Digital Imaging in Education and Distributed Pathology Practice

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Digital Imaging in Education andDistributed
Pathology Practice

• Elizabeth H Hammond MD
• Professor of Pathology
• University of Utah and Intermountain Healthcare
• Executive Editor for Pathology
• Amirsys, Inc.

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Is Digital Imaging Critical or Is it Just
a New Toy?

• Value in Pathologist Education
• Value in Pathology Practice

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Pathology Education Deficiencies

• Teaching methods limited in teaching certain
  disciplines and skills
• Some skills cannot be taught by current methods
• Some skills not examined by self assessment, a
  requirement of MOC.
• Pathologists accessibility requires better
  electronic tools

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Skills Required in Diagnostic Pathology

• Searching
• Identification
• Classification
• Comparison with previous experience by observer

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Searching Skill

• Searching
• Finding areas of interest
• Skill developed by experience
• Strategies are not taught but are learned
• Time to diagnosis less for skilled versus
  unskilled observers
• Can be detected by evaluating and comparing eye
  movements of novices and experts
• Not taught or glossed over because of limits of
  time

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Whole Slide Imaging is Highly Valuable in
Searching

• Static images are often poor at low magnification
  where searching occurs.
• Since static images include the lesion, the
  searching skill is bypassed.
• Observation of skillful observer by a novice
  promotes learning of searching skills

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Whole Slide Image Heart Transplant Biopsy
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Identification Skill

• Skills needed to identify areas of interest using
  low power visual clues
• Visual clues may not be obvious without training
• Areas on IHC exam to select for HER2 FISH
• Vascular lesions in transplant biopsies
• Areas of lobular carcinoma in breast

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Value in Identification

• Skilled observer can be instructed to define in
  words how the identification occurs while the
  less skilled observer is watching
• Areas of confusion or misidentification can be
  carefully reviewed and discussed
• Artifacts can be defined
• Limited preselected images do not fill this need

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Whole Slide Image HER2 Stained Slide
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Classification Skill

• Ability to compare test object with correctly
  classified objects reproducibly
• Can be combined with identification skill in
  learning
• Requires many high quality images of variously
  classified objects

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Value in Classification

• Combination of identification and classification
  skills is enabled
• Based on interaction with learners, various
  classification clues can be focused on
• Quality of static imaging is improved for
  documentation or teaching
• Number of images that can be easily obtained is
  high.

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Whole Slide Image HER2 Stained Slide
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How Can Such New Technology Be Deployed
Effectively?

• Video microscopy sessions at meetings
• Use unknowns to enhance conversation
• Describe process while doing it
• Webcasts with other members of department as
  intradepartmental consults
• Sessions with resident and staff at time of
  diagnosis.

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Accessibility

• Digital Imaging allows pathologist to practice
  skills
• Any place
• Any time
• Method can be incorporated for self assessment to
  help pathologist define their areas of deficiency

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Whole Slide Image Heart Transplant Biopsy
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Distributed Practice Issues

• Consistent interpretation required because
  Intermountain is a quality healthcare system
• Variable skill and knowledge by group members
• Variable availability of expert resources
• Occasional manpower issues
• Wide geographic separation

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Practice Demographics

• 5 pathology groups
• Distributed over 450 miles
• Group sizes
• 17 most specialties (4 hospitals)
• 4 Dermpath, Hematopath (2 hospitals)
• 3 (x2) Hematopath
• 2 None

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Process

• Pathology groups are separate entities
• Intermittent consultation
• Sharing of expert resources for technical
  functions and some professional functions
• Sharing during manpower shortages
• Communication via phone and courier
• Collegial environment

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Potential Utilities of Whole Slide Microscopy

• Intragroup consultation of specialists
• Intergroup consultation between sites and for
  double read situations
• Intergroup consultation for frozen sections
• Professional sign out of immunohistochemistry
  with or without expert consultation
• Tumor board presentations to clinicians
• Education sessions to improve consistency of
  interpretation and speed of integration on new
  members

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Specialty Consultations

• Faster turn around time because couriers not
  involved
• More common consultation because of increased
  availability
• Opportunity for learning of others because of
  multiple viewing options

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Intragroup Consultation

• Requirement for double reading in many cases
• New diagnosis of cancer
• Prostate needle biopsies
• Difficult cases which might benefit from
  consultation
• Difficult with multisite groups so that
  appropriate second reader might not be used

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Frozen Section Consultation

• Difficult frozens benefit from second opinions
• If no other pathologist on site, this is not
  utilized
• Diagnoses could be improved by having this
  capacity at each hospital

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Sign Out of IHC

• Currently, all IHC done in three sites and slides
  shipped to other sites
• Turn around time 24 hours for off site locations
• Could consolidate technical functions if virtual
  microscopy was available
• No option for dual viewing in difficult cases
• No option to educate new members of group

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Tumor Boards And Clinical Conferences

• One or two each day in largest group
• Slides that need to be included may not be
  available
• Lost in pathologist office
• Only at another hospital
• In process of filing
• Significant time required by pathologist to take
  required static images or drag photoscope to
  conference room

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Education of Group Pathologists

• Intermountain operates by developing standards
  which are transmitted throughout the system using
  data on provider behavior
• Pathologists expected to be consistent and
  complete in reports (data system)
• Education of pathologists required
• Nottingham Score
• HER2 scoring

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Summary

• Digital imaging has great value in improving
  pathology education
• Improving diagnostic skills
• Improving accessibility
• Digital imaging has great value in practice
• Allowing flexibility in sign out and consultation
• Allowing distributed conference functions
• Decreasing courier related process delays