Telepathologyand

The Future of Pathology(or Why did we change our Practice Model)

Jagdish Butany, MBBS, MS, FRCPC

Consultant Cardiovascular Pathologist/Director Autopsy Services Co-Editor-in-Chief, Cardiovascular Pathology

Professor, University of Toronto &Dir.Divn.of Pathology ,Dept. of Laboratory  Medicine and Pathobiology, Sectty/treasurer WASPaLM(2009--)

University Health Network / Laboratory Medicine Program Toronto General Hospital , 200 Elizabeth Street, E11-444

Toronto, Ontario     M5G 2C4,Canada. Tel: 416-340-3003 Fax: 416-586-9901 e-mail: jagdish.butany@uhn.on.ca

2 Feb 2011, Birmingham, UK.

I HAVE NO CONFLICT OF INTEREST WITH ANY Equipment/Supplier!

(a)Why did we implement telepathology (WSI) at UHN?

Imagine

1.Cover 3 sites2.No new staff available3.Increasing workload

• TGH, PMH, TWH

• No on-site TWH pathologist

• 2-10 frozen sections

per week (mostly

neurosurgery)

• Sept. 2004 – no NP

University Health Network

~ 1 mile

X

X

X

UHN

IMAGINE 2!

Research

S S

S

S= Service

UHN

IMAGINE3: 3 Departments of Pathology! # Q S Sites

Medical Laboratories

“-----and sometimes u get lucky!!”

The Perfect Storm---!

Right Circumstances

Right Leadership Right Tools!! Available!

Problem!!

TWH Frozen Sections: The Problems to Be Solved

• Single pathologist traveling to TWH– Inefficient process - traveling time and waiting

– Disruptive to regular workflow – 99% of departmental activity occurs at TGH

• delays in regular sign-out affecting other UHN patients

– No possibility for consultation on difficult cases – possibly affecting TWH surgical patients.

• Compromised diagnostic accuracy• Unnecessary deferred diagnoses

The Robotic System: November 2004-October 2006

• 350 frozen sections

• accurate

• deferral rate < 10%

• slow (~ 10 minutes/slide)

Toronto GeneralTelepathology Work Station(not a pathologist’s office)

Toronto Western

The Robotic System

Whole-Slide Imaging: October 2006-Present

• > 1800 frozen sections/1500 patients

• 90% from neurosurgery

• 98.5-100% accuracy (month to month)

• 14-16 minute turnaround time

• 5% deferral rate

- 2 pathologists review all deferrals

Telepathology Was A Viable Solution

• > 90% of the cases are single block• Surgeons select the tissue of interest

– no need for gross assessment by pathologist– surgeon-defined margins – submit in toto for frozen section/smear

• Robotic microscopy (2004-2006)– most intense development and validation

• Transition to WSI (late 2006- present)

• Easy consultation with colleagues – better for patient care

• WSI had essentially no learning curve (compared to robotic microscope)

Whole-Slide Imaging: Architecture

This was TGH/UHN

Pathology 2000-2010Pathology 2000-2010

Future of Pathology

Frontiers in Laboratory Medicine

Feb 1-2, 2011, Birmingham UK.

18

• Volume – aging population – higher sensitivity for early disease

• Demand– Sophisticated knowledgeable population– Culture of “instant gratification”

• New technologies– genomics– proteomics– informatics– robotics ‘tissue soup’ instead of tissue

Challenges for 2020Challenges for 2020

MONEY??

The Challenge for 2020 The Challenge for 2020

• Faster• Better

– Higher quality– Personalized

• Cheaper

• Innovative

The New Paradigm: The New Paradigm: FasterFaster

• Pathology must be faster

– “Same Day” diagnosis

– Automation

– 24/7 labs

FasterFaster

21

The New Paradigm: FasterThe New Paradigm: Faster

• Speech-recognition integrated with LIS

means instant reporting without

the need for dictatyping

CHEAPER

Technologic Advances: “omics”Technologic Advances: “omics”

HT-SequencingDNA

MicroarrayExpressionProfiling

RNA

Mass SpectrometryProtein

Metabolomics

What is “Correct”?• Objective classification by

– mRNA expression– DNA sequencing– Response to therapy

The New Paradigm: BetterThe New Paradigm: Better

• Synoptic Reporting– Complete

• Standardized formats (CAP checklists)

– Adaptable and flexible• No more verbose reports that no one reads!

– Database technology• Statistics collection• Administrative tracking• QA monitoring• Academic data mining

The New Paradigm: BetterThe New Paradigm: Better

25

The New Paradigm: BetterThe New Paradigm: Better(A Bit Controversial-(A Bit Controversial-still !!still !!))

Subspecialty Pathology– All cases reported by a pathologist with

expertise in the specific subspecialty required– Benefits:

• Better quality and faster patient care• Fiscal responsibility: 1 pathologist per case• Pathologist satisfaction – enhanced academic

excellence

– Challenges:• Requirement for appropriate staffing

in all areas and Built in redundancy

Requirements for Full Adoption Requirements for Full Adoption • Workflow integration

– From the lab to the pathologist

• LIS integration– Barcodes– Slide tracking and retrieval

CHEAPER

27

Digital Pathology EnablesDigital Pathology Enables• Remote access

• Multiple viewers

• Immediate access to the right pathologist at the right time

BETTER

Computer-Assisted DiagnosticsComputer-Assisted Diagnostics• Automated analysis of:

– Measurement– Mitoses– Ki67 LI – Other IHC

• intensity• distribution

– Her2 FISH– Hematology

• Cellavision

– More?

• QA of technical quality– Section thickness– Stain quality

? Need for Westgard rules in AP?

Epigenetic Control: Epigenetic Control: Can it Override the Genotype?Can it Override the Genotype?

N Engl J Med. 2007 Feb 15;356(7):731-3

What Is Anatomical Pathology?What Is Anatomical Pathology?• Integrative

morphology based interpretation

• Consultant’s ReportGross Morphology

Chemistry on a glass slide

Immunoassay on a glass slide

The Virtual AutopsyThe Virtual Autopsy

After “The Anatomy Lecture of Dr. Nicolaes Tulp” – Rembrandt, 1632(Courtesy of Dr. Carlos Cordón, New York, USA)

33

• Patient-Centred Care

• Individualized diagnostics

• Targeted therapies

All based on “omics”

Will “omics” replace pathology?

The New Paradigm: PersonalizedThe New Paradigm: Personalized

The Future of Pathology?The Future of Pathology?

$15.00 each $1000.00 each$15.00 each $1000.00 each

2020 Pathology2020 PathologyDigital radiology

Digital cardiology

Digital genetics

Biomarkers & CAD

ClinicalPathology

Gross Pathology

History, Physical,Family History

Digital EMR

QA

Labs/

Pathology:

the center

of

Personalized

Medicine !!Endoscopy

• Comprehensive & Integrated Pathology reports– Incorporation and integration of radiologic,

biochemical, morphologic , molecular, cytogenetic and epigenetic data

The 2020 ParadigmThe 2020 Paradigm

The Pathologist’s Cockpit

Gross Pathology

BiomarkersRadiology

Biochemistry

MolecularPathology

Histopathology

37

• To provide the right diagnosis

• To provide the right material

• To provide the right leads

• To provide the right experiments

• To evaluate the consequences of genetic manipulation

• To PROVIDE An INTELLIGIBLE, COMPREHENSIVE REPORT!!

The Expanding Role of Lab MedicineThe Expanding Role of Lab Medicine

2020 2020

2020 2020 THE THE Pathologist !!Pathologist !!

The Pathologist and the Patient!!

2020 2020 PathologistPathologist

Pathologist and Patient!“The Diagnosis is----, and the prognosis is----.”

“AS IS YOUR PATHOLOGYSO IS YOUR MEDICINE.”

Sir William OslerMcGill Univ, Hopkins, London (UK)

IMAGINE!!

X

X

XX

KuwaitX

42

The Future of PathologyThe Future of Pathology

The best way to predict the future is to invent it

Alan Kay