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Digital Consultation in Pathology Practice
Sylvia L. Asa, MD, PhD
Medical Director, Laboratory Medicine Program,
University Health Network, Toronto
April 16, 2011
Foundation.cap.org
v. #
Contents
• Definitions
• History
• The UHN Experience
• The Future
Contents
• Definitions
• History
• The UHN Experience
• The Future
What is Consultation?
Consultation:
• The act of consulting (providing advice
in a particular area of expertise)
• A conference for the exchange of
information and advice
• An appointment or meeting with a
professional person, such as a doctor
•Wiktionary 2011
© 2011 College of American Pathologists. All rights reserved.
4
What is a Pathology Consultation?
Pathology Consultation
•The act of providing advice in a particular
area of expertise
Examples:
•Intraoperative consultation
•Pathology report
•Secondary opinions
© 2011 College of American Pathologists. All rights reserved.
5
Digital Pathology Consultation
• The use of digital slide review for
pathologist consultations
Examples:
• Intraoperative consultation
• Pathology report
• Secondary opinions
Contents
• Definitions
• History
• The UHN Experience
• The Future
Historical Data: Telepathology
• 1973: Washington DC diagnosis of
leukemia via satellite from Brazil
• 1986: Dr. Ronald Weinstein coins
the name
• 1990s: Norway implements robotic
microscopy to support frozen
sections in remote hospitals
• 2000s: Whole Slide Imaging (WSI)
8
Barriers to Telepathology
• Cost
• FDA approval
• Billing/CPT codes
• Storage
• Transmission and privacy of PHI
• Pathologist issues
o learning curve/accuracy
o “images are good, but not ready for prime
time”
9
Contents
• Definitions
• History
• The UHN Experience
• The Future
The University Health Network
• A consolidation of three U of T
affiliated teaching hospitals
• Programmatic restructuring
o TGH cardiac care; transplantation;
advanced medicine and surgery
o PMH oncology center
o TWH neurosciences,
musculoskeletal care,
community health
11
The University Health Network
© 2011 College of American Pathologists. All rights reserved.
12
Digital Intraoperative Consultation
• Laboratory consolidation at TGH
• No on-site pathologist at TWH
o Staffing challenge
• Low volume of Intraoperative consults
• Need for surgical pathology expertise
in multiple areas including
neuropathology
Why not use telepathology??
Barriers to Telepathology
• Cost – cheaper than another Pathologist
• FDA approval – not applicable (Canada)
• Billing/CPT codes – not applicable
• Storage – low volume
• Transmission and privacy of PHI – internal
secure network
• Pathologist issues – young and innovative
department
14
Due Diligence Before Going Live
• Medical Malpractice Insurance Provider
o Canadian Medical Protective Association (CMPA)
o telepathology will not affect coverage
• UHN Medical Advisory Committee
o SOP presented for approval
• Health Canada – Therapeutic Products Program
o telepathology does not involve “medical devices”
(no direct contact between instrument and patient)
o no federal approval required
• Surgeon Education
o demonstrating the robotic microscope/slide scanner
− essential to get surgeon buy-in!
15
The Robotic System:
November 2004-October 2006
16
The Robotic System:
November 2004-October 2006
Toronto Western
Surgical Pathology
© 2011 College of American Pathologists. All rights reserved.
Toronto General
Telepathology Work Station
17
Whole-Slide Imaging:
October 2006-Present
18
Whole Slide Imaging:
System Parameters
© 2011 College of American Pathologists. All rights reserved.
19
UHN Telepathology Protocol
• System test each morning
• Pathologist reviews O.R. list, communicates
plan for the day to histotechnologist
• Surgeon defines tissue of interest
• Histotechnologist contacts Pathologist
- specimen description, processing specimen
• Histotechnologist at TWH scans the slide and
calls the Pathologist
• Pathologist speaks with surgeon by telephone
• QA the next day
20
1003 Frozen Sections from 802
Patients (Nov 2004-Sept 2008)
1200
1003
1000
800
653
600
# Frozen Sections
350
400
200
0
Robotic
WSI
Total
21
Performance: 1003 Cases/4 Years
• Accuracy
o 98% concordance with final pathology
o Not a function of technology
• Deferral rates
o Identical to on-site rates
o NOT a function of technology
− Sometimes you just don’t know for sure
− Sampling issues in the frozen section biopsy
• Turnaround times
o Well within 20 minutes required
22
Pathologist Interpretation Time
10
9
8
7
6
5
4
3
2
1
0
4-fold
*
*
Time/slide (min)
Receipt of image to
Report of diagnosis
Robotic
WSI
WSI
Frozen Frozen +
Smear
* p < 0.00001
Pathologists tended to go to TWH site for multi-block cases when
using the robotic microscope – not so for whole-slide imaging.
23
WSI Pathologist Interpretation Time
40
35
32
%
38
%
30
%
30
25
20
% of Cases
15
10
5
0
<1
1-2
>2
Minutes/slide
* 70% of cases reported in < 2 minutes after scan is received
24
Failure Mode Analysis
• PRE-CASE:
– Network failure
– Moving the scanner within the lab
•static vs dynamic IP addresses
•discovered on morning test run
• MID-CASE:
– Minute/pale pieces of tissue that the
scanner would not “recognize”
– Excess mounting media causing the cover
slip to stick to the scanner objective
25
Subspecialty Support for FS
26
Subspecialty Model
• How do we get the pituitary expert
to read a tough biopsy when she
is in Istanbul?
Telepathology Blackberry solution
27
Subspecialty Model
• How do we get the two liver
pathologists to read transplant
biopsies and attend all academic
meetings?
Telepathology solution
o USCAP 2008 all rush biopsies read on
laptops at the meeting
28
Subspecialty Model
• How do we get the subspecialty
support for weekend coverage?
Telepathology solution
o Summer 2008 all weekend cases read
on laptops at the home/cottage etc.
29
Ontario-Wide Implementation
• Timmins and District Hospital forms an
alliance with 9 other hospitals in North
East Ontario
• Seeks Laboratory Medical Directorship
• UHN provides a suitable proposal
o Team of subspecialists to support all
clinical needs from core in Toronto
• Initiation of a new model
30
Ontario-Wide Implementation
* * * **
*
*
*
*
422
miles
Google Maps
2008
Addition of New Clients
* * * **
*
*
*
*
422
miles
400
miles
Google Maps
2008
Subspecialty Consultation
• Requires sign-out of all cases by
subspecialist
o Slides shipped to Toronto by overnight
courier from Northern sites
• FS review by subspecialist must be
available
• Ultimately no pathologist on site
Telepathology solution
33
Transitions to Routine Diagnosis
• Success with intraoperative
consultations
• Need for subspecialty access
Barriers to Full Integration
• Integration of multiple slides into
workflow for case signout
o From the lab to the pathologist
• IT integration
o LIS
o Barcodes
• Pathologist satisfaction
o Assurance of job security
o “This could make pathology fun again”
Workflow Integration
• Lab
o High throughput
o Automated
o Flexible integration with
stain/coverslip equipment
• Pathologist
o Rapid image capture, easy
navigation
o Multiscreen capability
o Annotation capability
Contents
• Definitions
• History
• The UHN Experience
• The Future
Computer-Assisted Diagnostics
• Automated analysis of:
o Measurement
o Mitoses
•
QA
of
technical
o Ki67 LI
quality
o Other IHC
o Section thickness
− intensity
− distribution
o Stain quality
o Her2 FISH
o Hematology ? Need for Westgard rules in AP?
− Cellavision
o More?
Computer-Assisted Diagnostics
o The future will bring more innovation
GENIE© (GENetic Imagery Exploration) is a
GP software system that builds automatic
feature extraction algorithms for image
analysis, utilizing spectral and spatial
signatures of the images
“GENIE© can recognize benign and
malignant areas in H&E stained slides and
it does not have intra- or inter-observer
variation in the analysis”
Critical Requirement
$$$ Business Case
• Reduced microscope budget
• Analysis of time spent
o Finding slides
o Matching slides to case
o Retrieving slides for post-hoc review
Digital Secondary Consultation
• Rapid transmission of slides around
the world
• Provides immediate access to the
expert of choice
Barriers to Digital Secondary Dx
• Integration of more than a few slides
into workflow for case signout
o Gross description, patient demographics
o Privacy issues
• IT integration for reporting
• System compatibilties
Digital Pathology Enables
• Access to the right pathologist at
the right time
• Cost effectiveness
o To the lab
o To the system
The New Paradigm
• Comprehensive integrated consultations with
imaging, biochemical, histologic, molecular,
cytogenetic and epigenetic data
Bioche
mistry
Imaging
Gross Biomarkers
Pathology
Histopathology Molecular
Pathology
•The Pathologist’s Cockpit
The Philosophical Response
In a time of drastic change
it is the learners who
inherit the future. The
learned usually find
themselves equipped to
live in a world that no
longer exists.
Eric Hoffer
45
2020 Pathologist Consultation
The best way to predict the future
Is to invent it