1. Introduction to Telepathology Bruce E. Dunn, M.D. Milwaukee VA Medical Center E-mail: Bruce.Dunn@med.va.gov

2. Telepathology Definition: Provision of diagnostic, support or educational services in anatomic or clinical pathology by viewing gross or microscopic images electronically Rationale: Provide access to a generalist or specialist pathologist (or technologist) not available on-site

3. Telepathology System Images from www.bildanalys.se/tele.htm

4. Description of previous slide In a typical telepathology system, a microscope is connected to a camera through which static or dynamic images are sent via a local or wide area network to a computer where the image is observed by a consultant. In the previous slide, both sides are equipped with cameras and computers so that each can send images to the other.

5. Static (Store and Forward) Telepathology Static (still) images (photographs) selected by referring provider sent to consultant Requires skillful image collection by referrer

6. Static (Store and Forward) Telepathology Advantages –Simple - minimal hardware needs (computer, camera) –Inexpensive - hardware and image transmission (Internet) –Adaptable - many computer systems can be adapted Disadvantages –Image selection – referrer –Real time interaction - difficult –Not suitable for primary diagnosis by surgical pathologist at a distance Example: Armed Forces Institute of Pathology consultation service

7. Dynamic Telepathology Real-time (television) images selected by referrer as if operating a two-headed microscope Hybrid Dynamic/Store and Forward (HDSF) Telepathology Combines both store and forward and dynamic telepathology functions

8. Hybrid Dynamic/Store and Forward Telepathology Advantages –Dynamic and store and forward imaging functions available –Real time interaction with consultant –Image transmission speed Disadvantages –More complex than static TP (camera(s), computer system, accessories) –More expensive than static TP - requires broad bandwidth –Image selection - sender Examples: VISN 12 sites

9. Robotic Hybrid Dynamic/Store and Forward (HDSF) Telepathology Hybrid - combines both dynamic and store and forward telepathology functions Robotic - image selection at remote site (robotic microscope) controlled by consultant at the hub site

10. Robotic Hybrid Dynamic/Store and Forward Telepathology Advantages –Robotic control of remote microscope allows distant pathologist to view slides completely –Real time interaction with referrer/PA/clinician –Allows performance of frozen sections Disadvantages –Most complex telepathology system –Most expensive telepathology system - requires broad bandwidth telecommunications Examples: Milwaukee-Iron Mountain VAMCs; Richmond-Beckley VAMCs

11. Dynamic Robotic Telepathology 1 Tissue examined/sectioned by remote PA/Hub Pathologist 2 3 5 4 6 7 8 9 H & E Sections made Slides put onto stage of robotic microscope WAN Hub Pathologist examines slides using robotic microscope Slides read in Milwaukee Pathologist dictates report to PA PA enters report into Iron Mtn VistA Report reviewed, printed signed, faxed Router

12. Conclusions Multiple telepathology modalities exist Must balance clinical needs vs cost Users must be flexible, but do not have to be computer experts Strong support of telecommunications network is essential