1. Milwaukee Pathology Hub and Spoke Model Bruce E. Dunn, M.D. Milwaukee VA Medical Center E-mail: Bruce.Dunn@med.va.gov

2. Milwaukee Pathology Hub and Spoke Model Iron Mountain VAMC Tomah VAMC North Chicago VAMC Milwaukee VAMC 170 mi 220 mi 60 mi

3. Overview Since 1998, ~4.7 Milwaukee pathologist FTEE have provided service in anatomic, clinical and administrative pathology to the Milwaukee VAMC hub and to the spoke sites at Iron Mountain, Tomah and North Chicago VAMCs Prior to 1996, a total of ~11 pathologist FTEE served these four sites

4. Clinical Activity: Summary Iron Mountain –In- and outpatient general surgery Tomah –No surgery. Skin biopsies and resections only North Chicago –Outpatient surgery only Milwaukee (Diagnostic and educational hub) –In- and outpatient general and specialty surgery –Tertiary VA referral center All sites –Anatomic pathology, clinical laboratory, blood transfusion

5. Total Anatomic Pathology Workload Summary FY01 Surgical pathology – 5950 cases (2.38 FTEE) Cytology/FNA – 2910 cases (0.83 FTEE) Bone marrows – 150 cases (0.30 FTEE) Autopsies – 70 cases (0.28 FTEE) Neuropathology (0.125 FTEE) Total Pathologist FTEE (3.915 FTEE)

6. Additional Pathologist Activities at Hub and Spoke Sites Clinical Pathology Resident Training (2 slots at Milwaukee only) Administrative Functions –Medical Executive Committees –Blood Product Utilization Review –Surgical Case Review –Laboratory Proficiency Testing Review –Laboratory Procedure Review

7. Need for Pathologist Consolidation Increased cost-effectiveness Retirement of pathologists at Iron Mountain, Tomah and North Chicago VA Medical Centers between 1996 and 1998

8. Strategies for Consolidation of Pathologist Functions Telepathology – hybrid dynamic/store & forward system Milwaukee pathologists travel to spoke sites for selected clinical, administrative and educational functions Increased oversight role by lab managers Voice-activated dictation by pathologists

9. Telepathology: Hub and Spoke Model Tomah North Chicago Milwaukee Iron Mtn VHA WAN Internet DR RM NRM GS NRM GS NRM KEY RM - Robotic microscope NRM - Non-robotic microscope GS - Grossing station DR - Document reader POP - Point of presence WAN - Wide area network VistA -VHA info system WAN POP Multi-site conferencing DR Scanner DR Printer Interface to VistA Voice-Activated Dictation

10. Telepathology Equipment: Summary Iron Mountain –Robotic microscope with grossing station and document reader Tomah –Non-robotic microscope with document reader North Chicago –Non-robotic microscope with grossing station Milwaukee (Diagnostic and educational hub) –Non-robotic microscope with grossing station, document reader, scanner and printer. Voice-activated dictation All sites –VistA Imaging and multi-site conferencing (mid-2002)

11. Applications of Telepathology at Iron Mountain VAMC Surgical pathology –Primary diagnosis including frozen sections –Documentation of gross and histopathology –Consultation with clinicians Autopsy pathology –Clinico-pathologic correlation conferences Clinical pathology –Microbiology consultations (smears and cultures) Hematology –Review of peripheral blood smears Continuing education

12. Applications of Telepathology at Tomah VAMC Clinical pathology –Microbiology consultations (smears and cultures) Hematology –Review of peripheral blood smears Continuing education

13. Applications of Telepathology at North Chicago VAMC Surgical pathology –Documentation of gross and histopathology –Consultation with clinicians Clinical pathology –Microbiology consultations (smears and cultures) –Infectious diseases conferences and consultations Hematology –Review of peripheral blood smears Continuing education

14. Applications of Digital Imaging at Milwaukee VAMC Surgical pathology –Documentation of gross and histopathology Autopsy pathology –Documentation of gross and histopathology Clinical pathology –Documentation of interesting cases Hematology –Documentation of interesting cases Continuing education

15. Spoke Site Autopsy Performance Iron Mountain – Milwaukee pathologist travels Tomah – autopsies performed at Madison (by Madison pathologists) North Chicago – Milwaukee pathologist travels

16. Summary of Pathology Networking Activities in VISN 12 Standardization of equipment and procedures Consolidation of batched/esoteric testing Telepathology –Provide access to distant pathologists and technologists –Provide a single diagnostic standard of care Reduced personnel and “all other” expenses Focus: resource sharing rather than independent labs and employees (interdependence)