Pathology Visions 2010

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Pathology Visions 2010

Regional Telepathology in Fraser Health Authority:

A multisite, multimodality, multidiscipline deployment.

Dr. I. Scott CornellMedical Lead, FHA

Telepathology Project

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Project Team

Sponsor: Minnie DowneyIT: David Izzard

Gagan AtwalTechnical Coordinator: James OwenLab Scientists: Janet Tunnicliffe – Anatomic Path

Val Horak – Hematology

Kulvinder Mannan – Microbiology

Physicians: Scott Cornell – AP & Medical Lead

Lawrence Haley - Hematology

Dale Purych - Microbiology

Project Manager: 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 AuthorityLocation

FHA

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Map of Fraser Health Authority

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

Surgical Pathology Total Accessions 92,000

11,500

24,000

37,000

19,500

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The Promise of Digital Pathology

Diagnostics Consultations Conferencing Teaching Quality Assurance Archiving Image Analysis Efficiencies

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FHA IOC’s for 1 YearSITE – Hub Site in Red

Total IOCs (Apr ’08- Mar ’09)

BH 210

RCH 249

ERH 37

RMH 9

PAH 65

DH 12

ARH 104

CGH 46

SMH 220

LMH 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

HematologyMicrobiology

Anatomic Pathology

Consultation

Teaching

Archiving

Conferencing

Diagnostics

Anatomic pathology

Frozen Sections

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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 Financial aspects IT Liaison

AP Lab Scientist Technical

requirements Work flow

IT Input IT Manager Hardware Specialist Privacy & Security

Specialist Technical Architect Business Case

Specialist

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IM/IT

Pathology Admin

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IM/IT: Project Needs

1. Image Quality & Workflow2. Hardware & Software Evaluation3. Compatibility with Enterprise4. Business Case & RFP

Development5. Provincial Advisory Group &

Standards Group

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IM/IT: Enterprise Needs

1. Streaming Impact2. Storage Impact – integrate with PACS3. 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: 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: RCHSingle Site Deployment

Largest FS volume Proximity to OR Proximity to path lead & team Tech training: enroll all Pathologists

Hem & Micro: RCHSingle Site Deployment

Evaluate all imaging modalities

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Building the Team

Technical Coordinator 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

54 Cases Total

TP vs. IOC TP vs. Final IOC vs. Final

Agree 35 (65%) 37 (69%) 49 (91%)

Minor Disagreemen

t

17 (31%) 14 (26%) 4 (7%)

Major Disagreemen

t

2 (4%) 3 (5%) 1 (2%)

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Image Quality vs. Concordance level

(for TP vs. IOC)Image Score 1=Unacceptable,

2=Below Average, 3=Acceptable,

4=Exceeds expectations

Concordance Level

Image Score Totals

1 2 3 4

Agree - 10 23 2 35

Minor 1 8 8 - 17

Major 1 1 - - 2

Totals 2 19 31 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 Minor Disagreeme

nt

Major Disagreeme

nt

Image Score of

<3(Below average

orUnacceptable.)

10 / 3529%

9 / 1753%

2 / 2100%

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IOC Case Mix

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

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:

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 ScannerStreaming Camera

Still Camera

Digital Presente

r

Apollo software

Trained users

RCH 2 5 8 2 33 28

ARHCC 7 2 1 14 8

BH 5 2

DH 1 1 3

LMH 1 1 3 2

PAH 1 1 1

SMH 1 2 2 1 12 10

RMH 1 1 1 2 4

FHA Total

3 18 14 5 71 58

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TP vs IOC & TP vs Final

TP vs IOC Percent of Total

TP vs Final

Percent of Total

Agree 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%

Total 606 606

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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%

Total 6% 8% 10%

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Raw Case Mix NumbersPatient Case Mix Types Total Percent of Total

Cardiac/Thoracic 13 6%

Endocrine 22 10%

Gastrointestinal 9 4%

Gynecology 23 10%

Lymph Node 5 2%

Neuropathology 132 58%

Other 5 2%Pancreatic/Hepatobilliary

17 8%

Total 226

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Case Mix/Concordance Discordance

Patient Case Mix Types

Concordance% of Case Mix

Minor Disagreemen

t

Disagreement

Major Disagreemen

t

Total of Discordance

% of Discordance

Cardiac/Thoracic

6% 1 0 0 1 2%

Endocrine 10% 2 1 0 3 6%Gastrointestinal 4% 1 0 0 1 2%Gynecology 10% 8 1 2 11 22%Lymph Node 2% 1 0 1 2 4%Neuropathology 58% 23 2 0 25 49%Other 2% 0 0 0 0 0%Pancreatic/Hepatobilliary

8% 5 1 2 8 16%

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Image Quality as related to TP & IOC Concordance Level

Concordance Level

Image Quality ScoreTotal1 2 3 4

Unacceptable

Below Averag

e

Acceptable Exceeds Requirement

s

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

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Image Quality of Less than Three(3)

Concordance Level

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 Consultations4. 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 time4. Static images less useful, less

flexible5. Will not currently replace existing

rounds system

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Microbiology

1. Case Review Rounds2. Pathologist to Pathologist

Consultations3. Educational Rounds

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Micro: Modalities Trialed

1. WSI up to 83X oil2. Streaming: gross with Elmo

micro to 100X oil3. 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 best5. 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. WSI provides images that satisfy most diagnostic purposes in AP

2. WSI does not yet provide images suitable for diagnostic purposes in routine hematology and microbiology

3. WSI - an immature technology not yet suitable for routine surgical pathology in a practice setting like ours

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Conclusions




Issues: Speed

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Conclusions




Issues: SpeedStorage

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Conclusions




Issues: SpeedStorageWork Flow

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Couldn’t you have just handed me the

slides?

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Conclusions




Issues: SpeedStorageWork FlowRedundancy

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Conclusions




Issues: SpeedStorageWork FlowRedundancyCost

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Conclusions




Issues: - Speed - Work Flow- Storage - Redundancy- Cost

4. WSI is suitable for diagnostic purposes in certain niche applications

5. 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

Diagnostics Consultations Conferencing Teaching Quality Assurance Archiving Image Analysis Efficiencies

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The Promise of Digital PathologyTomorrow

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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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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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

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Documents

Pathology Visions 2010