1. Ronald S. Weinstein, M.D. Professor, Pathology Head, Pathology 1990 – 2007 Director, Arizona Telemedicine Program

2. Disclosure  DMetrix – Tucson, AZ Medical Director  Apollo Telemedicine – Falls Church, VA Shareholder

3. Telepathology  The use of telecommunications technology to facilitate the transfer of image-rich pathology data between remote locations for the purposes of diagnosis, education, and research.

4. Telepathology systems are divided into three major types: static image-based systems, real- time systems, and virtual slide systems. 1. Static image systems have major benefits of being the most reasonably priced and usable in the widest range of settings, but have the significant drawback in only being able to capture a selected subset of microscopic fields. 2. Real-time systems and virtual slides allow a consultant pathologist the opportunity to evaluate the entire specimen. With real-time systems, the consultant actively operates a microscope located at a distant site -- changing focus, illumination, magnification, and field of view at will. 3. Virtual slide systems utilize an automated scanner that takes a visual image of the entire slide, which can then be forwarded to another location for diagnosis.

5. Table 1. Arizona-International Telemedicine Network LocationPopulationDistance from Tucson (km [miles]) No. of beds in hospital* United States - AZ Tucson405,000-312 Phoenix983,000178 (111)350 Cottonwood6,000350 (217)99 Yuma55,000386 (240)350 Kingman13,000478 (297)50 China Hangzhou1,200,00012,800 (7,900)600 Mexico Hermosillo  449,000381 (237)250 *Hospital housing the telepathology workstation.  The Hospital General del Estado in Hermosillo served as the hub for a network of regional hospitals whose pathologists brought cases to the referring site for transmission to Tucson and teleconsultation.

6. University of Arizona Telepathology Services a ModalityClass b QA Second opinion Frozen sections Deferred cases c Static image telepathology 2A---239---17 Robotic dynamic telepathology 3B3064 d 81142228 Virtual slide telepathology 5C329--- Total3393320142245 a University of Arizona telepathology services, initial 4100 cases, 1993-2008. b Weinstein Classification of Telepathology Systems [2]. c For special studies, such as immunohistochemistry, or for glass slide review d Includes some second-opinion cases.

7. TELEMEDICINE JOURNAL Volume 1, Number 1, 1995 Mary Ann Liebert, Inc., Publishers Case Triage Model for the Practice of Telepathology A.K. BHATTACHARYYA, M.D., JOHN R. DAVIS, M.D., BRADFORD E. HALLIDAY M.D., ANNA R. GRAHAM, M.D., S. ANNE LEAVITT, M.D., RALPH MARTINEZ, Ph.D., RICARDO A. RIVAS, and RONALD S. WEINSTEIN, M.D.

8. Referring Pathologist Subspecialty Pathologist Triage Pathologist Case Sign-out PATHWAY APATHWAY B Case Triage Model Case Sign-out Triage Pathologist

9. AFIP Model Referring Pathologist Triage Clerk GI Path GYN PathRenal PathDerm PathEtc. Case Sign-out Case Sign-out Case Sign-out Case Sign-out Case Sign-out

10. University of Arizona Telepathology Services a ModalityClass b QA Second opinion Frozen sections Deferred cases c Static image telepathology 2A---239---17 Robotic dynamic telepathology 3B306481142228 Virtual slide telepathology 5C329--- Total3393320142245 a University of Arizona telepathology services, initial 4100 cases, 1993-2008. b Weinstein Classification of Telepathology System [2]. c For special studies, such as immunohistochemistry, or for glass slide review

11. Havasu Regional Medical Center University Medical Center Tucson, AZ 316 Miles

12. Quality Assurance Program  HRMC processes approximately 3500 surgical pathology cases annually  One pathologist, on-site, between July 2005 and October 2009.  All new cancer cases and challenging non-malignant cases were selected by the HRMC pathologist for telepathology re-review.

13. Case Read-Outs# of Cases % of Cases Average Time UMC on-service telepathologist 169290.87%3.78 (1-33 minutes) Deferred for glass slide review 1709.13%6.12 (1-18 minutes) Total1862

14. Deferral Rate Pathologists Total cases in general Deferred cases Total cases excluding the pathologist’s subspecialty Total deferred cases excluding the pathologist’s subspecialty Deferral rate in general Deferral rate excluding pathologist’s subspecialty Gastro Intestinal 50124344174.79%4.94% Heart and Lung 36930321258.13%7.78% Renal 188241502214.79%14.67% Soft Tissue 174371653621.26%21.81% GYN 16612161127.23%7.45% Renal 13912109108.63%9.17% Endocrine 85983910.59%10.84% ENT Path 8467667.14%7.89% Dermatology 58750512.07%10% Breast 5145047.84%8%

15. Deferral Rate Pathologists Total cases in general Deferred cases Total cases excluding the pathologist’s subspecialty Total deferred cases excluding the pathologist’s subspecialty Deferral rate in general Deferral rate excluding pathologist’s subspecialty Gastro Intestinal 50124344174.79%4.94% Heart and Lung 36930321258.13%7.78% Renal 188241502214.79%14.67% Soft Tissue 174371653621.26%21.81% GYN 16612161127.23%7.45% Renal 13912109108.63%9.17% Endocrine 85983910.59%10.84% ENT Path 8467667.14%7.89% Dermatology 58750512.07%10% Breast 5145047.84%8%

16. Deferral Rate Pathologists Total cases in general Deferred cases Total cases excluding the pathologist’s subspecialty Total deferred cases excluding the pathologist’s subspecialty Deferral rate in general Deferral rate excluding pathologist’s subspecialty Gastro Intestinal 50124344174.79%4.94% Heart and Lung 36930321258.13%7.78% Renal 188241502214.79%14.67% Soft Tissue 174371653621.26%21.81% GYN 16612161127.23%7.45% Renal 13912109108.63%9.17% Endocrine 85983910.59%10.84% ENT Path 8467667.14%7.89% Dermatology 58750512.07%10% Breast 5145047.84%8%

17. Deferral Rate  The case deferral rates for individual telepathologists ranged from 4.79% to 21.26%  The deferral rates were not significantly changed by exclusion of cases within the individual pathologists’ subspecialty area. These deferral rates ranged from 4.94% to 21.81%

18. The triage pathologist completed the telepathology consultation without any assistance of a subspecialty pathologist in 66% of the cases. A review panel examined the original glass slides from 134 cases by light microscopy. Concordance rates of the telepathologists’ provisional diagnosis or review panel’s diagnoses with the referring pathologists’ diagnoses were not statistically different ( P > 0.05).

19. Conclusions:  Deferral rates were minimally impacted by pathologist subspecialty.  Overall diagnostic discordance rate, comparing on-site light microscopy and telepathology diagnoses, was 5.73%.  Deferrals for glass-slide review represented less than 10% of telepathology QA cases.

20. Conclusions:  Deferral rates were minimally impacted by pathologist subspecialty.  Overall diagnostic discordance rate, comparing on-site light microscopy and telepathology diagnoses, was 5.73%.  Deferrals for glass-slide review represented less than 10% of telepathology QA cases.

21. Telepathology Practice Models

22. Thank you!