Digital Consultation in Pathology Practice Sylvia L Asa

Digital Consultation in Pathology Practice Sylvia L. Asa, MD, Ph. D Medical Director, Laboratory Medicine Program, University Health Network, Toronto April 16, 2011 Foundation. cap. org v. #

Contents • Definitions • History • The UHN Experience • The Future

Contents • Definitions • History • The UHN Experience • The Future

What is Consultation? Consultation: • The act of consulting (providing advice in a particular area of expertise) • A conference for the exchange of information and advice • An appointment or meeting with a professional person, such as a doctor • Wiktionary 2011 © 2011 College of American Pathologists. All rights reserved. 4

What is a Pathology Consultation? Pathology Consultation • The act of providing advice in a particular area of expertise Examples: • Intraoperative consultation • Pathology report • Secondary opinions © 2011 College of American Pathologists. All rights reserved. 5

Digital Pathology Consultation • The use of digital slide review for pathologist consultations Examples: • Intraoperative consultation • Pathology report • Secondary opinions

Contents • Definitions • History • The UHN Experience • The Future

Historical Data: Telepathology • 1973: Washington DC diagnosis of leukemia via satellite from Brazil • 1986: Dr. Ronald Weinstein coins the name • 1990 s: Norway implements robotic microscopy to support frozen sections in remote hospitals • 2000 s: Whole Slide Imaging (WSI) 8

Barriers to Telepathology • • • Cost FDA approval Billing/CPT codes Storage Transmission and privacy of PHI Pathologist issues o learning curve/accuracy o “images are good, but not ready for prime time” 9

Contents • Definitions • History • The UHN Experience • The Future

The University Health Network • A consolidation of three U of T affiliated teaching hospitals • Programmatic restructuring o TGH cardiac care; transplantation; advanced medicine and surgery o PMH oncology center o TWH neurosciences, musculoskeletal care, community health 11

The University Health Network ~1 e mil © 2011 College of American Pathologists. All rights reserved. 12

Digital Intraoperative Consultation • Laboratory consolidation at TGH • No on-site pathologist at TWH o Staffing challenge • Low volume of Intraoperative consults • Need for surgical pathology expertise in multiple areas including neuropathology Why not use telepathology? ?

Barriers to Telepathology • • • Cost – cheaper than another Pathologist FDA approval – not applicable (Canada) Billing/CPT codes – not applicable Storage – low volume Transmission and privacy of PHI – internal secure network • Pathologist issues – young and innovative department 14

Due Diligence Before Going Live • Medical Malpractice Insurance Provider o Canadian Medical Protective Association (CMPA) o telepathology will not affect coverage • UHN Medical Advisory Committee o SOP presented for approval • Health Canada – Therapeutic Products Program o telepathology does not involve “medical devices” (no direct contact between instrument and patient) o no federal approval required • Surgeon Education o demonstrating the robotic microscope/slide scanner − essential to get surgeon buy-in! 15

The Robotic System: November 2004 -October 2006 16

The Robotic System: November 2004 -October 2006 Toronto Western Surgical Pathology © 2011 College of American Pathologists. All rights reserved. Toronto General Telepathology Work Station 17

Whole-Slide Imaging: October 2006 -Present 18

Whole Slide Imaging: System Parameters © 2011 College of American Pathologists. All rights reserved. 19

UHN Telepathology Protocol • System test each morning • Pathologist reviews O. R. list, communicates plan for the day to histotechnologist • Surgeon defines tissue of interest • Histotechnologist contacts Pathologist - specimen description, processing specimen • Histotechnologist at TWH scans the slide and calls the Pathologist • Pathologist speaks with surgeon by telephone • QA the next day 20

1003 Frozen Sections from 802 Patients (Nov 2004 -Sept 2008) 1003 653 350 WSI 21

Performance: 1003 Cases/4 Years • Accuracy o 98% concordance with final pathology o Not a function of technology • Deferral rates o Identical to on-site rates o NOT a function of technology − Sometimes you just don’t know for sure − Sampling issues in the frozen section biopsy • Turnaround times o Well within 20 minutes required 22

Pathologist Interpretation Time 4 -fold * * Receipt of image to Report of diagnosis * p < 0. 00001 Pathologists tended to go to TWH site for multi-block cases when using the robotic microscope – not so for whole-slide imaging. 23

WSI Pathologist Interpretation Time 38% 32% 30% Minutes/slide * 70% of cases reported in < 2 minutes after scan is received 24

Failure Mode Analysis • PRE-CASE: – Network failure – Moving the scanner within the lab • static vs dynamic IP addresses • discovered on morning test run • MID-CASE: – Minute/pale pieces of tissue that the scanner would not “recognize” – Excess mounting media causing the cover slip to stick to the scanner objective 25

Subspecialty Support for FS 26

Subspecialty Model • How do we get the pituitary expert to read a tough biopsy when she is in Istanbul? ØTelepathology Blackberry solution 27

Subspecialty Model • How do we get the two liver pathologists to read transplant biopsies and attend all academic meetings? ØTelepathology solution o USCAP 2008 all rush biopsies read on laptops at the meeting 28

Subspecialty Model • How do we get the subspecialty support for weekend coverage? ØTelepathology solution o Summer 2008 all weekend cases read on laptops at the home/cottage etc. 29

Ontario-Wide Implementation • Timmins and District Hospital forms an alliance with 9 other hospitals in North East Ontario • Seeks Laboratory Medical Directorship • UHN provides a suitable proposal o Team of subspecialists to support all clinical needs from core in Toronto • Initiation of a new model 30

Ontario-Wide Implementation * ** * * 422 miles Google Maps 2008

Addition of New Clients * ** * * 400 miles Google Maps 2008 422 miles

Subspecialty Consultation • Requires sign-out of all cases by subspecialist o Slides shipped to Toronto by overnight courier from Northern sites • FS review by subspecialist must be available • Ultimately no pathologist on site ØTelepathology solution 33

Transitions to Routine Diagnosis • Success with intraoperative consultations • Need for subspecialty access

Barriers to Full Integration • Integration of multiple slides into workflow for case signout o From the lab to the pathologist • IT integration o LIS o Barcodes • Pathologist satisfaction o Assurance of job security o “This could make pathology fun again”

Workflow Integration • Lab o High throughput o Automated o Flexible integration with stain/coverslip equipment • Pathologist o Rapid image capture, easy navigation o Multiscreen capability o Annotation capability

Contents • Definitions • History • The UHN Experience • The Future

Computer-Assisted Diagnostics • Automated analysis of: o Measurement o Mitoses • QA of technical o Ki 67 LI quality o Other IHC o Section thickness − intensity − distribution o Stain quality o Her 2 FISH o Hematology ? Need for Westgard rules in AP? − Cellavision o More?

Computer-Assisted Diagnostics o The future will bring more innovation GENIE© (GENetic Imagery Exploration) is a GP software system that builds automatic feature extraction algorithms for image analysis, utilizing spectral and spatial signatures of the images “GENIE© can recognize benign and malignant areas in H&E stained slides and it does not have intra- or inter-observer variation in the analysis”

Critical Requirement $$$ Business Case • Reduced microscope budget • Analysis of time spent o Finding slides o Matching slides to case o Retrieving slides for post-hoc review

Digital Secondary Consultation • Rapid transmission of slides around the world • Provides immediate access to the expert of choice

Barriers to Digital Secondary Dx • Integration of more than a few slides into workflow for case signout o Gross description, patient demographics o Privacy issues • IT integration for reporting • System compatibilties

Digital Pathology Enables • Access to the right pathologist at the right time • Cost effectiveness o To the lab o To the system

The New Paradigm • Comprehensive integrated consultations with imaging, biochemical, histologic, molecular, cytogenetic and epigenetic data Bioche mistry Imaging Gross Biomarkers Pathology Histopathology Molecular Pathology • The Pathologist’s Cockpit

The Philosophical Response In a time of drastic change it is the learners who inherit the future. The learned usually find themselves equipped to live in a world that no longer exists. Eric Hoffer 45

2020 Pathologist Consultation

The best way to predict the future Is to invent it