1. Telepathology and The Future of Pathology (or Why did we change our Practice Model) Jagdish Butany, MBBS, MS, FRCPC Consultant Cardiovascular Pathologist/Director Autopsy Services Co-Editor-in-Chief, Cardiovascular Pathology Professor, University of Toronto &Dir.Divn.of Pathology,Dept. of Laboratory Medicine and Pathobiology, Sectty/treasurer WASPaLM(2009--) University Health Network / Laboratory Medicine Program Toronto General Hospital, 200 Elizabeth Street, E11-444 Toronto, Ontario M5G 2C4,Canada. Tel: 416-340-3003 Fax: 416-586-9901 e-mail: jagdish.butany@uhn.on.ca 2 Feb 2011, Birmingham, UK. I HAVE NO CONFLICT OF INTEREST WITH ANY Equipment/Supplier!

2. (a)Why did we implement telepathology (WSI) at UHN?

3. Imagine 1.Cover 3 sites 2.No new staff available 3.Increasing workload

4. TGH, PMH, TWH No on-site TWH pathologist 2-10 frozen sections per week (mostly neurosurgery) Sept. 2004 – no NP University Health Network ~ 1 mile X X X

5. UHN IMAGINE 2! Research SS S S= Service

6. UHN IMAGINE3: 3 Departments of Pathology ! # Q S Sites

7. Medical Laboratories

8. “-----and sometimes u get lucky!!”

9. The Perfect Storm---! Right Circumstances Right Leadership Right Tools!! Available! Problem!!

10. TWH Frozen Sections: The Problems to Be Solved Single pathologist traveling to TWH –Inefficient process - traveling time and waiting –Disruptive to regular workflow – 99% of departmental activity occurs at TGH delays in regular sign-out affecting other UHN patients –No possibility for consultation on difficult cases – possibly affecting TWH surgical patients. Compromised diagnostic accuracy Unnecessary deferred diagnoses

11. The Robotic System: November 2004-October 2006 350 frozen sections accurate deferral rate < 10% slow (~ 10 minutes/slide)

12. Toronto General Telepathology Work Station (not a pathologist’s office) Toronto Western The Robotic System

13. Whole-Slide Imaging: October 2006-Present > 1800 frozen sections/1500 patients 90% from neurosurgery 98.5-100% accuracy (month to month) 14-16 minute turnaround time 5% deferral rate - 2 pathologists review all deferrals

14. Telepathology Was A Viable Solution > 90% of the cases are single block Surgeons select the tissue of interest –no need for gross assessment by pathologist –surgeon-defined margins –submit in toto for frozen section/smear Robotic microscopy (2004-2006) –most intense development and validation Transition to WSI (late 2006- present)

15. Easy consultation with colleagues – better for patient care WSI had essentially no learning curve (compared to robotic microscope) Whole-Slide Imaging: Architecture This was TGH/UHN

16. Pathology 2000-2010

17. Future of Pathology Frontiers in Laboratory Medicine Feb 1-2, 2011, Birmingham UK.

18. 18 Volume –aging population –higher sensitivity for early disease Demand –Sophisticated knowledgeable population –Culture of “instant gratification” New technologies –genomics –proteomics –informatics –robotics ‘tissue soup’ instead of tissue Challenges for 2020 MONEY??

19. The Challenge for 2020 Faster Better – Higher quality –Personalized Cheaper Innovative

20. The New Paradigm: Faster Pathology must be faster – “Same Day” diagnosis –Automation –24/7 labs Faster

21. 21 The New Paradigm: Faster Speech-recognition integrated with LIS means instant reporting without the need for dictatyping CHEAPER

22. Technologic Advances: “omics” HT-Sequencing DNA Microarray Expression Profiling RNA Mass Spectrometry Protein Metabolomics

23. What is “Correct”? Objective classification by –mRNA expression –DNA sequencing –Response to therapy The New Paradigm: Better

24. Synoptic Reporting –Complete Standardized formats (CAP checklists) –Adaptable and flexible No more verbose reports that no one reads! –Database technology Statistics collection Administrative tracking QA monitoring Academic data mining The New Paradigm: Better

25. 25 The New Paradigm: Better (A Bit Controversial- still !! ) Subspecialty Pathology –All cases reported by a pathologist with expertise in the specific subspecialty required –Benefits: Better quality and faster patient care Fiscal responsibility: 1 pathologist per case Pathologist satisfaction – enhanced academic excellence –Challenges: Requirement for appropriate staffing in all areas and Built in redundancy

26. Requirements for Full Adoption Workflow integration –From the lab to the pathologist LIS integration –Barcodes –Slide tracking and retrieval CHEAPER

27. 27 Digital Pathology Enables Remote access Multiple viewers Immediate access to the right pathologist at the right time BETTER

28. Computer-Assisted Diagnostics Automated analysis of: –Measurement –Mitoses –Ki67 LI –Other IHC intensity distribution –Her2 FISH –Hematology Cellavision –More? QA of technical quality –Section thickness –Stain quality ? Need for Westgard rules in AP?

29. Epigenetic Control: Can it Override the Genotype? N Engl J Med. 2007 Feb 15;356(7):731-3

30. What Is Anatomical Pathology? Integrative morphology based interpretation Consultant’s Report Gross Morphology Chemistry on a glass slide Immunoassay on a glass slide

31. The Virtual Autopsy

32. After “The Anatomy Lecture of Dr. Nicolaes Tulp” – Rembrandt, 1632 (Courtesy of Dr. Carlos Cordón, New York, USA)

33. 33 Patient-Centred Care Individualized diagnostics Targeted therapies All based on “omics” Will “omics” replace pathology? The New Paradigm: Personalized

34. The Future of Pathology? $15.00 each$1000.00 each $15.00 each$1000.00 each

35. 2020 Pathology Digital radiology Digital cardiology Digital genetics Biomarkers & CAD Clinical Pathology Gross Pathology History, Physical, Family History Digital EMR QA Labs/ Pathology: the center of Personalized Medicine !! Endoscopy

36. Comprehensive & Integrated Pathology reports –Incorporation and integration of radiologic, biochemical, morphologic, molecular, cytogenetic and epigenetic data The 2020 Paradigm The Pathologist’s Cockpit Gross Pathology Biomarkers Radiology Biochemistry Molecular Pathology Histopathology

37. 37 To provide the right diagnosis To provide the right material To provide the right leads To provide the right experiments To evaluate the consequences of genetic manipulation To PROVIDE An INTELLIGIBLE, COMPREHENSIVE REPORT!! The Expanding Role of Lab Medicine

38. 2020 2020 THE Pathologist !! The Pathologist and the Patient!!

39. 2020 Pathologist Pathologist and Patient! “The Diagnosis is----, and the prognosis is----.”

40. “AS IS YOUR PATHOLOGY SO IS YOUR MEDICINE.” Sir William Osler McGill Univ, Hopkins, London (UK)

41. IMAGINE!! X X X X Kuwait X

42. 42 The Future of Pathology The best way to predict the future is to invent it Alan Kay