Ronald S. Weinstein, M.D.

Professor, Pathology

Head, Pathology 1990 – 2007

Director, Arizona Telemedicine Program

Disclosure

DMetrix – Tucson, AZMedical Director

Apollo Telemedicine – Falls Church, VAShareholder

Telepathology

The use of telecommunications technology to facilitate the transfer of image-rich pathology data between remote locations for the purposes of diagnosis, education, and research.

Telepathology systems are divided into three major types: static image-based systems, real-time systems, and virtual slide systems.1. Static image systems have major benefits of being the

most reasonably priced and usable in the widest range of settings, but have the significant drawback in only being able to capture a selected subset of microscopic fields.

2. Real-time systems and virtual slides allow a consultant pathologist the opportunity to evaluate the entire specimen. With real-time systems, the consultant actively operates a microscope located at a distant site -- changing focus, illumination, magnification, and field of view at will.

3. Virtual slide systems utilize an automated scanner that takes a visual image of the entire slide, which can then be forwarded to another location for diagnosis.

Table 1. Arizona-International Telemedicine Network

Location Population Distance from Tucson (km

[miles])

No. of beds in hospital*

United States - AZ

Tucson 405,000 - 312

Phoenix 983,000 178 (111) 350

Cottonwood 6,000 350 (217) 99

Yuma 55,000 386 (240) 350

Kingman 13,000 478 (297) 50

China

Hangzhou 1,200,000 12,800 (7,900) 600

Mexico

Hermosillo 449,000 381 (237) 250

*Hospital housing the telepathology workstation.The Hospital General del Estado in Hermosillo served as the hub for a network of regional hospitals whose pathologists brought cases to the referring site for transmission to Tucson and teleconsultation.

University of Arizona Telepathology ServicesUniversity of Arizona Telepathology Servicesaa

Modality Classb QASecond opinion

Frozen sections

Deferred casesc

Static image telepathology

2A --- 239 --- 17

Robotic dynamic telepathology

3B 3064d 81 142 228

Virtual slide telepathology

5C 329 --- --- ---

Total 3393 320 142 245

a University of Arizona telepathology services, initial 4100 cases, 1993-2008.b Weinstein Classification of Telepathology Systems [2].c For special studies, such as immunohistochemistry, or for glass slide reviewd Includes some second-opinion cases.

TELEMEDICINE JOURNALVolume 1, Number 1, 1995Mary Ann Liebert, Inc., Publishers

Case Triage Model for the Practice of Telepathology

A.K. BHATTACHARYYA, M.D., JOHN R. DAVIS, M.D., BRADFORD E. HALLIDAY M.D., ANNA R. GRAHAM, M.D., S. ANNE LEAVITT, M.D., RALPH MARTINEZ, Ph.D.,

RICARDO A. RIVAS, and RONALD S. WEINSTEIN, M.D.

ReferringPathologist

SubspecialtyPathologist

Triage Pathologist

CaseSign-out

PATHWAY A PATHWAY B

Case Triage Model

CaseSign-out

Triage Pathologist

AFIP ModelReferring Pathologist

Triage Clerk

GI Path GYN Path Renal Path Derm Path Etc.

Case Sign-out

CaseSign-out

CaseSign-out

CaseSign-out

CaseSign-out

University of Arizona Telepathology Servicesa

Modality Classb QASecond opinion

Frozen sections

Deferred casesc

Static image telepathology

2A --- 239 --- 17

Robotic dynamic telepathology

3B 3064 81 142 228

Virtual slide telepathology

5C 329 --- --- ---

Total 3393 320 142 245

a University of Arizona telepathology services, initial 4100 cases, 1993-2008.b Weinstein Classification of Telepathology System [2].c For special studies, such as immunohistochemistry, or for glass slide review

Havasu Regional Medical Center

University Medical Center Tucson, AZ

316 Miles

Quality Assurance Program

HRMC processes approximately 3500 surgical pathology cases annually

One pathologist, on-site, between July 2005 and October 2009.

All new cancer cases and challenging non-malignant cases were selected by the HRMC pathologist for telepathology re-review.

Case Read-Outs # of Cases

% of Cases

Average Time

UMC on-service telepathologist

1692 90.87% 3.78(1-33 minutes)

Deferred for glass slide review

170 9.13% 6.12(1-18 minutes)

Total 1862

Deferral Rate

Pathologists

Total cases in general

Deferred cases

Total cases excluding the pathologist’s subspecialty

Total deferred cases

excluding the pathologist’s subspecialty

Deferral rate in general

Deferral rate excluding

pathologist’s subspecialty

Gastro Intestinal 501 24 344 17 4.79% 4.94%

Heart and Lung 369 30 321 25 8.13% 7.78%

Renal 188 24 150 22 14.79% 14.67%

Soft Tissue 174 37 165 36 21.26% 21.81%

GYN 166 12 161 12 7.23% 7.45%

Renal 139 12 109 10 8.63% 9.17%

Endocrine 85 9 83 9 10.59% 10.84%

ENT Path 84 6 76 6 7.14% 7.89%

Dermatology 58 7 50 5 12.07% 10%

Breast 51 4 50 4 7.84% 8%

Deferral Rate

Pathologists

Total cases in general

Deferred cases

Total cases excluding the pathologist’s subspecialty

Total deferred cases

excluding the pathologist’s subspecialty

Deferral rate in general

Deferral rate excluding

pathologist’s subspecialty

Gastro Intestinal 501 24 344 17 4.79% 4.94%

Heart and Lung 369 30 321 25 8.13% 7.78%

Renal 188 24 150 22 14.79% 14.67%

Soft Tissue 174 37 165 36 21.26% 21.81%

GYN 166 12 161 12 7.23% 7.45%

Renal 139 12 109 10 8.63% 9.17%

Endocrine 85 9 83 9 10.59% 10.84%

ENT Path 84 6 76 6 7.14% 7.89%

Dermatology 58 7 50 5 12.07% 10%

Breast 51 4 50 4 7.84% 8%

Deferral Rate

Pathologists

Total cases in general

Deferred cases

Total cases excluding the pathologist’s subspecialty

Total deferred cases

excluding the pathologist’s subspecialty

Deferral rate in general

Deferral rate excluding

pathologist’s subspecialty

Gastro Intestinal 501 24 344 17 4.79% 4.94%

Heart and Lung 369 30 321 25 8.13% 7.78%

Renal 188 24 150 22 14.79% 14.67%

Soft Tissue 174 37 165 36 21.26% 21.81%

GYN 166 12 161 12 7.23% 7.45%

Renal 139 12 109 10 8.63% 9.17%

Endocrine 85 9 83 9 10.59% 10.84%

ENT Path 84 6 76 6 7.14% 7.89%

Dermatology 58 7 50 5 12.07% 10%

Breast 51 4 50 4 7.84% 8%

Deferral Rate

The case deferral rates for individual telepathologists ranged from

4.79% to 21.26% The deferral rates were not significantly

changed by exclusion of cases within the individual pathologists’ subspecialty area. These deferral rates ranged from

4.94% to 21.81%

• The triage pathologist completed the telepathology consultation without any assistance of a subspecialty pathologist in 66% of the cases.

• A review panel examined the original glass slides

from 134 cases by light microscopy.

• Concordance rates of the telepathologists’ provisional diagnosis or review panel’s diagnoses with the referring pathologists’ diagnoses were not statistically different ( P > 0.05).

Conclusions: Deferral rates were minimally impacted by

pathologist subspecialty.

Overall diagnostic discordance rate,

comparing on-site light microscopy and telepathology diagnoses, was 5.73%.

Deferrals for glass-slide review represented less than 10% of

telepathology QA cases.

Conclusions: Deferral rates were minimally impacted by

pathologist subspecialty.

Overall diagnostic discordance rate,

comparing on-site light microscopy and telepathology diagnoses, was 5.73%.

Deferrals for glass-slide review represented less than 10% of

telepathology QA cases.

Telepathology Practice Models

Thank you!