1. Digital Imaging in Education and Distributed Pathology Practice
Elizabeth H Hammond MD
Professor of Pathology
University of Utah and Intermountain Healthcare
Executive Editor for Pathology
Amirsys, Inc.

2. Is Digital Imaging Critical or Is it Just a New Toy?
Value in Pathologist Education
Value in Pathology Practice

3. Pathology Education Deficiencies
Teaching methods limited in teaching certain disciplines and skills
Some skills cannot be taught by current methods
Some skills not examined by self assessment, a requirement of MOC.
Pathologists accessibility requires better electronic tools

4. Skills Required in Diagnostic Pathology
Searching
Identification
Classification
Comparison with previous experience by observer

5. Searching Skill Searching Finding areas of interest
Skill developed by experience
Strategies are not taught but are learned
Time to diagnosis less for skilled versus unskilled observers
Can be detected by evaluating and comparing eye movements of novices and experts
Not taught or glossed over because of limits of time

6. Whole Slide Imaging is Highly Valuable in Searching
Static images are often poor at low magnification where searching occurs.
Since static images include the lesion, the searching skill is bypassed.
Observation of skillful observer by a novice promotes learning of searching skills

9. Whole Slide Image
Heart Transplant Biopsy

10. Identification Skill
Skills needed to identify areas of interest using low power visual clues
Visual clues may not be obvious without training
Areas on IHC exam to select for HER2 FISH
Vascular lesions in transplant biopsies
Areas of lobular carcinoma in breast

11. Value in Identification
Skilled observer can be instructed to define in words how the identification occurs while the less skilled observer is watching
Areas of confusion or misidentification can be carefully reviewed and discussed
Artifacts can be defined
Limited preselected images do not fill this need

13. Whole Slide Image
HER2 Stained Slide

14. Classification Skill
Ability to compare test object with correctly classified objects reproducibly
Can be combined with identification skill in learning
Requires many high quality images of variously classified objects

15. Value in Classification
Combination of identification and classification skills is enabled
Based on interaction with learners, various classification clues can be focused on
Quality of static imaging is improved for documentation or teaching
Number of images that can be easily obtained is high.

18. Whole Slide Image
HER2 Stained Slide

19. How Can Such New Technology Be Deployed Effectively?
Video microscopy sessions at meetings
Use unknowns to enhance conversation
Describe process while doing it
Webcasts with other members of department as intradepartmental consults
Sessions with resident and staff at time of diagnosis.

20. Accessibility Digital Imaging allows pathologist to practice skills
Any place
Any time
Method can be incorporated for self assessment to help pathologist define their areas of deficiency

23. Whole Slide Image
Heart Transplant Biopsy

24. Distributed Practice Issues
Consistent interpretation required because Intermountain is a quality healthcare system
Variable skill and knowledge by group members
Variable availability of expert resources
Occasional manpower issues
Wide geographic separation

25. Practice Demographics
5 pathology groups
Distributed over 450 miles
Group sizes:
17: most specialties (4 hospitals)
4: Dermpath, Hematopath (2 hospitals)
3 (x2): Hematopath
2: None

26. Process Pathology groups are separate entities
Intermittent consultation
Sharing of expert resources for technical functions and some professional functions
Sharing during manpower shortages
Communication via phone and courier
Collegial environment

27. Potential Utilities of Whole Slide Microscopy
Intragroup consultation of specialists
Intergroup consultation between sites and for double read situations
Intergroup consultation for frozen sections
Professional sign out of immunohistochemistry with or without expert consultation
Tumor board presentations to clinicians
Education sessions to improve consistency of interpretation and speed of integration on new members

28. Specialty Consultations
Faster turn around time because couriers not involved
More common consultation because of increased availability
Opportunity for learning of others because of multiple viewing options

29. Intragroup Consultation
Requirement for double reading in many cases
New diagnosis of cancer
Prostate needle biopsies
Difficult cases which might benefit from consultation
Difficult with multisite groups so that appropriate second reader might not be used

30. Frozen Section Consultation
Difficult frozens benefit from second opinions
If no other pathologist on site, this is not utilized
Diagnoses could be improved by having this capacity at each hospital

31. Sign Out of IHC
Currently, all IHC done in three sites and slides shipped to other sites
Turn around time 24 hours for off site locations
Could consolidate technical functions if virtual microscopy was available
No option for dual viewing in difficult cases
No option to educate new members of group

32. Tumor Boards And Clinical Conferences
One or two each day in largest group
Slides that need to be included may not be available
Lost in pathologist office
Only at another hospital
In process of filing
Significant time required by pathologist to take required static images or drag photoscope to conference room

33. Education of Group Pathologists
Intermountain operates by developing standards which are transmitted throughout the system using data on provider behavior
Pathologists expected to be consistent and complete in reports (data system)
Education of pathologists required
Nottingham Score
HER2 scoring

34. Summary
Digital imaging has great value in improving pathology education
Improving diagnostic skills
Improving accessibility
Digital imaging has great value in practice
Allowing flexibility in sign out and consultation
Allowing distributed conference functions
Decreasing courier related process delays