pathology visions 2010
DESCRIPTION
Pathology Visions 2010. Regional Telepathology in Fraser Health Authority: A multisite, multimodality, multidiscipline deployment. Dr. I. Scott Cornell Medical Lead, FHA Telepathology Project. Project Team. Sponsor:Minnie Downey IT:David Izzard Gagan Atwal - PowerPoint PPT PresentationTRANSCRIPT
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Pathology Visions 2010
Regional Telepathology in Fraser Health Authority:
A multisite, multimodality, multidiscipline deployment.
Dr. I. Scott CornellMedical Lead, FHA
Telepathology Project
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Project Team
Sponsor: Minnie DowneyIT: David Izzard
Gagan AtwalTechnical Coordinator: James OwenLab Scientists: Janet Tunnicliffe – Anatomic Path
Val Horak – Hematology
Kulvinder Mannan – Microbiology
Physicians: Scott Cornell – AP & Medical Lead
Lawrence Haley - Hematology
Dale Purych - Microbiology
Project Manager: Julie Harrison
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Introduction
1. Presentation of our 5 year
project
2. Results and conclusions to date.
3. Our current deployment.
4. Our take on the future.
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Fraser Health AuthorityLocation
FHA
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Map of Fraser Health Authority
12 Hospital sites .
150km or 95 miles wide
Serving 1.5 million people
Over 1750 acute care beds
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Pathology Hub Sites
Surgical Pathology Total Accessions 92,000
11,500
24,000
37,000
19,500
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The Promise of Digital Pathology
Diagnostics Consultations Conferencing Teaching Quality Assurance Archiving Image Analysis Efficiencies
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FHA IOC’s for 1 YearSITE – Hub Site in Red
Total IOCs (Apr ’08- Mar ’09)
BH 210
RCH 249
ERH 37
RMH 9
PAH 65
DH 12
ARH 104
CGH 46
SMH 220
LMH 66
Total FHA IOC Cases 1018
Travel IOC Cases 235
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Project Goals
Evaluate the use of digital imaging technology as part of the Intraoperative Consultation process
Evaluate the potential transition of the technical duties from the pathologist to a qualified Histotechnologist.
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Potential Telepathology Application
HematologyMicrobiology
Anatomic Pathology
Consultation
Teaching
Archiving
Conferencing
Diagnostics
Anatomic pathology
Frozen Sections
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Project Background
Funded: Provincial Laboratory Coordinating
Office (PLCO) Canada Health Infoway (CHI) FHA
Phase 1 – 2005 to 2007 Technology review Business case (Project Budget) RFP for equipment and software
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Building the Team:Preparing for RFP
LIS Manager Financial aspects IT Liaison
AP Lab Scientist Technical
requirements Work flow
IT Input IT Manager Hardware Specialist Privacy & Security
Specialist Technical Architect Business Case
Specialist
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IM/IT
Pathology Admin
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IM/IT: Project Needs
1. Image Quality & Workflow2. Hardware & Software Evaluation3. Compatibility with Enterprise4. Business Case & RFP
Development5. Provincial Advisory Group &
Standards Group
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IM/IT: Enterprise Needs
1. Streaming Impact2. Storage Impact – integrate with PACS3. Server Requirements:
Standard Compatible with FHA desktop
4. Compatible with “Live Meeting” & “Communicator”
5. Security & Privacy Impact
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IM/IT: Specifics Tasks
Hardware & Software Evaluations: Standards Security Impact on network Authentication compatibility Scaleable across our enterprise
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Phase 2a Focus
Image Quality WSI Streaming Still
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Project
AP IOC: RCHSingle Site Deployment
Largest FS volume Proximity to OR Proximity to path lead & team Tech training: enroll all Pathologists
Hem & Micro: RCHSingle Site Deployment
Evaluate all imaging modalities
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Building the Team
Technical Coordinator Histopathology skills IT skills Project experience Motivated Interpersonal skills Enthusiasm for concept
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Phase 2a
August 2007 to April 2008 Evaluation of digital imaging for
Intraoperative Consultations (IOC) at RCH Technology – hardware, software, and network Role of Technical Coordinator Collection of IOC metrics Development of operating and training
documents
Enhancements Initial review by Hematology and Medical
Microbiology ? expansion to other FHA sites / users
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Frozen Section Room in the OR
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ELMO & Microscope Set up
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Whole Slide Scans
Slide scanner: Aperio
Image management software: Apollo PathPACs
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Streaming Image
Live video Gross (macro)
image presenter Microscope
camera
Capture FOV
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Action on the gross table…
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Assessing the margins…
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Correlation of TP to IOC and Final Diagnosis
54 Cases Total
TP vs. IOC TP vs. Final IOC vs. Final
Agree 35 (65%) 37 (69%) 49 (91%)
Minor Disagreemen
t
17 (31%) 14 (26%) 4 (7%)
Major Disagreemen
t
2 (4%) 3 (5%) 1 (2%)
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Image Quality vs. Concordance level
(for TP vs. IOC)Image Score 1=Unacceptable,
2=Below Average, 3=Acceptable,
4=Exceeds expectations
Concordance Level
Image Score Totals
1 2 3 4
Agree - 10 23 2 35
Minor 1 8 8 - 17
Major 1 1 - - 2
Totals 2 19 31 2 54/54
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Image Quality Score of Less Than 3
Out of 54 cases, 21 cases had image score <3
Agree Minor Disagreeme
nt
Major Disagreeme
nt
Image Score of
<3(Below average
orUnacceptable.)
10 / 3529%
9 / 1753%
2 / 2100%
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IOC Case Mix
Tissue type Raw count of cases Percent of total cases
Neuropathology 26 48%
Cardio / Thoracic 10 19%
Gastrointestinal 8 15%
Gynecology 7 13%
Other 3 5%
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Case Type for Major and Minor Disagreement
Tissue type MINOR Disagreement
MAJOR Disagreement
Neuropathology 5 -
Cardio / Thoracic 3 1
Gastrointestinal 1 -
Gynecology 6 1
Other 2 -
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Phase 2a Findings
Concordance of WSI to glass was promising Technical issues identified:
Stain consistency Section consistency Resolution / 1st time capture Image magnification
TC role - skilled histotechnologist is essential
Time to acquire image Storage capacity Remote grossing appeared advantageous
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Conclusions
We are unable to recommend at this time implementation of this technology for provision of routine frozen sections during intraoperative consultations.
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Future Plans
Deploy software to all surgical pathologists at RCH & select users at other sites
On-going evaluation of H&E staining Incorporate 40X images routinely Use of WSI for AP rounds Heme & Micro expanded evaluations Assess PathPACs and LIS integration
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Phase 2b Goals
Anatomic Pathology IOC’s:
Expand WSI correlations to 3 pathologists 200+ cases
TC role: encourage greater use of skills by Paths
Encourage use of remote grossing & WSI viewing during an IOC
Evaluate off site remote grossing WSI for all AP rounds
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Phase 2b Goals
Heme & Micro Deploy to multiple sites Evaluate role for
consultations teaching conferencing/rounds
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Equipment Deployment
Site ScannerStreaming Camera
Still Camera
Digital Presente
r
Apollo software
Trained users
RCH 2 5 8 2 33 28
ARHCC 7 2 1 14 8
BH 5 2
DH 1 1 3
LMH 1 1 3 2
PAH 1 1 1
SMH 1 2 2 1 12 10
RMH 1 1 1 2 4
FHA Total
3 18 14 5 71 58
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TP vs IOC & TP vs Final
TP vs IOC Percent of Total
TP vs Final
Percent of Total
Agree 555 91.6% 558 92.1%Minor Disagreement
41 6.8% 30 5%
Disagreement
5 0.8% 11 1.8%
Major Disagreement
5 0.8% 7 1.2%
Total 606 606
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Review Pathologist Discordance Rate
Pathologist #1
Pathologist #2
Pathologist #3
Percent Minor Disagreement
5% 7% 9%
Percent Disagreement
0% 0% 1%
Percent Major Disagreement
1% 1% 0%
Total 6% 8% 10%
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Raw Case Mix NumbersPatient Case Mix Types Total Percent of Total
Cardiac/Thoracic 13 6%
Endocrine 22 10%
Gastrointestinal 9 4%
Gynecology 23 10%
Lymph Node 5 2%
Neuropathology 132 58%
Other 5 2%Pancreatic/Hepatobilliary
17 8%
Total 226
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Case Mix/Concordance Discordance
Patient Case Mix Types
Concordance% of Case Mix
Minor Disagreemen
t
Disagreement
Major Disagreemen
t
Total of Discordance
% of Discordance
Cardiac/Thoracic
6% 1 0 0 1 2%
Endocrine 10% 2 1 0 3 6%Gastrointestinal 4% 1 0 0 1 2%Gynecology 10% 8 1 2 11 22%Lymph Node 2% 1 0 1 2 4%Neuropathology 58% 23 2 0 25 49%Other 2% 0 0 0 0 0%Pancreatic/Hepatobilliary
8% 5 1 2 8 16%
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Image Quality as related to TP & IOC Concordance Level
Concordance Level
Image Quality ScoreTotal1 2 3 4
Unacceptable
Below Averag
e
Acceptable Exceeds Requirement
s
Agreement - 32 386 137 555
Minor Disagreement
- 4 22 15 41
Disagreement
- 1 4 - 5
Major Disagreement
- 1 4 - 5
Total - 38 416 152 606
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Image Quality of Less than Three(3)
Concordance Level
Image Quality Score of less than 3
Total Cases Cases with Image score of< 3
Percent of Total
Agreement 555 32 6%
Minor Disagreement
41 4 10%
Disagreement
5 1 20%
Major Disagreement
5 1 20%
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AP Conclusions
Diagnostic Accuracy WSI Acceptable
Image Quality Acceptable
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AP Conclusions
Software: Well acceptable Minimal training Easy to operate
Well Trained Technical Coordinator Essential Technical quality Hardware/software expertise Time efficiency
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AP Conculsions
Remote Gross Specimen Viewing Well accepted Time efficient
Education & QA Rounds Enhanced plus Continue & expand
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Evaluation Forms
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Hematopathology
1. Case Review Rounds (6 pathologists at 3 sites)
2. Pathologist to Pathologist Consultations
3. Tech to Tech Consultations4. Educational Rounds
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Heme: Modalities Trialed
WSI up to 83X oil Streaming – dry + oil Static: still camera
FOV from streaming
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Heme: Conclusions
1. All modalities unacceptable at this time for definitive diagnosis
2. Streaming images – images of choice
3. WSI not useful at this time4. Static images less useful, less
flexible5. Will not currently replace existing
rounds system
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Microbiology
1. Case Review Rounds2. Pathologist to Pathologist
Consultations3. Educational Rounds
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Micro: Modalities Trialed
1. WSI up to 83X oil2. Streaming: gross with Elmo
micro to 100X oil3. Static: still camera
FOV from streaming
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Micro: Conclusions
1. Major role at this time - Educational Rounds & Documentation
2. Images by all modalities are not yet adequate for diagnostic uses
3. Imaging not yet adequate to incorporate into routine use
4. Static image capture: still camera best5. WSI: good for general impression of
specimen quality and general morphology
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Microbiology ELMO Images
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Medical Microbiology
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Medical Microbiology
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Conclusions
1. WSI provides images that satisfy most diagnostic purposes in AP
2. WSI does not yet provide images suitable for diagnostic purposes in routine hematology and microbiology
3. WSI - an immature technology not yet suitable for routine surgical pathology in a practice setting like ours
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Conclusions
1. WSI provides images that satisfy most diagnostic purposes in AP
2. WSI does not yet provide images suitable for diagnostic purposes in routine hematology and microbiology
3. WSI - an immature technology not yet suitable for routine surgical pathology in a practice setting like ours
Issues: Speed
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Conclusions
1. WSI provides images that satisfy most diagnostic purposes in AP
2. WSI does not yet provide images suitable for diagnostic purposes in routine hematology and microbiology
3. WSI - an immature technology not yet suitable for routine surgical pathology in a practice setting like ours
Issues: SpeedStorage
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Conclusions
1. WSI provides images that satisfy most diagnostic purposes in AP
2. WSI does not yet provide images suitable for diagnostic purposes in routine hematology and microbiology
3. WSI - an immature technology not yet suitable for routine surgical pathology in a practice setting like ours
Issues: SpeedStorageWork Flow
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Couldn’t you have just handed me the
slides?
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Conclusions
1. WSI provides images that satisfy most diagnostic purposes in AP
2. WSI does not yet provide images suitable for diagnostic purposes in routine hematology and microbiology
3. WSI - an immature technology not yet suitable for routine surgical pathology in a practice setting like ours
Issues: SpeedStorageWork FlowRedundancy
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Conclusions
1. WSI provides images that satisfy most diagnostic purposes in AP
2. WSI does not yet provide images suitable for diagnostic purposes in routine hematology and microbiology
3. WSI - an immature technology not yet suitable for routine surgical pathology in a practice setting like ours
Issues: SpeedStorageWork FlowRedundancyCost
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Conclusions
1. WSI provides images that satisfy most diagnostic purposes in AP
2. WSI does not yet provide images suitable for diagnostic purposes in routine hematology and microbiology
3. WSI - an immature technology not yet suitable for routine surgical pathology in a practice setting like ours
Issues: - Speed - Work Flow- Storage - Redundancy- Cost
4. WSI is suitable for diagnostic purposes in certain niche applications
5. Telepathology in general, using streaming gross & microscopic images has a broad range of applications for routine uses that are cost effective and efficient
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The Promise of Digital Pathology
Diagnostics Consultations Conferencing Teaching Quality Assurance Archiving Image Analysis Efficiencies
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The Promise of Digital PathologyTomorrow
Diagnostics Anatomic Pathology
Intraoperative Consultations at RCH Trial scanning of daily pathology workload Capture of gross room specimen images Surgical Pathology off site gross images
Consultations AP
WSI and Streaming Hematopathology
Streaming images between Hematopathologists
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Conferencing Anatomic Pathology
Weekly surgical pathology conference Breast conference Combined gastrointestinal / surgical pathology conference Regional AP conference ( Web access or Live Meeting)
Hematopathology Multi site conference
Teaching / Education Hematopathology and Medical Microbiology
Teaching archive Anatomic Pathology
Teaching archive – Residents, laboratory staff, laboratory students
Quality Assurance Anatomic Pathology
Internal technical QA review Breast Receptor Immunohistochemistry
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Archiving Medical Microbiology
Images for procedure / documentation Image Analysis
Immunohistochemistry – Prognostic markers Efficiencies
All departments Interface to laboratory Information System
Anatomic Pathology Frozen section gross completed from office Surgical pathology scanned images available to view by
off site pathologist Hematopathology
Multisite pathologist consultations
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