1. 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

2. 21 Veterans Integrated Service Networks (VISNs)

3. Hospitals and CBOCs in VISN 12

4. Robotic Telepathology (TP) at Iron Mountain VAMC: Background
Iron Mountain is an active, rural DVA hospital with a general surgery program
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

5. 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

9. 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

10. 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

11. Case Mix (1999) Organ/system Percent of total Gastrointestinal 42.9
Skin
Prostate
Hernia sac
Urinary bladder
Bone/synovium/tendon 2.1
Penis/testis/spermatic cord 1.9
Gallbladder
Extremity amputation
Appendix
Gynecologic
Breast
Miscellaneous

12. 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

13. 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 30 fps
Static imaging: 1280 x 960 x 24-bit color
Images transmitted at 500 kbps – 8 mbps over WAN controllable by user

14. Current and Future

15. 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

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

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

18. Overall Comparison by Phase
Phase I II III (ASAP) Total
Total opportunities 2, , , ,553
Deferral rate (%)
Discordance (%)

19. Overall Pathologist-Specific Discordance Rates

20. Major Discordance Rate (%) by Technology
Pathologist
Technology B E F G All
Pre-ASAP ND ND *
ASAP
*0.33 excluding pathologist D

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

22. 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

23. 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

24. 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

25. 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