The Laval University (Québec) virtual slide telepathology project;

A structured patient-oriented network involving 21 sites

Bernard Têtu MD, Medical director

Christine Houde MD, Jean BoulangerCo-chairs, telehealth steering committee,

Laval UniversityQuébec, Canada

2www.ulaval.ca

Canada: 34, 108, 752

Québec: 7, 907, 375

3www.ulaval.ca

Integrated University Health Networks

1,729,000 408,760 Km2

4www.ulaval.ca

1

2

3

7

5

30

Density of population and Distribution of pathologists on the territory

5www.ulaval.ca

History of the project

• August 2004: • Quebec MOH mandates the Integrated University Health Networks to develop telehealth in the province.

• Laval University prioritizes telepathology• Fall 2004:

• Creation of telehealth steering committee• Spring 2005:

• Survey on needs and services in the territory

6www.ulaval.ca

Telepathology – clinical context

• Part-time pathologists available:• Schedule of operations depends on the presence of a pathologist

• Difficulty recruiting surgeons

Surgeon’s perspective

7www.ulaval.ca

Telepathology – clinical context

• No pathology department but oncologic surgery:

• Two-step surgeries (sentinel lymph node)• Patient transferred if frozen section expected

• Resection margins not available• Difficulty recruiting surgeons

Surgeon’s perspective

8www.ulaval.ca

Telepathology – clinical context

• Insecurity, especially in early practice• Impossibility to rapidly obtain a second opinion• IHC performed in university hospitals: delays

to get slides back• Limited continued medical education

Pathologist’s perspective

9www.ulaval.ca

Telepathology – clinical context

• Difficulty in being absent without disturbing the organization of the surgical unit

• Average age of pathologists increasing and entries in residency stable: worsening of the shortage is expected

• Resources merely adequate, even in university hospitals

Pathologist’s perspective

10www.ulaval.ca

Telepathology – clinical context

Creaghan Commission, New Brunswick:

Recommendation #12: The Department of Health study and plan for the potential of providing pathology services for regional hospital laboratories through new technology in the field of pathology digital imaging and computer transmission…

Reports of Commissions of Inquiry in Canada

11www.ulaval.ca

Telepathology – clinical context

Cameron Commission, Newfoundland:

Recommendation #24: The Department of Health and Community Services should also ensure that adequate resources are available to fund technical resources such as telemedicine technology, particularly for pathologists who work alone, as well as new technology in the field of pathology digital imaging and computer transmission.

Reports of Commissions of Inquiry in Canada

12www.ulaval.ca

History of the project

• January 2006:• Project charter accepted by the MOH and Canada Health Infoway; phase 0

• Summer 2006:• Extensive consultation of medical teams and professionals to better identify needs and services required

• January 2007:• MOH authorizes the continuation of the project toward further steps

• 6,136,662$ covered equally by MOH and CHI

13www.ulaval.ca

History of the project

• Summer 2008:• Request for proposals

• October 2008:• Call for tender (slide scanner, gross station/videoconferencing and viewer)

• April 2009:• Compliancy testing of technologies (pathologists, technologists, experts in information and change management)

14www.ulaval.ca

History of the project

• Summer 2009:• Final choice of solutions

• Fall 2009:• Contracts, agreements on physician’s fees

• January 2010:• Deployment and validation

• January 2011:• Expected completion of the deployment

15www.ulaval.ca

Aims of the project

• Implement an innovative solution to provide uniform pathology services in the whole Laval University Health Network territory

Main objective

16www.ulaval.ca

Aims of the project

• Provide frozen sections anywhere, anytime• Provide second opinion from a colleague or a

panel of experts• Allow fast return of IHC performed in university

hospitals

Specific objectives

17www.ulaval.ca

Aims of the project

• 21 sites (3 additional possible sites)• 6 hospitals devoid of pathology laboratory• 15 sites with pathology laboratory

• 7 with 1 pathologist• 7 with 2 or more pathologists• 1 with no pathologist

Deployment

18www.ulaval.ca

Slide scanner: nanoZoomer RS & HT

19www.ulaval.ca

Gross station (PathStand) and videoconferencing (Sony HD)

20www.ulaval.ca

Viewer and image sharing solution: mScope, Aurora

21www.ulaval.ca

Internet

Serveur WebSlide

Station devisualisation 2Bus

Schéma simplifié du réseau proposé

RTSS

NanoZoomer HT

Réseau de l'hôpital (grand volume)

Visioconférence

Serveur WebSlide

Station devisualisation 2Bus

NanoZoomer RS

Réseau de l'hôpital (petit volume)

Visioconférence

Accès à distancede l'extérieur du RTSS PathStand

PathStand

Simplified schema of network

A

B

22www.ulaval.ca

Région 01 Bas-Saint-Laurent

3,25 PATHOLOGISTES

Région 02 Saguenay-Lac-St-Jean

7 pathologistes

Région 03 Québec

30 pathologistes

Région 09 Côte-Nord

2 pathologistes

Région 11 Gaspésie-îles-de-la-

Madeleine

1 pathologiste

Région 12 Chaudière-Appalaches

5 pathologistes

CSSS de Matane

O pathologiste

CSSS de la Matapédia

0 pathologiste

CSSS de Kamouraska

0 pathologiste

CSSS Témiscouata

0 pathologiste

CSSS Maria-Chapdeleine

0 pathologiste

CSSS CharlevoixHôpital de la

Malbaie 0 pathologiste

CH de Charlevoix 0 pathologiste

CSSS des Îles0 pahologiste

CSSS du Rocher-Percé

0 pathologiste

CSSS de la Haute-Gaspésie0 pathologiste

CSSS de Beauce1 pathologiste

CSSS de la région de Thetford

0 pathologiste(itinérance)

Hôpital Laval3 pathologistes

CHAUQ12pathologistes

CHUQ15 pathologistes

CSSS Lac St-Jean Est

1 pathologiste

CSSS Domaine du Roy

1 pathologiste

CSSS Baie-des-Chaleurs

0 pathologiste

CSSS de Montmagny

1 pathologiste

Centre local

CentreUniversitaire

Région

CSSS de Rivière-du-Loup

1,25 pathologistes

CSSS de Rimouski-Neigette

2 pathologistes

CSSS de Chicoutimi

5 pathologistes

CSSS de Sept-îles

1 pathologiste

CSSS de Manicouagan1pathologiste

CSSS de la Côte-de-Gaspé1 pathologiste

(+itinérance)

CHAU - Hôtel-Dieu-de-Lévis

3 pathologistes

Centre régional

Health Authorities in Eastern Quebec

23www.ulaval.ca

CSSS Cléophas-Claveau

CSSS de Jonquière

Région 02 Saguenay-

Lac-St-Jean

CSSS Domaine du

Roy

CSSS Maria-Chapdeleine

CSSS Lac St-Jean Est

CSSS de Chicoutimi

CSSS de Témiscouata

CSSS de la Matapédia

CSSS de Kamouraska

CSSS de Matane CSSS du

Rocher Percé

CSSS de la Mitis

CSSS les Basques

CSSS des Etchemins

CSSS du Grand Littoral

Centre Hospitalier

Robert-Giffard

CSSS de Charlevoix

Hôpital Laval

CHAUQHôpital de

l’Enfant-Jésus

CHAUQHôpital du Saint-

Sacrement

CHUQ HôpitalSaint-François

d’assise

Région 01 Bas-Saint-

Laurent

CSSS de Rivière-du-Loup

CSSS de Rimouski-Neigette

Région 03 Québec

CSSS de la Minganie

CSSS de la Haute-Côte-

Nord

CSSS de la Basse-Côte-

Nord

CSSS de Port-Cartier

CLSC Naskapi CSSS de l’Hématite

Région 09 Côte-Nord

Région 11 Gaspésie-îles-de-la-Madeleine

CSSS de la Côte-de-Gaspé

CSSS des Îles

CSSS Baie-des-Chaleurs

Région 12 Chaudière-Appalaches

CSSS de Sept-îles

CSSS de Manicoua-

gan

CHA - Hôtel-Dieu-

de-Lévis

CSSS de Beauce

CSSS de la région de Thetford

CHUQCHUL

CHUQLaboratoire

central

Centre Régional

CSSSCentreUniversitaire

Région

CSSS de Montmagny

CSSS de la Haute-Gaspésie

24www.ulaval.ca

Expected volume of activities

• Over 2000 frozen sections and second opinions • Over 4000 immunohistochemistries returned

by telepathology

25www.ulaval.ca

Governance of the project

Electronic medical record, MOH

Telehealth executive committee

Project manager

Management committee

Medical director

Committee of experts

6 health authorities

26www.ulaval.ca

Committee of experts

• 18 members from university and community hospitals

• Mandate:• Propose organizational models• Develop clinical protocols• Evaluate and select solutions• Advise executive and management committees

• Advise on the deployment of the project (cohesion, respect of project charter)

27www.ulaval.ca

Conclusions: strengths of the project• For patients:

• Improved medical cares• Decreased transfers to regional hospitals• Faster diagnoses and treatment

• For pathologists:• Easier access to second opinion • Decreased professional isolation

• For organizations:• Easier recruitment of surgeons and pathologists

• Less movement of pathologists = efficiency• Easily transportable technology

28www.ulaval.ca

Future direction

• Grant application:• « Partnerships for health system improvement »

• Canadian Institutes of Health Research• Objectives:

• General: evaluation of telepathology to improve the quality of cares

29www.ulaval.ca

Future direction• Specific objectives:

• Patients: • Transfers prevented• two step surgeries prevented

• Pathologists• Consultations performed• TAT for cases with IHC• Overall satisfaction

• Organisations : • Stability of the frozen section coverage• Time saved to start treatment• Retention of pathologists and surgeons

30www.ulaval.ca