Title: Practical Applications of Robotic Telepathology
1Practical Applications of Robotic Telepathology
- Bruce E. Dunn, M.D.
- Chief Pathologist, Veterans Integrated Service
Network (VISN) 12 - Professor and Vice-Chair, Dept of Pathology,
Medical College of Wisconsin - Bruce.Dunn_at_med.va.gov
2Disclosure
- No financial interest in nor support from any
vendor
321 Veterans Integrated Service Networks
(VISNs)
4Marquette
Houghton/ Hancock
Sault Ste. Marie
Iron Mt.
Chicago Metro VAs
Menomonie
Rhinelander
Wausau
Evanston
Chippewa Falls
Loyal
Appleton
Tomah
Chicago
Cleveland
Milwaukee
Hines
VISN 12 Hospitals Clinics
Oak Park
Woodlawn
Madison
Union Grove
Gurnee
North Chicago
Aurora
Rockford
Elgin
Chicago Heights
Crown Point
LaSalle
Joliet
Manteno
5Robotic Telepathology (TP) in VISN 12
- Iron Mountain is an active, rural DVA hospital
with a general surgery program - 1000 surgical pathology cases per year
- Part-time on-site Iron Mountain pathologist
announced retirement in 1996 - Iron Mountain clinical and technical staff
recommended robotic telepathology from Milwaukee
(gt200 miles away) - Feasibility study started late 1995
- Full implementation of commercial hybrid dynamic
store/forward system in July 1996 - Two senior surgical telepathologists trained
- Feasibility study performed - published 1997
6Current and Future
7(No Transcript)
8(No Transcript)
9Current and Future
10Current and Future Non-Robotic
Telepathology System
11Technical Summary (published 1999)(first 2,200
cases)
- Same 2 experienced pathologists
- Deferral rate 2
- Major concordance on non-deferred cases 99.7
- Time per case 11.6 min (cases 1-200), reduced
to 3.58 min (cases 2001-2200) - Time per slide 4.25 min (cases 1-200), reduced
to 1.13 min (cases 2001-2200) - Case turn-around-time lt 1.5 days (vs gt 4 days)
12Factors influencing robotic TP in VISN 12since
1999
- Milwaukee became core AP lab for Tomah and N.
Chicago in 1999 and Madison cytology in 2001 - One senior telepathologist retired from VA in
late 1998 - Junior surgical pathologists (3) hired in 1999
and 2000 - Several iterations of TP hardware and software
implemented, but basic dynamic imaging remained
unchanged through 2004
13Goals of this study
- Determine rates of case deferral and TP
concordance with light microscopy (LM) among four
pathologists during 1999-2004 to compare with
previous results - Three junior naĂŻve telepathologists
- One senior experienced telepathologist
- Determine whether concordance rates improve
and/or deferral rates decrease with experience
14Summary of cases (from 1999 study)
- Organ/system Percent of total
- Gastrointestinal 42.9
- Skin 27.5
- Prostate 10.2
- Hernia sac 3.8
- Urinary bladder 2.6
- Bone/synovium/tendon 2.1
- Penis/testis/spermatic cord 1.9
- Gallbladder 1.3
- Extremity amputation 1.1
- Appendix 0.5
- Gynecologic 0.5
- Breast 0.3
- Miscellaneous 5.2
15Technical aspects of work flow
- Tissue grossed in Iron Mtn by experienced PA
(tele-gross imaging available) - Slides processed by Iron Mtn histotechnician
- Telepathology systems linked up
- PA puts slides individually onto stage in Iron
Mtn - Pathologist controls robotic microscope remotely
from Milwaukee
16Robotic 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
17Methods
- Each of 4 pathologists read cases by TP,
completed reports where appropriate, then read
same cases by LM - Reasons for case deferral to LM documented
- Revised reports generated based on LM diagnosis,
if necessary clinicians notified - Rates of deferral, concordance and TAT determined
by pathologist - QA 30 of cases subjected to second read
- Notes
- TURP cases deferred automatically
- Gastric biopsies reviewed for H. pylori-like
organisms by PA in Iron Mtn by LM
18Deferral to light microscopy (LM)
- If due to computer down-time during one of
several upgrades, then not counted as a TP
deferral - Turn-around-time (days) calculated for all
deferred and non-deferred cases
19Concordance rates by pathologist
- Deferred cases not included
- Major discordance
- Benign vs malignant
- Different patient outcome or therapy
- Report modified and clinician called
- Total discordance
- Any case including major and minor discordances
in which a modified report was generated as a
result of diagnostic differences between TP and LM
20Overall summary 1999-2004
- Pathologist A B C D Total
- Total cases 997 1031 2231 1582 5841
- No. deferred 326 270 319 290 1205
- Deferral rate () 32.7 26.2 14.3 18.3
20.6 - TP cases 671 761 1912 1292 4636
- Ave TAT (days) 1.72 1.65 1.70 1.68 1.69
21Major discordance/concordance
- Pathologist A B C D Total
- Maj discord 1 8 7 5 21
- TP cases 671 761 1912 1292 4636
- Discordance 0.15 1.05 0.37 0.39 0.45
-
- Concordance 99.85 98.95 99.63 99.61 99.55
22Total discordance/concordance(modified reports)
- Pathologist A B C D Total
- Tot discord 7 36 28 76 147
- TP cases 671 761 1912 1292 4636
- Discordance 1.0 4.7 1.5 5.9 3.2
-
- Concordance 99.0 95.3 98.5 94.1 96.8
23Rates of Deferral by Pathologist
24Major Concordance Rate by Pathologist
25Pathologist C Major concordance rate (initial
2200 cases)
26Pathologist C Major concordance rate (N3012)
27Report Modification Rate by Pathologist
28Summary
- Deferral rates (14-33) were much higher in
1999-2004 than in our previous report (1999) - Reasons for deferral insufficient staffing, case
difficulty, special stains not performed at Iron
Mtn - Deferral rates influenced more by perceived
staffing levels than by TP experience - Despite variable deferral rates, all pathologists
had very similar average TAT - Major concordance rate from 1999-2004 was 99.55
compared with 99.67 in previous report (1999) - Highest rate of concurrence (99.85) observed in
pathologist with highest rate of deferral (32.6)
29Summary
- Most telepathology diagnoses made solely using
the dynamic imaging mode - Despite extensive experience, the quality of
dynamic imaging used through 2004 still allowed
occasional major errors, even by the most
experienced pathologist - All TP cases continue to be reviewed by LM
- Total TP primary diagnoses now gt 7,000
- Improved dynamic imaging installed in late 2004
- TP is one tool which has allowed reduction of
pathologists from 32 (1996) to 16 in VISN 12
30VISN 12 Telepathology Network
NRM
Iron Mtn
RM
Tomah
Iron Mtn
Tomah
DR
GS
POP
POP
DR
NRM
Milwaukee
Madison
Milw
Madison
DR
Interface to VistA
POP
POP
WAN
Westside
NRM
Multi-site conferencing
Hines Micro
N. Chicago
DR
POP
POP
Dedicated Server
NRM
NRM
Hines
North Chicago
GS
Hines Path
Chicago
GS
POP
POP
DR
KEY POP point of presence VistA VA
computerized patient record system
VHA WAN Internet
VHA WAN Internet
31Licensure and credentialing in VHA
- One valid state license sufficient in VHA
- Pathology/telepathology credentialing required at
each VA hospital at which the pathologist
practices - VISN-wide credentialing not available
32Acknowledgements
- Sarah Kerr, MD PGY1 Pathology U VA
- Ben Wagenma, MD - PGY1 Pathology U GA
33Related 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. 288-1. - 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.
5323-337.