1. Telepathology as a Networking Tool in VISN 12 Bruce E. Dunn, M.D. Milwaukee VA Medical Center E-mail: Bruce.Dunn@med.va.gov

2. VISN 12 Hospitals Milwaukee (M,R,S) Iron Mt. (S) Tomah Madison (M,R,S) N. Chicago(M) Hines, (M,R,S) Westside(M,R,S) Lakeside (M,R,S) Chicago Metro VAs M = Affiliated with medical school R = Pathology residence training program S = Surgery program Legend

3. VISN 12 Distance Schematic Madison Iron Mountain Tomah North Chicago Milwaukee Hines LakesideWestside 92 mi 220 mi 60 mi 35 mi 3 mi9 mi 78 mi

4. VISN 12 Telepathology Network Hines Lakeside Madison Tomah North Chicago Westside Milw Iron Mtn VHA WAN Internet VHA WAN Internet DR GS RM NRM DR GS NRM GS NRM KEY GS - gross station DR - document reader RM - robotic microscope NRM - non-robotic microscope * New function WAN Printer POP Multi-site Conferencing* DR Scanner DR Printer ST Micro (Hines) NRMDR POP Interface to VistA* Voice-Activated Dictation

5. Applications of Telepathology Surgical pathology –Primary diagnosis or consultation –Documentation of gross pathology –Consultation with clinicians Autopsy pathology Clinical pathology –Microbiology –Protein electrophoresis and immunofixation Continuing education

6. Clinical Need for Telepathology at Iron Mountain VAMC Retirement of pathologist –Surgical pathology (~1,000 cases per year) –Frozen sections –Autopsies (~10 per year) –Diagnostic Nuclear Medicine studies –(Service chief, clinical pathology) Component of comprehensive telemedicine program

7. Dynamic Robotic Telepathology 1 Tissue examined/ hub site pathologist 2 3 5 4 6 7 8 9 H & E Sections made Slides examined using robotically-controlled microscope WAN Pathologist views images in real time Slides read in Milwaukee Pathologist dictates report to PA PA enters report into Iron Mt.. DHCP Report printed locally and signed IRM Router IRM Router

8. Surgical Pathology TAT for Iron Mountain VA Medical Center TP used only to cover on-site pathologistabsence TP implemented completely;dictationsstreamlined Histotech/PA both involved in TP PA begins on-line transcription and correction PA only involved in TP Iron Mtn. Transcriptionistretires

9. Technical Summary (first 2,200 cases) Deferral rate: ~2% Concordance on non-deferred cases: 99.7% Time per case: 11.6 min (cases 1-200), reduced to 3.58 min (cases 2001-2200) Time per slide: 4.25 min (cases 1-200), reduced to 1.13 min (cases 2001-2200) Case turn-around-time: < 1.5 days

10. Telepathology and the Autopsy Send key images electronically to attending along with PAD Submit tissue sections from a distance Documentation of sections Autopsy conference presentations VistA Imaging as permanent record

11. Consolidation of Microbiology Functions Plate, incubate and send (portable incubators) Telepathology to view gram stains and early culture growth - primary lab Telepathology to view gram stains and show cultures to clinicians - core lab

12. Conclusions Telepathology can be extended to all areas of anatomic and clinical pathology Multiple capabilities available Must balance access, diagnostic accuracy and cost Users must be flexible, but do not have to be computer experts Strong support of telecommunications network is essential