More Efficient Preparation Process “This is 2 to 3 times as fast” “Time savings of at least 50%...” “This is so much easier…there was less stress, it took less time, got me out of the zoo of taking photos” Average time saved = 65 minutes/week (preparation for one tumor conference)

Tumor Conference: Better Preparation Process “The tech scans the slides freeing me up to do other tasks” “I can pre-select the areas of highest interest” “I liked that the label was scanned and I could double-check to make sure it’s the right patient”

Tumor Conference: A Better Presentation “The low power images are as good as the microscope” “I like being able to put up the H&E and the immuno right next to each other” “It conveyed more information to clinicians” “You can show relationships that are hard to show with only a single picture”

Tumor Conference: Overall Comments “This is a superior way of presenting a case” “It was like going down to pathology to look at slides with the pathologist”—Radiation Oncologist “This would enable system-wide conferences” “Dr. X, though initially slow to put his trust in the technology, now seems to prefer it” “It would be nice to have the same level of technology as the radiologists”

Frozen Sections: Overall 2 studies, 2 sites, 6 pathologists, 127 cases Overall conclusions by study directors: “I would be comfortable making a frozen section diagnosis on a digital slide” “With the appropriate technical support and experience, use of the Aperio digital slides can effectively be used for nearly all frozen sections…” % concordance rate, no major discrepancies

Frozen Sections: Learning Curve “The diagnosis and scanning times got better as we got more practice” “It took a little longer to view a digital image, but if you factor in the time to drive to American Fork, it saves time”

Frozen Sections: Comments “This could improve patient care because you can get consultants to look at a frozen” “Frozens are of great interest to me because I’m the only one here” “A slightly higher deferral rate can be expected” The possible issues include: Added time involved in scanning slides Trust in non- pathologist to select and prepare sections Technical scanning problems, even minor ones, in this time- sensitive setting

Remote Viewing of Immunos, Special Stains: Promising but Not Fully Tested Image Quality Both low and high power image quality rated 4.7 on scale of 1-5 “The digital slide was an accurate representation” “I could do any regular immuno…more limited for a few microorganisms” “The quality of the scans was excellent” Turnaround Time “This did speed up the case” “This would save at least a day” “A day early would be great. It would be huge over the weekend” “This would take the wildcard of the courier out”

Remote Second Opinions: Inadequate Testing but Interest Remains High A few consultations requested from Stanford Some consultants enthusiastic, others not In one case “it worked the way it was supposed to”…they called right back, suggested some immunos. We did those and scanned them and kept the billing inside” Remote consultations within Intermountain did not take off, though “despite these failures, they may be beneficial in certain circumstances” “I would use this quite a bit”

Network Architecture Slides scanned and stored locally Slides viewed from anywhere on the network American Fork IMC Dixie Image Pointers stored on central database (not images)

IT Concerns and Solutions IT ConcernSolution “Moving images will impact the network” Meta-data only is moved across the WAN. Images viewed remotely using pixel-on demand (40 Kb/sec). No negative impact was seen “Can you guarantee patient confidentiality outside IHC?” Authentication for pre-approved users only. Pre-pilot agreement on approach to scrub patient data at conclusion “How do we support a project we don’t understand?” Pre-pilot discussions, regular communications while live “Equipment arrives and never goes away” Project scope clearly defined

General Issues / Considerations One-time/Pilot Issue Ongoing Issue Pre-Installation / Installation Issues Time-consuming to agree upon project scope, define network architecture Training Issues Difficult to engage participants for a time-limited event Time-consuming to learn new application, come up the learning curve Usage Issues Access to outside consultants Hard to scan difficult slides (poorly-cut, frozens, etc.) Availability of skilled staff to choose tissue and cut slides for frozens Server access Scanner noise

Conclusions Tumor conferences – overwhelming positive results Frozen sections – % concordance with glass slides Remote interpretation of IHC slides – excellent scans with at least 24 hr improvement in turnaround time Remote consultations – inadequate testing with mixed results though interest remains high Primary conclusion: digital pathology can solve or at least ameliorate some distance related problems in a geographically distributed health care system

Generous and extraordinary support from Aperio Intermountain pathology staff and IT department staff Intermountain affiliated pathologists Acknowledgement Intermountain Healthcare Digital Pathology Experience