Pathology Visions 2010
Regional Telepathology in
Fraser Health Authority:
A multisite, multimodality, multidiscipline
deployment.
Dr. I. Scott Cornell
Medical Lead, FHA
Telepathology Project
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Project Team
Sponsor:
IT:
Technical Coordinator:
Lab Scientists:
Physicians:
Project Manager:
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Minnie Downey
David Izzard
Gagan Atwal
James Owen
Janet Tunnicliffe – Anatomic Path
Val Horak – Hematology
Kulvinder Mannan – Microbiology
Scott Cornell – AP & Medical Lead
Lawrence Haley - Hematology
Dale Purych - Microbiology
Julie Harrison
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Introduction
1. Presentation of our 5 year project
2. Results and conclusions to date.
3. Our current deployment.
4. Our take on the future.
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Fraser Health Authority
Location
FHA
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4
Map of Fraser Health Authority
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.

12 Hospital sites

150km or 95 miles wide

Serving 1.5 million people

Over 1750 acute care beds
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Pathology Hub Sites
1
Surgical Pathology Total Accessions 92,000
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The Promise of Digital Pathology
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Diagnostics
Consultations
Conferencing
Teaching
Quality Assurance
Archiving
Image Analysis
Efficiencies
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FHA IOC’s for 1 Year
SITE – Hub Site in Red
BH
210
RCH
249
ERH
37
RMH
9
PAH
65
DH
12
ARH
CGH
SMH
LMH
8
Total IOCs (Apr ’08- Mar ’09)
104
46
220
66
Total FHA IOC Cases
1018
Travel IOC Cases
235
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Project Goals
 Evaluate the use of digital imaging
technology as part of the Intraoperative
Consultation process
 Evaluate the potential transition of the
technical duties from the pathologist to
a qualified Histotechnologist.
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Potential Telepathology Application
Anatomic pathology
Frozen Sections
Hematology
Microbiology
Anatomic Pathology
Consultation
Conferencing
Teaching
Archiving
Diagnostics
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Project Background
 Funded:
 Provincial Laboratory Coordinating Office
(PLCO)
 Canada Health Infoway (CHI)
 FHA
 Phase 1 – 2005 to 2007
 Technology review
 Business case (Project Budget)
 RFP for equipment and software
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Building the Team:
Preparing for RFP
LIS Manager
IT Input
 Financial aspects
 IT Liaison
 IT Manager
 Hardware Specialist
 Privacy & Security
Specialist
 Technical Architect
 Business Case Specialist
AP Lab Scientist
 Technical requirements
 Work flow
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IM/IT
Pathology
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Admin
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IM/IT: Project Needs
1.
2.
3.
4.
5.
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Image Quality & Workflow
Hardware & Software Evaluation
Compatibility with Enterprise
Business Case & RFP Development
Provincial Advisory Group &
Standards Group
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IM/IT: Enterprise Needs
1. Streaming Impact
2. Storage Impact – integrate with PACS
3. Server Requirements:


Standard
Compatible with FHA desktop
4. Compatible with “Live Meeting” &
“Communicator”
5. Security & Privacy Impact
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IM/IT: Specifics Tasks
 Hardware & Software Evaluations:





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Standards
Security
Impact on network
Authentication compatibility
Scaleable across our enterprise
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Phase 2a Focus
Image Quality
 WSI
 Streaming
 Still
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Project
AP IOC: RCH
Single Site Deployment
 Largest FS volume
 Proximity to OR
 Proximity to path lead & team
 Tech training: enroll all Pathologists
Hem & Micro: RCH
Single Site Deployment
 Evaluate all imaging modalities
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Building the Team
Technical Coordinator
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Histopathology skills
IT skills
Project experience
Motivated
Interpersonal skills
Enthusiasm for concept
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Phase 2a
August 2007 to April 2008
 Evaluation of digital imaging for Intraoperative
Consultations (IOC) at RCH




Technology – hardware, software, and network
Role of Technical Coordinator
Collection of IOC metrics
Development of operating and training documents
 Enhancements
 Initial review by Hematology and Medical Microbiology
 ? expansion to other FHA sites / users
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Frozen Section Room in the OR
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ELMO & Microscope Set up
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Whole Slide Scans
 Slide scanner:
Aperio
 Image management
software: Apollo
PathPACs
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Streaming Image
 Live video
 Gross (macro)
image presenter
 Microscope camera
 Capture FOV
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Action on the gross table…
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Assessing the margins…
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Correlation of TP to IOC and Final
Diagnosis
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54 Cases Total
TP vs. IOC
TP vs. Final
IOC vs. Final
Agree
35 (65%)
37 (69%)
49 (91%)
Minor
Disagreement
17 (31%)
14 (26%)
4 (7%)
Major
Disagreement
2 (4%)
3 (5%)
1 (2%)
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Image Quality vs. Concordance level
(for TP vs. IOC)
Image Score
Concordance
Level
Agree
Minor
Major
Totals
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1=Unacceptable,
2=Below Average,
3=Acceptable,
4=Exceeds expectations
1
1
1
2
Image Score
2
3
10
23
8
8
1
19
31
Totals
4
2
2
35
17
2
54/54
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Image Quality Score of Less Than 3
Out of 54 cases, 21 cases had image score <3
Agree
Image
Score of
<3
(Below average or
Unacceptable.)
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10 / 35
29%
Minor
Major
Disagreement Disagreement
9 / 17
53%
2/2
100%
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IOC Case Mix
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Tissue type
Raw count of cases
Percent of total cases
Neuropathology
26
48%
Cardio / Thoracic
10
19%
Gastrointestinal
8
15%
Gynecology
7
13%
Other
3
5%
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Case Type for Major and Minor
Disagreement
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Tissue type
MINOR
Disagreement
MAJOR
Disagreement
Neuropathology
5
-
Cardio / Thoracic
3
1
Gastrointestinal
1
-
Gynecology
6
1
Other
2
-
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Phase 2a Findings
 Concordance of WSI to glass was promising
 Technical issues identified:








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Stain consistency
Section consistency
Resolution / 1st time capture
Image magnification
TC role - skilled histotechnologist is essential
Time to acquire image
Storage capacity
Remote grossing appeared advantageous
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Conclusions
We are unable to recommend at this time
implementation of this technology for
provision of routine frozen sections
during intraoperative consultations.
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Future Plans
 Deploy software to all surgical
pathologists at RCH & select users at
other sites
 On-going evaluation of H&E staining
 Incorporate 40X images routinely
 Use of WSI for AP rounds
 Heme & Micro expanded evaluations
 Assess PathPACs and LIS integration
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Phase 2b Goals
Anatomic Pathology
 IOC’s:
 Expand WSI correlations to
 3 pathologists
 200+ cases
 TC role: encourage greater use of skills by Paths
 Encourage use of remote grossing & WSI viewing
during an IOC
 Evaluate off site remote grossing
 WSI for all AP rounds
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Phase 2b Goals
Heme & Micro
 Deploy to multiple sites
 Evaluate role for
 consultations
 teaching
 conferencing/rounds
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Equipment Deployment
Site
Scanner
Streaming
Camera
Still
Camera
Digital
Presenter
Apollo
software
Trained
users
RCH
2
5
8
2
33
28
7
2
1
14
8
5
2
1
3
3
2
1
1
ARHCC
BH
DH
1
LMH
1
PAH
1
SMH
1
RMH
FHA Total
39
3
1
2
2
1
12
10
1
1
1
2
4
18
14
5
71
58
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TP vs IOC & TP vs Final
TP vs IOC
Percent of
Total
555
91.6%
558
92.1%
Minor
Disagreement
41
6.8%
30
5%
Disagreement
5
0.8%
11
1.8%
Major
Disagreement
5
0.8%
7
1.2%
Agree
Total
40
606
TP vs Final Percent of
Total
606
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Review Pathologist Discordance Rate
Pathologist #1
Pathologist #2
Pathologist #3
Percent Minor
Disagreement
5%
7%
9%
Percent
Disagreement
0%
0%
1%
Percent Major
Disagreement
1%
1%
0%
6%
8%
10%
Total
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Raw Case Mix Numbers
Patient Case Mix Types
Total
Percent of Total
Cardiac/Thoracic
Endocrine
Gastrointestinal
Gynecology
Lymph Node
Neuropathology
Other
13
22
9
23
5
132
5
17
226
6%
10%
4%
10%
2%
58%
2%
8%
Pancreatic/Hepatobilliary
Total
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Case Mix/Concordance Discordance
Patient
Case Mix
Types
Major
Total of
% of
Disagreement
Discordance
Discordance
0
0
1
2%
2
1
0
3
6%
4%
1
0
0
1
2%
Gynecology
10%
8
1
2
11
22%
Lymph Node
2%
1
0
1
2
4%
58%
23
2
0
25
49%
Other
2%
0
0
0
0
0%
Pancreatic/Hepato
billiary
8%
5
1
2
8
16%
Cardiac/Thoracic
Endocrine
Gastrointestinal
Neuropathology
43
Concordance
% of
Case
Mix
Minor
Disagreement
6%
1
10%
Disagreement
43
Image Quality as related to TP & IOC
Concordance Level
Image Quality Score
Concordance
Level
44
Total
1
2
3
4
Unaccept
able
Below
Average
Acceptable
Exceeds
Requirements
Agreement
-
32
386
137
555
Minor
Disagreement
-
4
22
15
41
Disagreement
-
1
4
-
5
Major
Disagreement
-
1
4
-
5
Total
-
38
416
152
606
44
Image Quality of Less than Three(3)
Concordance
Level
45
Image Quality Score of less than 3
Total Cases
Cases with
Image score
of< 3
Percent of Total
Agreement
555
32
6%
Minor
Disagreement
41
4
10%
Disagreement
5
1
20%
Major
Disagreement
5
1
20%
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AP Conclusions
 Diagnostic Accuracy WSI
 Acceptable
 Image Quality
 Acceptable
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AP Conclusions
 Software:
 Well acceptable
 Minimal training
 Easy to operate
 Well Trained Technical Coordinator
Essential
 Technical quality
 Hardware/software expertise
 Time efficiency
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AP Conculsions
 Remote Gross Specimen Viewing
 Well accepted
 Time efficient
 Education & QA Rounds
 Enhanced plus
 Continue & expand
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Evaluation
Forms
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Hematopathology
1. Case Review Rounds (6 pathologists at 3
sites)
2. Pathologist to Pathologist Consultations
3. Tech to Tech Consultations
4. Educational Rounds
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Heme: Modalities Trialed
 WSI up to 83X oil
 Streaming – dry + oil
 Static: still camera
FOV from streaming
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Heme: Conclusions
1. All modalities unacceptable at this
time for definitive diagnosis
2. Streaming images – images of choice
3. WSI not useful at this time
4. Static images less useful, less flexible
5. Will not currently replace existing
rounds system
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Microbiology
1. Case Review Rounds
2. Pathologist to Pathologist Consultations
3. Educational Rounds
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Micro: Modalities Trialed
1. WSI up to 83X oil
2. Streaming: gross with Elmo
micro to 100X oil
3. Static: still camera
FOV from streaming
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Micro: Conclusions
1. Major role at this time - Educational Rounds
& Documentation
2. Images by all modalities are not yet
adequate for diagnostic uses
3. Imaging not yet adequate to incorporate
into routine use
4. Static image capture: still camera best
5. WSI: good for general impression of
specimen quality and general morphology
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Microbiology ELMO Images
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Medical Microbiology
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Medical Microbiology
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Conclusions
1.
2.
3.
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WSI provides images that satisfy most diagnostic
purposes in AP
WSI does not yet provide images suitable for
diagnostic purposes in routine hematology and
microbiology
WSI - an immature technology not yet suitable for
routine surgical pathology in a practice setting like
ours
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Conclusions
1.
2.
3.
WSI provides images that satisfy most diagnostic
purposes in AP
WSI does not yet provide images suitable for
diagnostic purposes in routine hematology and
microbiology
WSI - an immature technology not yet suitable for
routine surgical pathology in a practice setting like
ours
Issues: Speed
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Conclusions
1.
2.
3.
WSI provides images that satisfy most diagnostic
purposes in AP
WSI does not yet provide images suitable for diagnostic
purposes in routine hematology and microbiology
WSI - an immature technology not yet suitable for
routine surgical pathology in a practice setting like ours
Issues: Speed
Storage
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Conclusions
1.
2.
3.
WSI provides images that satisfy most diagnostic
purposes in AP
WSI does not yet provide images suitable for diagnostic
purposes in routine hematology and microbiology
WSI - an immature technology not yet suitable for
routine surgical pathology in a practice setting like ours
Issues: Speed
Storage
Work Flow
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Couldn’t you have
just handed me the
slides?
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Conclusions
1.
2.
3.
WSI provides images that satisfy most diagnostic
purposes in AP
WSI does not yet provide images suitable for diagnostic
purposes in routine hematology and microbiology
WSI - an immature technology not yet suitable for
routine surgical pathology in a practice setting like ours
Issues: Speed
Storage
Work Flow
Redundancy
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Conclusions
1.
2.
3.
WSI provides images that satisfy most diagnostic
purposes in AP
WSI does not yet provide images suitable for diagnostic
purposes in routine hematology and microbiology
WSI - an immature technology not yet suitable for
routine surgical pathology in a practice setting like ours
Issues: Speed
Storage
Work Flow
Redundancy
Cost
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Conclusions
1.
2.
3.
4.
5.
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WSI provides images that satisfy most diagnostic
purposes in AP
WSI does not yet provide images suitable for diagnostic
purposes in routine hematology and microbiology
WSI - an immature technology not yet suitable for
routine surgical pathology in a practice setting like ours
Issues: - Speed
- Work Flow
- Storage - Redundancy
- Cost
WSI is suitable for diagnostic purposes in certain niche
applications
Telepathology in general, using streaming gross &
microscopic images has a broad range of applications
for routine uses that are cost effective and efficient
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The Promise of Digital Pathology








74
Diagnostics
Consultations
Conferencing
Teaching
Quality Assurance
Archiving
Image Analysis
Efficiencies
74
The Promise of Digital Pathology
Tomorrow
 Diagnostics
 Anatomic Pathology




Intraoperative Consultations at RCH
Trial scanning of daily pathology workload
Capture of gross room specimen images
Surgical Pathology off site gross images
 Consultations
 AP
 WSI and Streaming
 Hematopathology
 Streaming images between Hematopathologists
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The Promise of Digital Pathology
Tomorrow
 Conferencing
 Anatomic Pathology




Weekly surgical pathology conference
Breast conference
Combined gastrointestinal / surgical pathology conference
Regional AP conference ( Web access or Live Meeting)
 Hematopathology
 Multi site conference
 Teaching / Education
 Hematopathology and Medical Microbiology
 Teaching archive
 Anatomic Pathology
 Teaching archive – Residents, laboratory staff, laboratory students
 Quality Assurance
 Anatomic Pathology
 Internal technical QA review
 Breast Receptor
 Immunohistochemistry
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The Promise of Digital Pathology
Tomorrow
 Archiving
 Medical Microbiology
 Images for procedure / documentation
 Image Analysis
 Immunohistochemistry – Prognostic markers
 Efficiencies
 All departments
 Interface to laboratory Information System
 Anatomic Pathology
 Frozen section gross completed from office
 Surgical pathology scanned images available to view by off site
pathologist
 Hematopathology
 Multisite pathologist consultations
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THE
END
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