Robotic Telepathology: Practical Applications

Bruce E. Dunn, M.D.

Chief Pathologist, Veterans Integrated Service Network (VISN) 12

Professor and Vice-Chair, Dept of Pathology, Medical College of Wisconsin

Conflict-of-interest statement

Bruce E. Dunn, MD has no financial interest in any commercially-available telepathology system

21 Veterans Integrated Service Networks (VISNs)

Hospitals and CBOCs in VISN 12

Robotic Telepathology (TP) at Iron Mtn

• Iron Mountain is an active, rural DVA hospital with a general surgery program– 1000 - 1500 surgical pathology cases per year– Occasional frozen sections requested

• 1996: part-time Iron Mountain pathologist retired• Full implementation of commercial hybrid

dynamic store/forward system operated by two senior pathologists in Milwaukee

• Feasibility study performed - published in 1997

Three Phases of Robotic TP at Iron Mtn

• Phase I: mid-1996 – early 1999– Two senior surgical pathologists exclusively read cases with

extensive documentation– 2,200 cases available for TP– Summary published in 1999

• Phase II: early 1999 – end of 2004– One senior pathologist retired; three junior pathologists hired– Consolidation in VISN resulted in increased AP workload– 5,841 cases available for TP

• Phase III: 2005 – present (through July 2006)– One original senior pathologist and two new pathologists– ASAP ImagingTM implemented– 2,015 cases available for TP through July 2006

Objectives

• Compare rates of case deferral and major TP discordance with light microscopy (LM) among seven pathologists during three phases of robotic telepathology

• Compare rates of major discordance before and after implementing the ASAP ImagingTM system

Summary of Cases (1999)

Organ/system Percent of totalGastrointestinal 42.9Skin 27.5Prostate 10.2Hernia sac 3.8Urinary bladder 2.6Bone/synovium/tendon 2.1Penis/testis/spermatic cord 1.9Gallbladder 1.3Extremity amputation 1.1Appendix 0.5Gynecologic 0.5Breast 0.3Miscellaneous 5.2

Technical Aspects of Workflow

• Tissue grossed in Iron Mtn by experienced PA (tele-gross imaging available)

• Slides processed by Iron Mtn histotechnician

• Telepathology systems “linked up”

• PA places slides onto stage in Iron Mtn

• Pathologist controls robotic microscope remotely from Milwaukee

Current and Future

Robotic Microscopy• Commercial hybrid dynamic store/forward system• Olympus microscope with motorized stage, objectives,

lighting control• CODEC used for gross & microscopic imaging and

videoconferencing• 4x,10x, 20x 40x 100 (oil free) objectives• Dynamic imaging: 350 x 288 x 24-bit color• Static imaging: 1520 x 1144 x 24-bit color• Images transmitted at 768 kbps over WAN• 2005: ASAP ImagingTM enables remote access with live

streaming imaging

VISN 12 Telepathology Network

Hines

Madison

Tomah

NorthChicago

Westside

Milw

IronMtn

VHA WANInternet

VHA WANInternet

DR

DR

GS

RM

DR

GS

NRM

NRM

NRM

GS

NRM

NRM

KEYPOP – point of presenceVistA – VA computerized patient record system

WAN

POP

POP

POP

POP

POP

POP

POP

Multi-siteconferencing

DR

DR

POP

DedicatedServer

Current and Future

Tomah

Madison

Hines

Hines Micro

Iron Mtn

Milwaukee

N. Chicago

Chicago

Interface to HIS

Current and Future

Methods• Each of 7 pathologists read cases by TP, completed

reports where appropriate, then read same cases by LM• Over 50% of cases read by second pathologist by LM• Revised reports generated based on LM diagnosis, if

necessary, and clinician notified • Reasons for case deferral to LM documented• Pathologist-specific rates of deferral and discordance

determined • Notes:

– TURP and bone marrow cases deferred automatically– Gastric biopsies reviewed for H. pylori-like organisms by PA

in Iron Mtn by LM

Current and Future

Non-Robotic Telepathology System

Deferral to Light Microscopy

• Reasons for deferral: case difficulty, need for consultation, special or immuno stains, “short staffing”

• If case referred to Milwaukee due to computer unavailability (malfunction or upgrade), or the assigned pathologist was not yet competent to use telepathology, then case not counted as a deferral

Discordance Rates by Pathologist

• Deferred cases not included

• Major discordance– Benign versus malignant– Different patient outcome or therapy

• Report modified and clinician called

Phase I Individual SummariesPathologist A B Total

Total opportunities 1121 1079 2200

No. deferred 34 22 56

Deferral rate (%) 3.0 2.0 2.5

TP cases 1087 1057 2144

Maj discord 5 2 7

Discordance (%) 0.46 0.19 0.33

Phase II Individual SummariesPathologist B C D E Total

Total opportunities 2231 1582 1031 997 5841

No. deferred 319 290 270 326 1205

Defer rate (%) 14.3 18.3 26.2 32.7 20.6

TP cases 1912 1292 761 671 4636

Maj discord 7 5 8 1 21

Discordance (%) 0.37 0.39 1.05 0.15 0.45

Phase III Individual Summaries (ASAP) (July 2006)

Pathologist B D E F G Total

Total opportunities 795 17 185 683 335 2015

No. deferred 40 0 12 78 65 195

Deferral rate (%) 5.0 0 6.5 11.4 19.4 9.7

TP cases 755 17 173 605 270 1820

Maj discord 1 0 0 2 1 4

Discordance (%) 0.13 0 0 0.33 0.37 0.22

Comparison by Phase (July 2006)

Phase I II III Total

Total opportunities 2,200 5,841 2,015 10,056

No. deferred 56 1,205 195 1,456

Deferral rate (%) 2.5 20.6 9.7 14.5

TP cases 2,144 4,636 1,820 8,600

Maj discord 7 21 4 32

Discordance (%) 0.33 0.45 0.22 0.37

Pathologist B: Major concordance rate (N=3,724)(July 2006)

95

96

97

98

99

100

0-10

0

201-

300

401-

500

601-

700

801-

900

1001

-110

0

1201

-130

0

1401

-150

0

1601

-170

0

1801

-190

0

2001

-210

0

2201

-230

0

2401

-250

0

2601

-270

0

2801

-290

0

3001

-310

0

3201

-330

0

3401

-350

0

3601

-370

0

% c

onco

rdan

ce

Pathologist-Specific Discordance Rates

0.12

0.270.33 0.37 0.39

0.46

1.03

0

0.2

0.4

0.6

0.8

1

1.2

E B F G C A D

Pathologist

Dis

cord

ance

Rat

e (%

)

Major Discordance Rate by Technology (July 2006)

Pathologist

Technology B E All

Pre-ASAP 0.30 0.15 0.41*

ASAP 0.13 0 0.22

*0.33 excluding pathologist D

Summary

• Pathologist-specific discordance rates ranged from 0.12% to 1.03%, with median of 0.37% and overall rate of 0.37%

• Despite extensive experience of one senior pathologist, occasional discordances continue to occur

• The rates of discordance using ASAP ImagingTM are lower that those observed previously

• All TP cases continue to be reviewed by LM

References

• Dunn, B.E., U.A. Almagro, H. Choi, N.K. Sheth, J.S. Arnold, D.L.Recla, E.A. Krupinski, A.R. Graham and R.S. Weinstein. 1997. Dynamic-robotic telepathology: Department of Veterans Affairs feasibility study. Human Pathol. 28:8-1.

• Dunn, B.E., H. Choi, U.A. Almagro, D.L. Recla, and R.S. Weinstein. 1999. Routine surgical telepathology in the Department of Veterans Affairs: Experience-related improvements in pathologist performance in 2200 cases. Telemed J. 5:323-337.