Digital Imaging in Education and Distributed Pathology Practice Elizabeth H Hammond MD Professor of Pathology University of Utah and Intermountain Healthcare Executive Editor for Pathology Amirsys, Inc.

Is Digital Imaging Critical or Is it Just a New Toy? Value in Pathologist Education Value in Pathology Practice

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

Skills Required in Diagnostic Pathology Searching Identification Classification Comparison with previous experience by observer

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

Whole 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

Whole Slide Image Heart Transplant Biopsy

Identification 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

Value 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

Whole Slide Image HER2 Stained Slide

Classification 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

Value 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.

Whole Slide Image HER2 Stained Slide

How 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.

Accessibility 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

Whole Slide Image Heart Transplant Biopsy

Distributed 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

Practice 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

Process 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

Potential 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

Specialty 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

Intragroup 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

Frozen 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

Sign 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

Tumor 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

Education 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

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