Digital Imaging in Education andDistributed Pathology Practice

Elizabeth H Hammond MDElizabeth H Hammond MD

Professor of PathologyProfessor of Pathology

University of Utah and Intermountain University of Utah and Intermountain HealthcareHealthcare

Executive Editor for PathologyExecutive Editor for Pathology

Amirsys, Inc.Amirsys, Inc.

Is Digital Imaging Critical or

Is it Just a New Toy?

Value in Pathologist EducationValue in Pathologist Education

Value in Pathology PracticeValue in Pathology Practice

Pathology Education Deficiencies

Teaching methods limited in teaching Teaching methods limited in teaching certain disciplines and skillscertain disciplines and skills Some skills cannot be taught by current Some skills cannot be taught by current

methodsmethods Some skills not examined by self Some skills not examined by self

assessment, a requirement of MOC.assessment, a requirement of MOC. Pathologists accessibility requires better Pathologists accessibility requires better

electronic toolselectronic tools

Skills Required in Diagnostic Pathology

SearchingSearching IdentificationIdentification ClassificationClassification Comparison with previous experience by Comparison with previous experience by

observerobserver

Searching Skill SearchingSearching

Finding areas of interestFinding areas of interest Skill developed by experienceSkill developed by experience Strategies are not taught but are learnedStrategies are not taught but are learned

Time to diagnosis less for skilled versus Time to diagnosis less for skilled versus unskilled observersunskilled observers

Can be detected by evaluating and Can be detected by evaluating and comparing eye movements of novices and comparing eye movements of novices and expertsexperts

Not taught or glossed over because of limits of Not taught or glossed over because of limits of timetime

Whole Slide Imaging is Highly Valuable in Searching Static images are often poor at low Static images are often poor at low

magnification where searching occurs.magnification where searching occurs. Since static images include the lesion, the Since static images include the lesion, the

searching skill is bypassed.searching skill is bypassed. Observation of skillful observer by a novice Observation of skillful observer by a novice

promotes learning of searching skills promotes learning of searching skills

Whole Slide Image

Heart Transplant Biopsy

Identification Skill

Skills needed to identify areas of interest Skills needed to identify areas of interest using low power visual cluesusing low power visual clues

Visual clues may not be obvious without Visual clues may not be obvious without trainingtraining Areas on IHC exam to select for HER2 Areas on IHC exam to select for HER2

FISHFISH Vascular lesions in transplant biopsiesVascular lesions in transplant biopsies Areas of lobular carcinoma in breastAreas of lobular carcinoma in breast

Value in Identification

Skilled observer can be instructed to define Skilled observer can be instructed to define in words how the identification occurs in words how the identification occurs while the less skilled observer is watchingwhile the less skilled observer is watching

Areas of confusion or misidentification can Areas of confusion or misidentification can be carefully reviewed and discussedbe carefully reviewed and discussed

Artifacts can be definedArtifacts can be defined Limited preselected images do not fill this Limited preselected images do not fill this

needneed

Whole Slide Image HER2 Stained Slide

Classification Skill

Ability to compare test object with correctly Ability to compare test object with correctly classified objects reproduciblyclassified objects reproducibly

Can be combined with identification skill in Can be combined with identification skill in learninglearning

Requires many high quality images of Requires many high quality images of variously classified objectsvariously classified objects

Value in Classification

Combination of identification and Combination of identification and classification skills is enabledclassification skills is enabled

Based on interaction with learners, various Based on interaction with learners, various classification clues can be focused onclassification clues can be focused on

Quality of static imaging is improved for Quality of static imaging is improved for documentation or teachingdocumentation or teaching

Number of images that can be easily Number of images that can be easily obtained is high.obtained is high.

Whole Slide Image HER2 Stained Slide

How Can Such New Technology Be Deployed Effectively? Video microscopy sessions at meetingsVideo microscopy sessions at meetings

Use unknowns to enhance conversationUse unknowns to enhance conversation Describe process while doing itDescribe process while doing it

Webcasts with other members of Webcasts with other members of department as intradepartmental consultsdepartment as intradepartmental consults

Sessions with resident and staff at time of Sessions with resident and staff at time of diagnosis.diagnosis.

Accessibility

Digital Imaging allows pathologist to Digital Imaging allows pathologist to practice skillspractice skills Any placeAny place Any time Any time

Method can be incorporated for self Method can be incorporated for self assessment to help pathologist define their assessment to help pathologist define their areas of deficiencyareas of deficiency

Whole Slide Image

Heart Transplant Biopsy

Distributed Practice Issues

Consistent interpretationConsistent interpretation required because required because Intermountain is a quality healthcare Intermountain is a quality healthcare systemsystem

Variable skill and knowledge by group Variable skill and knowledge by group membersmembers

Variable availability of expert resourcesVariable availability of expert resources Occasional manpower issuesOccasional manpower issues Wide geographic separationWide geographic separation

Practice Demographics

5 pathology groups5 pathology groups Distributed over 450 milesDistributed over 450 miles Group sizes:Group sizes:

17: most specialties (4 hospitals)17: most specialties (4 hospitals) 4: Dermpath, Hematopath (2 hospitals)4: Dermpath, Hematopath (2 hospitals) 3 (x2): Hematopath 3 (x2): Hematopath 2: None2: None

Process

Pathology groups are separate entitiesPathology groups are separate entities Intermittent consultationIntermittent consultation Sharing of expert resources for technical Sharing of expert resources for technical

functions and some professional functions and some professional functionsfunctions

Sharing during manpower shortagesSharing during manpower shortages Communication via phone and courierCommunication via phone and courier Collegial environmentCollegial environment

Potential Utilities of Whole Slide Microscopy Intragroup consultation of specialistsIntragroup consultation of specialists Intergroup consultation between sites and for double Intergroup consultation between sites and for double

read situationsread situations Intergroup consultation for frozen sectionsIntergroup consultation for frozen sections Professional sign out of immunohistochemistry with Professional sign out of immunohistochemistry with

or without expert consultationor without expert consultation Tumor board presentations to cliniciansTumor board presentations to clinicians Education sessions to improve consistency of Education sessions to improve consistency of

interpretation and speed of integration on new interpretation and speed of integration on new membersmembers

Specialty Consultations

Faster turn around time because couriers Faster turn around time because couriers not involvednot involved

More common consultation because of More common consultation because of increased availabilityincreased availability

Opportunity for learning of others because Opportunity for learning of others because of multiple viewing optionsof multiple viewing options

Intragroup Consultation

Requirement for double reading in many Requirement for double reading in many casescases New diagnosis of cancerNew diagnosis of cancer Prostate needle biopsiesProstate needle biopsies Difficult cases which might benefit from Difficult cases which might benefit from

consultationconsultation Difficult with multisite groups so that Difficult with multisite groups so that

appropriate second reader might not be usedappropriate second reader might not be used

Frozen Section Consultation

Difficult frozens benefit from second Difficult frozens benefit from second opinionsopinions

If no other pathologist on site, this is not If no other pathologist on site, this is not utilizedutilized

Diagnoses could be improved by having Diagnoses could be improved by having this capacity at each hospitalthis capacity at each hospital

Sign Out of IHC

Currently, all IHC done in three sites and slides Currently, all IHC done in three sites and slides shipped to other sitesshipped to other sites Turn around time 24 hours for off site locationsTurn around time 24 hours for off site locations Could consolidate technical functions if virtual Could consolidate technical functions if virtual

microscopy was availablemicroscopy was available No option for dual viewing in difficult casesNo option for dual viewing in difficult cases No option to educate new members of group No option to educate new members of group

Tumor Boards And Clinical Conferences One or two each day in largest groupOne or two each day in largest group Slides that need to be included may not be Slides that need to be included may not be

availableavailable Lost in pathologist officeLost in pathologist office Only at another hospitalOnly at another hospital In process of filingIn process of filing

Significant time required by pathologist to take Significant time required by pathologist to take required static images or drag photoscope to required static images or drag photoscope to conference roomconference room

Education of Group Pathologists

Intermountain operates by developing Intermountain operates by developing standards which are transmitted throughout standards which are transmitted throughout the system using data on provider behaviorthe system using data on provider behavior

Pathologists expected to be consistent and Pathologists expected to be consistent and complete in reports (data system)complete in reports (data system)

Education of pathologists required Education of pathologists required Nottingham ScoreNottingham Score HER2 scoringHER2 scoring

Summary

Digital imaging has great value in improving Digital imaging has great value in improving pathology educationpathology education Improving diagnostic skillsImproving diagnostic skills Improving accessibilityImproving accessibility

Digital imaging has great value in practiceDigital imaging has great value in practice Allowing flexibility in sign out and Allowing flexibility in sign out and

consultationconsultation Allowing distributed conference functionsAllowing distributed conference functions Decreasing courier related process delaysDecreasing courier related process delays