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Telepathology
History of Telemedicine and Telepathology
Any diagnosis or treatment of a patient is subject to communication in medicine.
As long as actual or possible patients are able to consult their house physician or
medical specialist within a couple of minutes or even hours, no major need has
been noticed to perform any kind of electronic information transfer. When man
achieved the technical feat of leaving the earth, traveling into space and landing
on the moon, there was an immediate need to measure and transfer medical data
over a long distance, and to potentially give medical advice, for example, in the
case of unforeseen illness or emergencies. NASA became interested in telemedicine for its practical needs in the mid-1960s, in the beginning only to transfer
medical data, including images and reverse acoustic capability, in the case of actual
need. As all of the NASA missions have been controlled by earth-bound computer
centers and their teams, transfer of medical data and advice was only part of a
more complex and integrated control and navigation system. An example is shown
in Figure 11. However, the experiences of remote control and distant diagnosis
capabilities of computerized systems can also be applied to non-extraterrestrial
medicine, and have contributed to the development of telemedicine.
The first reported clinical trials of multispecialty telemedicine were performed
in the late 1960s. An image transmission service was installed between Logan
Fig. 11. Health control and visual contact during space missions have been important promoters of telemedicine
History of Telemedicine and Telepathology
25
International Airport and Massachusetts General Hospital in Boston, based upon
microwave transmission. This system was used to transmit macroscopic and microscopic images – mainly skin diseases – and served for expert consultation at
a time when image acquisition and display were not technically advanced.
However, even at these early stages it was possible to perform medical diagnosis
at a distance based upon images transmitted electronically.
Although NASA continued to perform telemedicine in its space missions, an
additional 20 years would pass before the first experiments with a dynamic-robotic telepathology system were accomplished in 1986–1987. The National Bladder Cancer Group in the United States was concerned with problems in
interobserver variability. A dynamic-robotic telepathology system was developed
to provide robotic expert consultation. To overcome the problem of interobserver
variability, a pathologist, located at the Central Pathology Department, was to
render a primary histological diagnosis by use of the system prior to a decision
for therapy which would be performed by urologists, oncologists or radiotherapists. A telepathology system was developed by Corabi International
Telemetrics, Inc.; however, the National Bladder Cancer Group terminated its
activities before the Corabi system was ready for use. A Corabi system, with
bidirectional robotics, was installed and became fully operational in Atlanta,
Georgia, in 1989. This used microwave telecommunication, linked two teaching
hospitals which were 4 miles apart, and was used for second opinions and
teaching.
Independent of these first steps, a more comprehensive telemedicine service
was started in Norway in 1988. A new university was founded in the extreme
northern parts of Norway, located in Tromsö, and new technological pathways
should bring improvement to the health care system in these parts of Norway.
The Norwegian group was well aware of Dr. Weinstein’s work on robotic
telepathology in the United States since it had been reported by the international
press. A robotic system was developed based upon specific broad-band connections. After extensive testing and evaluation of the results obtained by using the
system in comparison with microscopic evaluation of frozen sections, it was installed between two small hospitals located at distances about 400 km from the
Department of Pathology at Tromsö University. More than 150 frozen sections
were performed by this system, which was used until mid-1995, and there was no
unusual error rate observed by the team led by Dr. T. Eide and Dr. I. Nordrum. At
the same time, a Swiss group led by Dr. M. Oberholzer installed a comparable
system at the Department of Pathology, University of Basle, to perform telepathology-based frozen section services for two small hospitals located in the
Swiss Alps (Engadine). In contrast to the Norwegian system, it used ISDN connections. Transmission times were extended in comparison to the Norwegian system; the error rate was small and demonstrated no significant difference to conventional frozen section services. Whereas in Norway the first attempts at robotic
control of the microscope were performed using a so-called super mouse, the
Swiss attempts were directed at simulating control of the microscope at the monitors, an approach which has been followed by systems developed later.
At the same time, a different team grouped around Dr. K. Kayser in Heidelberg
set up a different goal of telepathology: distant expert consultation. The first at-
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Telepathology
tempts were undertaken in 1988, and included histological slide evaluation of
experimental material between three different institutions located in Darmstadt,
Hannover and Gießen. Immediate trials followed between the Institutes of Pathology at the Baumgärtner Höhe Hospital, Vienna (Dr. M. Drlizek), at the
Thoraxklinik, Heidelberg (Dr. K. Kayser), and at the Institute of Pathology,
Klinikum Heckeshorn, Berlin (Dr. W. Rahn). These highly specialized departments of pathology had the need for expert consultation in the diagnoses of
difficult pulmonary diseases. The system used normal analog lines with no robotic control of the partner’s microscope, transmitting still images only. Consultations were performed regularly, three times per week. In addition, a study
on the diagnostic accuracy of the four major cell types of bronchial carcinomas was performed. Approximately 90% of all 600 cases analyzed could be classified in complete concordance. The first reported board session by the use of
this technology revealed a practical and efficient application of this telecommunication tool.
The first international conference dedicated to telepathology was held in
Heidelberg under the auspices of the European Committee on Telepathology
(founded in Basle in 1989) in June 1992, called the First European Conference on
Telepathology. This was the start of a series of biannual symposia on telepathology which still continues. Also, in May of 1992, the first International Conference on Telemedicine took place in Tromsö. After these symposia in 1992, the
theme of telepathology was incorporated into most national and international
conferences on pathology.
The earliest steps in telepathology were performed by use of specific hardware and software with point-to-point connections. The use of the Internet started
in 1997. Originally designed for image storage and asynchronous expert
consultations, telepathology programs specifically designed for remote control
of a microscope are now available. Interactive telepathology via the Internet is
now possible, and the results are promising. The teams of Dr. C. Beltrami (Udine),
Dr. J. Szymas (Poznan), and Dr. K. Kayser (Heidelberg) have reported reliable
results of telepathology consultations via the Internet.
An additional milestone of telepathology was its intercontinental application
for the support of colleagues working in Africa and Asia. The trials between
Umtata in South Africa and Heidelberg, as well as the foundation of a Thai-German telepathology group (led by Dr. G. Stauch) in 1997, are an indication that the
field of telepathology is expanding. A similar approach to that of Drs. E. Martin
and P. Dussere in France in 1992 was used in 1993 by the Arizona International
Telemedicine Network (AITN). This linked the University of Arizona in Tucson,
Arizona, with hospitals in Hangzhou, China, as well as that in Hermosillo, Mexico.
Although large institutes of pathology were involved in this technique, the
application of telepathology is not limited to the large institutions. The reliable
use of telepathology for frozen section services by a private pathology institution
in northern Germany (Dr. G. Stauch, Aurich)started in 1995.
From a scientific point of view, a major advance took place when the largest
international telepathology project, the Europath project, was established by the
EC in 1996. Led by Dr. G. Brugal, Grenoble, and Dr. K. Kunze, Dresden, it was
primarily designed for the development of standards and the definition of
History of Telemedicine and Telepathology
27
Fig. 12. Front page of the Europath sever
user needs and their practical solutions. The project includes all aspects of telepathology including specialist consultations, intraoperative services, remote
quantitation of cytologic and histologic images, such as DNA analysis, the creation of image data banks, and the implementation of teleeducation in pathology. The Internet home page of Europath is shown in Figure 12.
Having demonstrated that telepathology can provide expert consultation under various circumstances, the Armed Forces Institute of Pathology, Washington, installed a telepathology system for field and interhospital consultation.
Launched in 1995 (led by Dr. A. El Said, and later by Dr. P. Fontelo), more than
100 institutions of pathology have used the telepathology services offered by the
AFIP, with accrual to date of more than 1500 cases.
Whereas the origins of telepathology are well documented, it is difficult to
trace these steps for electronic publication. Within medicine, the first international
scientific journal regularly published solely on an electronic medium was the
Electronic Journal of Pathology and Histology. This journal, created in 1995, was
designed to be independent from the Internet, to allow colleagues working under difficult economic conditions use of the opportunities offered by electronic
media. Presentation of other scientific journals on the Internet has occurred
mainly during and since 1997.
In 1998, an international team of reviewers was created to offer colleagues presenting articles the opportunity of peer review without any obligation to the contributors. The so-called PARIS team (Pathology Review International Score) was
founded by Dr. K. Kayser in 1998; the Internet home page is shown in Figure 13.
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Telepathology
Fig. 13. Front page of the pathology review international score (PARIS), an institution which
offers anonymous scientific reviews of medical articles sent via the Internet
The first international conference incorporating the theme of electronic publications in pathology took place in Singapore in 1997. To our knowledge, no other
conference related specifically to electronic publication in medicine or pathology has taken place. Will this happen in the near future? What are the specific
conditions of electronic publication in medical science? Will they contribute significantly to the development of research and science in medicine?
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