Presentation

Teleconferencing for Pathologists

Adam LandmanHeathcare Information Systems

February 24, 1999

2Teleconferencing for Pathologists

Outline

• Introduction to Pathology• Introduction to Telepathology• Major Software Vendors• Requirements• Evaluation• Recommendation


Introduction to Pathology

A u top sy P a tho lo gy S u rg ica l P a tho lo gy C ytop a tho lo gy

A n ato m ic P a th o lo gy

H e m ato lo gy M ic ro b io lo gy C yto g en e tics B lo od B a nk ing

C lin ica l P a th o lo gy


Surgical Pathology

• Diagnosis ~ 5 - 7 min, Turnaround < 15 min

• Large universities and hospitals provide this service on demand

• Frozen Section - small sections of tissue removed from a patient during surgery requiring diagnosis

• What about smaller or outlying hospitals?


What about smaller/outlying hospitals?

• “Travelling Salesman” -- rely on periodic visits from pathologists– Surgeries must be scheduled to coincide with visit

– What if pathologist is not present?

• Glass slides express mailed to remote laboratory– Patient may have to undergo second surgery after

diagnosis is available

•Neither solution is very efficient!


Introduction to Telepathology

• Telepathology - practice of pathology from a distance– viewing images on a video monitor rather than light microscope

– Images acquired by video camera mounted on light microscope

– Images transmitted over a telecommunications link to remote workstation for analysis by telepathologist

Location 2P atho logist's H om e or O ffice

Location 1R em ote Laboratory

F igure 1. T e lepathology R em ote M icroscope Setup

Nikon E1000 Robotic M icroscopeconnected to server

Personal Com puter(client workstation)

N etwork In frastructure

(ISDN, T1, Internet)

Referrin

g Pathologist Telepathologist


Telepathology System Types• What kinds of images are displayed?

• Who has control over selection of images?

FTP

VideoConferencing

DynamicRobotic

Slave Master

Static

Dynamic

Imag

es

Microscope Control


Static Dynamic (Slave) Dynamic (Master)Image system Still Live LiveMotorized microscope No Maybe YesRobotic remote control No No YesImages per average case 5 Unlimited UnlimitedSpecimen sampling Limited Limited by Referring

PathologistComprehensive

Image selection Referring Pathologist Referring Pathologist TelepathologistTransmission time/image 45 sec 1/15 sec 1/15 secAverage time/diagnosis 15 min 8 min 3 minImage compression Yes Yes YesEquipment cost $20,000 $20,000 - $100,000 $100,000

Source: Weinstein, R.S., K.J. Bloom, and L.S. Rozek. 1990. “Static and Dynamic Imaging in Pathology,” in: Mun, S.K., Greberman, M., Hendee, W.R., and Shannon, R. (eds.), Image Management and Communications in Patient Care: Implementation and Impact. Los Alamitos, CA: IEEE Computer Soc. Press, pp. 77-85.

Static vs. Dynamic Systems


Telepathology Issue

• Static image analysis not normal– Control of microscope

– Sequence of images can affect outcome

– Omissions are unacceptable

• Can video images be used by pathologists to render primary diagnostic opinions or second opinions?


Telepathology Issues (cont.)

• Static Imaging -- overall diagnostic accuracy fails to meet accuracy standards (Ito, et al)

• Video Microscopy -- validated for diagnostic pathology by Weinstein et al– 15” Sony Trinitron 950-line monitor

– 11” Sony 300-line monitor

• Dynamic-Robotic -- achieved overall diagnostic accuracy equal to that of light microscopy (Shimosato et al)

• So what??


Telepathology Issues (cont.)

• Static imaging is unacceptable for diagnosis• Dynamic-robotic is best, but expensive and

difficult to setup and operate

We will consider COTS Video Conferencing products (dynamic, slave)


Major Vendors

White Pine Enhanced CU-SeeMeWhite Pine Software, Inc.542 Amherst StreetNashua, New Hampshire 03063800-241-PINEhttp://www.wpine.com/

Microsoft NetMeeting 2.0Microsoft CorporationOne Microsoft WayRedmond, WA 98052800-426-9400http://www.microsoft.com/netmeeting/


Requirements

• Developed requirements based on background and consultation with two experienced UPMC anatomic pathologists

– Compatibility

– Performance

– Product Features

– Standards

– Ease of Use

– Administrative


Compatibility Requirement

• Compatibility with Existing Environment– Teleconferencing software must be compatible with

hardware and software environment

Note: Compatibility is not pertinent to ultimate product comparison


Typical Technical EnvironmentComputer

CPU Intel Pentium II 266 MHz equivalent or betterMemory (RAM) 32 MB or moreHard Disk Storage Space 2 GB or largerDisplay Card Capable of 1024x768 at 16-bit color depth or betterMonitor 17” with resolution of 1024x768 pixels or better and with dot pitch

less than or equal to 0.28Sound card, speakers, and microphoneOperating System Microsoft Windows 95/98/NT

Teleconferencing HardwareCamera Connectix QuickCam™ or equivalent


Performance Requirements

• Image Quality– Difficult to standardize

– 1,024x768 pixels, 16-bit resolution not currently possible with video conferencing

– Current capability:• 128x96 pixels, Sub Quarter Common Intermediate Format (SQCIF)

• 176x140 pixels, Quarter Common Intermediate Format (QCIF)

• 352x288 pixels, Common Intermediate Format (CIF)

Performance --> Image Quality, Compression, Frame Rate


Performance Requirements• Compression

– Decrease file size, Increase network performance

– Two standard video codecs:• H.263 - low bandwidth (28.8 Kbps modem)

• H.261 - high bandwidth (LAN and ISDN)

• Frame Rate– Video 24 fps, Film 30 fps

– Internet frame rate much lower expectations (12-15fps)

– Rate using two ranges:• 3-7 fps for low bandwidth

• 7-15 fps for high bandwidth


Product Feature Requirements

• Multipoint data conferencing - allows users to collaborate and share information with one or more meeting participants in real-time.

• Audio conferencing - allows pathologist to talk in real-time with colleagues.

• Video conferencing - allows pathologist to send and receive video images. – consider how many concurrent video sessions are possible

• pathologist’s facial image

• microscope field view


Product Feature Requirements

• Whiteboard – allows users to share pictures, draw diagrams, and graphically update information in real time.

• Application Sharing – lets users share Windows application with other participants in a meeting.– might be useful for application to control robotic microscope

• Chat – text-based chat application.

• Binary File Transfer – enables files to be sent to participants during a meeting. – natural integration of standard static telepathology


Standards Requirements

• Standards - ensure users can call, connect, and communicate with people using compatible conferencing products

– International Telecommunications Union (ITU) Standards• T.120 - standard for multipoint data conferencing

• H.323 - standard for audio and video conferencing

– Broad industry support with > 120 vendors participating


Ease of Use Requirements

• “Easy to Use” is imperative for Pathologists• Difficult to evaluate without using software• Proxies

– Installation Wizard

– Graphical User Interface

– On-line Help


Administrative Requirements

• Miscellaneous software attributes:

– Cost• particularly important in hospitals and labs with budget

constraints (everywhere!)

– Product support

– Upgradeability

– Cross-platform support


Requirement Priority WeightingPerformance 0.30Product Features 0.30Standards 0.20Ease of Use 0.10Administrative 0.10

Evaluation

• Developed priority weights in collaboration with two experienced UPMC anatomic pathologists


Evaluation


Evaluation

Microsoft NetMeeting White Pine Enhanced CU-SeeMeRaw

Score WeightScaled Score

Raw Score Weight

Scaled Score

Performance 8 0.3 2.4 4 0.3 1.2Product Features 7 0.3 2.1 7 0.3 2.1Standards 3 0.2 0.6 0 0.2 0Ease of Use 3 0.1 0.3 3 0.1 0.3Administrative 4 0.1 0.4 5 0.1 0.5

Total 5.8 4.1


Recommendation

• Microsoft NetMeeting 2.0– Cost-effective solution that delivers a complete,

integrated Internet conferencing solution suited to meet the needs of the practicing pathologist

• Sensitivity Analysis of weights• Formal methodology may have been overkill• CU-SeeMe major revision due March 1999


Recommendation (Limitations)

• Not generalizable to larger user community• Needs more complete analysis

– hands-on usage of products

• General telepathology issues need consideration– Medical-legal

– Diagnostic accuracy

– Patient confidentiality


Acknowledgements/References

• Vaughn, G.L., “Tendencies of pathologists in observing frozen sections,” feasibility study, UAB Center for Telecommunications Education & Research, 1994.

• Weinstein, R.S., K.J. Bloom, and L.S. Rozek. 1990. “Static and Dynamic Imaging in Pathology,” in: Mun, S.K., Greberman, M., Hendee, W.R., and Shannon, R. (eds.), Image Management and Communications in Patient Care: Implementation and Impact. Los Alamitos, CA: IEEE Computer Soc. Press, pp. 77-85.

• Ito, H., H. Adachi, K. Taniyama, Y. Fukuda, and K. Dohi. 1994. “Telepathology Is Available for Transplantation-Pathology: Experience in Japan Using an Integrated, Low-Cost, and High-Quality System,” Modern Pathology, 17: 801-05.

• Oberholzer, M., H-R Fischer, H. Christen, S. Gerber, M. Bruhlmann, M. Mihatsch, M. Famos, C. Winkler, P.Fehr, L. Bachthold, and K. Kayser. 1993. “Telepathology with an Integrated Services Digital Network – A New Tool for Image Transfer in Surgical Pathology, A Preliminary Report.” Human Pathology, 24: 1078-85.

• Eide, T.J., and I. Nordrum. 1992. “Frozen Section Service via the Telenetwork in Northern Norway,” Zentralblatt Pathologie, 138: 409-12.

• Bloom, K.J., L.S. Rozek, and R.S. Weinstein. 1987. “ROC Curve Analysis of Super High Resolution Video for Histopathology,” SPIE Proc Visual Image Process, 845: 408-12.

• http://www.zdnet.com/pccomp/features/fea0297/sub5.html/

• http://www.microsoft.com/netmeeting

• http://www.wpine.com/

Special thanks to Ms. Yukako Yagi, Dr. John Gilbertson, and Dr. Bob Dawson for their assistance and insightful comments.


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