Evolution of Digital Pathology in the Armed Services

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Evolution of Digital Pathology in the Armed
Services
Telepathology Vision Enabler of
Revolutionary Healthcare
Col Robert Zalme, USAF 10 September
2007 Pittsburgh, PA
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U.S. Military and Telepathology

• Army
• - Has established gt23 robotic scope sites, c
  regular frozen section
• conferences
• Navy
• - Utilizing VTC for tumor board between Okinawa
  and Hawaii
• Air Force
• - Developed educational Web-Conferencing
• Pre-posting scanned and/or static images of
  interesting cases
• Rotating weekly discussions
• - Developing of robotic technology at seven
  sites
• - Developing digital imaging for education and
  consultation

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U.S. Air Force and Telepathology

• Congressional Special Interest Appropriations
• - Since FY02 More than 20 M for
  telemedicince projects
• Partner with UPMC, a world-class telemedicine
  academic institution
• Begin with sharing static images on a serve
• Initiate consultaion with robotic scopes
• Progress to sharing of whole slide images
• Greatest obstacles
• Communication certification (DIA CAP)
• 1. First, approval of AFMS
• 2. Second, approval of Air Force Communications
  Agency
• 3. Third, approval of local communication
  officials
• 4. Fourth, constant battles to correct obstacles
  that shouldnt exist
• Change in work flow
• Time constraints of busy daily case load
• Fear of new technology of fear of losing
  microscope

DIA CAP
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Revolutionary Change

• Essentially no change in microscopy
• since Leeuwnehoek and Hooke
• Photomicrography enabled pathologists
• to teach pathology, discuss diagnoses
• and share cases for consultation
• Yet, surgical pathology remains isolated
• from the rest of medicine
• Even now, the understanding of diagnoses by
  clinicians and
• colleagues is obscured
• High quality virtual images and digital
• storage offers a vision unforeseen.

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Glass vs Digital

• Glass requires a microscope
• - Not available everywhere
• - Requires special skill
• - Limited access
• - Slide cant be found, how peculiar
• - Difficult to examine
• (broken, dirty, lost)
• Digital requires a computer
• - Available almost everywhere today
• - No special skill required
• - Everyone can see simultaneously
• - Easy to examine and analyze
• Neither technology is perfect

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Primary Applications

• Consultation or QA
• Primary diagnosis
• Image analysis
• Specialized applications, such as immunos, FISH,
  and
• tissue micro-arrays

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Primary Applications

• Consultation or QA
• Primary diagnosis
• Image analysis
• Specialized applications, such as immunos, FISH,
  and
• tissue micro-arrays

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Primary Applications

• Consultation or QA
• Primary diagnosis
• Image analysis
• Specialized applications, such as immunos, FISH,
  and
• tissue micro-arrays

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Primary Applications

• Consultation or QA
• Primary diagnosis
• Image analysis
• Specialized applications, such as immunos, FISH,
  and
• tissue micro-arrays

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Primary Applications

• Consultation or QA
• Primary diagnosis
• Image analysis
• Specialized applications, such as immunos, FISH,
  and
• tissue micro-arrays

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Primary Applications

• Consultation or QA
• Primary diagnosis
• Image analysis
• Specialized applications, such as immunos, FISH,
  and
• tissue micro-arrays

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Primary Applications

• Consultation or QA
• Primary diagnosis
• Image analysis
• Specialized applications, such as immunos, FISH,
  and
• tissue micro-arrays

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Primary Applications

• Consultation or QA
• Primary diagnosis
• Image analysis
• Specialized applications, such as immunos, FISH,
  and
• tissue micro-arrays

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Primary Applications

• Consultation or QA
• Primary diagnosis
• Image analysis
• Specialized applications, such as immunos, FISH,
  and
• tissue micro-arrays

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Primary Applications

• Consultation or QA
• Primary diagnosis
• Image analysis
• Specialized applications, such as immunos, FISH,
  and
• tissue micro-arrays

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Primary Applications

• Consultation or QA
• Primary diagnosis
• Image analysis
• Specialized applications, such as immunos, FISH,
  and
• tissue micro-arrays

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Primary Applications

• Consultation or QA
• Primary diagnosis
• Image analysis
• Specialized applications, such as immunos, FISH,
  and
• tissue micro-arrays

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Three Arm Approach

• Establish a powerful database server to manage
  images (Eagle Scope)
• Manage the project via AFKN web based
  conferences
• 1 -Institute storage and sharing of static images
  initially
• 2 - Implement robotic microscopes
• - Nikon Coolscopelooks like a computer and not
  a scope
• - Trestlelooks and functions just like a
  scope, doubles as a scope
• - Apollolooks and functions just like a scope,
  doubles as a scope
• 3 - Implement scanned whole slide images
• - Aperio
• - Interscope
• - D-Metrix
• - Bacus/Olympus
• - Zeiss
• Seek DICOM standard for images
• Support development of PACS for pathology images
• Incorporate as part of the electronic medical
  record (EMR)

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Why Telepathology?

• Telepathology is not just moving images for
  consultation and not just to distant places
  during duty hours.
• Lessons from radiologists of today - everything
  at your fingertips
• Current case, all imaging modalities
• Previous case(s)
• Clinical diagnosis, history, procedure request,
  etc.
• Manipulation of the image to enhance
  visualization
• Data analysis of images
• Share with your colleagues
• - Tumor Board
• - Frozen sections with surgeons in OR
• - The clinician
• - Friends across the country, subspecialists,
  residents, students
• And where and when?
• - Any where.at home, TDY, leave, Europe, golf
  course, etc.
• - Anytimewhy wait on the consultation or
  reference lab report, why 9-5?
• ..... Pathology is destined to become an integral
  part of the emerging electronic medical record.

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Where are we now?

• Three Developing Projects
• Create a WSI educational image/slide collection
• - 150 cases from various organ systems
• - Stored on server with controlled enterprise
  wide acess
• 2. Conduct WSI-based inter-facility Quality
  assurance (QA)
• - Conduct case reviews of 50 de-identified
  cases
• - Use teleconferences to discuss/resolve
  discrepant cases
• 3. Compare robotic microscopy with WSI for real
  time consultation
• - Compare 50 cases 5050 robotic vs WSI
• - Utilize WHMC, AFIP, and UPMC for cnsultation

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Will Telepathology Happen?
Where would we be if Henry Fords audience would
have said that to be forced to go to the village
to get fuel or to drive on a dag-blamed road
was too obstructive to their daily work
flow? Where would you and I be if George
Papanicolaou would not have willingly shared his
technology with his staff or students? To believe
that our retina can collect and analyze all the
data, and find Waldo and his similar looking
other brother Waldo in a tissue specimen is
simply not true. Digital images promises
enormous value. MOST COMPELLING Within
eight years the new pathology residents will not
have seen any microscopic images with
the aid of a microscope.like the typewriter of
our age. Furthermore, they will have computer
savvy and analytic abilities beyond our ability
to comprehend! Allow us to deliver pathology
services to third world countries.
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Recommendations

• Develop cockpit capabilities
• Digitize local images for inclusion in AHLTA
• Share digitized images across the enterprise
• Revolutionary technology is calling visionaries
• Not for the weak of spirit

Today it's time to begin the hard labor
DSN 591-4469
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