Gail P. Barker

Overview of telepathology, virtual microscopy, and whole slide imaging: prospects for the future ☆

Telepathology, the practice of pathology at a long distance, has advanced continuously since 1986. Today, fourth-generation telepathology systems, so-called virtual slide telepathology systems, are being used for education applications. Both conventional and innovative surgical pathology diagnostic services are being designed and implemented as well. The technology has been commercialized by more than 30 companies in Asia, the United States, and Europe. Early adopters of telepathology have been laboratories with special challenges in providing anatomic pathology services, ranging from the need to provide anatomic pathology services at great distances to the use of the technology to increase efficiency of services between hospitals less than a mile apart. As to what often happens in medicine, early adopters of new technologies are professionals who create model programs that are successful and then stimulate the creation of infrastructure (ie, reimbursement, telecommunications, information technologies, and so on) that forms the platforms for entry of later, mainstream, adopters. The trend at medical schools, in the United States, is to go entirely digital for their pathology courses, discarding their student light microscopes, and building virtual slide laboratories. This may create a generation of pathology trainees who prefer digital pathology imaging over the traditional hands-on light microscopy. The creation of standards for virtual slide telepathology is early in its development but accelerating. The field of telepathology has now reached a tipping point at which major corporations now investing in the technology will insist that standards be created for pathology digital imaging as a value added business proposition. A key to success in teleradiology, already a growth industry, has been the implementation of standards for digital radiology imaging. Telepathology is already the enabling technology for new, innovative laboratory services. Examples include STAT QA surgical pathology second opinions at a distance and a telehealth-enabled rapid breast care service. The innovative bundling of telemammography, telepathology, and teleoncology services may represent a new paradigm in breast care that helps address the serious issue of fragmentation of breast cancer care in the United States and elsewhere. Legal and regulatory issues in telepathology are being addressed and are regarded as a potential catalyst for the next wave of telepathology advances, applications, and implementations.

Virtual slide telepathology enables an innovative telehealth rapid breast care clinic

An innovative telemedicine-enabled rapid breast care service is described that bundles telemammography, telepathology, and teleoncology services into a single day process. The service is called the UltraClinics Process. Because the core services are at 4 different physical locations, a challenge has been to obtain stat second opinion readouts on newly diagnosed breast cancer cases. To provide same day quality assurance rereview of breast surgical pathology cases, a DMetrix DX-40 ultrarapid virtual slide scanner (DMetrix Inc, Tucson, AZ) was installed at the participating laboratory. Glass slides of breast cancer and breast hyperplasia cases were scanned the same day the slides were produced by the University Physicians Healthcare Hospital histology laboratory. Virtual slide telepathology was used for stat quality assurance readouts at University Medical Center, 6 miles away. There was complete concurrence with the primary diagnosis in 139 (90.3%) of cases. There were 4 (2.3%) major discrepancies, which would have resulted in a different therapy and 3 (1.9%) minor discrepancies. Three cases (1.9%) were deferred for immunohistochemistry. In 2 cases (1.3%), the case was deferred for examination of the glass slides by the reviewing pathologists at University Medical Center. We conclude that the virtual slide telepathology quality assurance program found a small number of significant diagnostic discrepancies. The virtual slide telepathology program service increased the job satisfaction of subspecialty pathologists without special training in breast pathology, assigned to cover the general surgical pathology service at a small satellite university hospital.

Virtual slide telepathology for an academic teaching hospital surgical pathology quality assurance program.

Virtual slide telepathology is an important potential tool for providing re-review of surgical pathology cases as part of a quality assurance program. The University of Arizona pathology faculty has implemented a quality assurance program between 2 university hospitals located 6 miles apart. The flagship hospital, University Medical Center (UMC), in Tucson, AZ, handles approximately 20 000 surgical pathology specimens per year. University Physicians Healthcare Hospital (UPHH) at Kino Campus has one tenth the volume of surgical pathology cases. Whereas UMC is staffed by 10 surgical pathologists, UPHH is staffed daily by a single part-time pathologist on a rotating basis. To provide same-day quality assurance re-reviews of cases, a DMetrix DX-40 ultrarapid virtual slide scanner (DMetrix, Inc, Tucson, AZ) was installed at the UPHH in 2005. Since then, glass slides of new cases of cancer and other difficult cases have been scanned the same day the slides are produced by the UPHH histology laboratory. The pathologist at UPHH generates a provisional written report based on light microscopic examination of the glass slides. At 2:00 pm each day, completed cases from UPHH are re-reviewed by staff pathologists, pathology residents, and medical students at the UMC using the DMetrix Iris virtual slide viewer. The virtual slides are viewed on a 50-in plasma monitor. Results are communicated with the UPHH laboratory by fax. We have analyzed the results of the first 329 consecutive quality assurance cases. There was complete concordance with the original UPHH diagnosis in 302 (91.8%) cases. There were 5 (1.5%) major discrepancies, which would have resulted in different therapy and/or management, and 10 (3.0%) minor discrepancies. In 6 cases (1.8%), the diagnosis was deferred for examination of the glass slides by the reviewing pathologists at UMC, and the diagnosis of another 6 (1.8%) cases were deferred pending additional testing, usually immunohistochemistry. Thus, the quality assurance program found a small number of significant diagnostic discrepancies. We also found that implementation of a virtual slide telepathology quality assurance service improved the job satisfaction of academic subspecialty pathologists assigned to cover on-site surgical pathology services at a small, affiliated university hospital on a rotating part-time basis. These findings should be applicable to some community hospital group practices as well.

Telemedicine versus in-person dermatology referrals: an analysis of case complexity.

The goal of this study was to determine whether teledermatology referrals differ significantly from in-person referrals with respect to case complexity and diagnosis of cases referred. Teledermatology cases were compared to in-person cases seen by the same university dermatologist who also reviews the teledermatology cases. These were also compared with in-person cases evaluated by a different dermatologist at local clinics using traditional referral patterns. Study parameters included Current Procedural Terminology (CPT) codes as a measure of case complexity, International Classification of Disease (ICD) codes as a measure of case types, and time from referral to actual consultation. The most common CPT codes used for teledermatology were 99241 and 99242 with no significant differences in the frequency of assigned CPT codes for teledermatology versus in-person consultation. An analysis of the diagnostic codes revealed no significant differences between the types of cases referred to telemedicine and those referred for in-person consultation. Time between referral and actual encounter with the dermatologist was significantly shorter via telemedicine than either local or university clinic in-person visits.

The innovative bundling of teleradiology, telepathology, and teleoncology services

Teleradiolosy, telepathology, and teleoncology are important applications of telemedicine. Recent advances in these fields include a preponderance of radiology PACS (Picture Archiving and Communications System) users, the implementation of around-the-clock teleradiology services at many hospitals, and the invention of the first ultrarapid whole-slide digital scanner based on the array microscope. These advances have led to the development of a new health-care-delivery clinical pathway called the ultrarapid breast care process (URBC), which has been commercialized as the UltraClinics® process. This process bundles telemammography, telepathology, and teleoncology services and has reduced the time it takes for a woman to obtain diagnostic and therapeutic breast-care planning services from several weeks to a single day. This paper describes the UltraClinics process in detail and presents the vision of a network of same-day telemedicine-enabled UltraClinics facilities, staffed by a virtual group practice of teleradiologists, telepathologists, and teleoncologists.

The challenges of following patients and assessing outcomes in teledermatology.

We retrospectively reviewed the follow-up and outcomes of 50 store-and-forward teledermatology patients, and compared the findings with those from a control group of 50 patients who had been seen in person. Patient records were examined for a six-month period following the initial referral to a dermatologist. Variables examined included medical records from the referral, evidence of actions taken (e.g. biopsy), evidence of follow-up visits, and what (if any) clinical outcomes were noted. There were few differences between the teledermatology and in-person groups. The main difference was whether there was any report in the record that the referring clinician took some action based on the consultation with the specialist: there were more reports of action being taken in the teledermatology group than in the in-person group. Reports of outcomes were found in only 6% and 8% of the records of the teledermatology and in-person groups, respectively. The challenges of assessing outcomes in teledermatology for rural patients include patient loss to follow-up, lack of information in the patient records and low rates of patient return to the referring clinician for follow-up.

An analysis of unsuccessful teleconsultations

Over six years, 4317 teleconsultations were scheduled in the Arizona Telemedicine Program. A total of 402 scheduled teleconsultations (9.3%) did not take place. A review showed that 254 were cancelled but eventually took place (5.9%), while 148 never took place (3.4%). The cost of a teleconsultation to the service provider was, at minimum, US

Flexner 3.0—Democratization of Medical Knowledge for the 21st Century Teaching Medical Science Using K-12 General Pathology as a Gateway Course

228. Telepsychiatry accounted for all the missed consultations that eventually took place, and 92% of these were from three of the six sites referring telepsychiatry patients. Pain management (23%) and psychiatry (21%) accounted for the largest proportions of teleconsultations that never took place. Telepsychiatry cases accounted for 71% of all unsuccessful consultations and accounted for only 34% of successful teleconsultations during the same period. Most missed teleconsultations had been scheduled as realtime sessions (84%). The most common reason for unsuccessful teleconsultations was that the patient did not attend (26%), followed by the patient having to be seen in person (17%). Although all referring sites had unsuccessful cases, certain sites accounted for more than others. These were sites that scheduled more telepsychiatry consultations than the others. The proportion of unsuccessful cases per site ranged from 4% to 17% of the total number of scheduled teleconsultations.

Fluctuations in service loads in an established telemedicine program.

A medical school general pathology course has been reformatted into a K-12 general pathology course. This new course has been implemented at a series of 7 to 12 grade levels and the student outcomes compared. Typically, topics covered mirrored those in a medical school general pathology course serving as an introduction to the mechanisms of diseases. Assessment of student performance was based on their score on a multiple-choice final examination modeled after an examination given to medical students. Two Tucson area schools, in a charter school network, participated in the study. Statistical analysis of examination performances showed that there were no significant differences as a function of school (F = 0.258, P = .6128), with students at school A having an average test scores of 87.03 (standard deviation = 8.99) and school B 86.00 (standard deviation = 8.18; F = 0.258, P = .6128). Analysis of variance was also conducted on the test scores as a function of gender and class grade. There were no significant differences as a function of gender (F = 0.608, P = .4382), with females having an average score of 87.18 (standard deviation = 7.24) and males 85.61 (standard deviation = 9.85). There were also no significant differences as a function of grade level (F = 0.627, P = .6003), with 7th graders having an average of 85.10 (standard deviation = 8.90), 8th graders 86.00 (standard deviation = 9.95), 9th graders 89.67 (standard deviation = 5.52), and 12th graders 86.90 (standard deviation = 7.52). The results demonstrated that middle and upper school students performed equally well in K-12 general pathology. Student course evaluations showed that the course met the student’s expectations. One class voted K-12 general pathology their “elective course-of-the-year.”

Fluctuations in Telemedicine Case Volume: Correlation with Personnel Turnover Rates

The goal of this investigation was to determine if there were identifiable patterns in the volume and types of teleconsults provided by an established telemedicine program over an extended period of time. Data from over 3 years of providing telemedicine consults within a university-based telemedicine programs were analyzed to identify trends and points of significant change in service provision. Teleconsult volume over a 40-month period was best fit by a logarithmic transformation of the regression curve that is characteristic of slow but steady growth. Consults have been provided in 53 subspecialties, with an average of 12 different subspecialties each month. Number of subspecialties per month was best fit by a sixth-order polynomial. Teleconsult volume has varied on a monthly basis, but overall volume has increased over time. This program has maintained its initial goal of being a multispecialty provider. Analyzing telemedicine consult data over extended periods of time is especially useful for long-term program evaluation and development of a successful business plan.