Technology Evolution in Pathology:Technology Evolution in Pathology:The University Health Network Experience The University Health Network Experience

Across OntarioAcross Ontario

Sylvia L. Asa, MD, PhDPathologist-in-Chief

Medical Director, Laboratory Medicine Program

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ObjectivesObjectives

• The nature of pathology practice in Ontario• The reason for a centralized laboratory program• The IT requirements for success of centralized

pathology• The reason for using digital imaging

Participants should have an understanding of:

AssumptionsAssumptions

• A single payer, publically funded health care system

• A large geographic area with population concentration in 5 large centers

• A shortage of Pathologists

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Initial StatusInitial Status• Multiple hospitals of variable size scattered

throughout the province– Toronto (GTA) has 7 major teaching hospitals and 35

other hospitals

– 5 medical schools in various cities with 1-5 affiliated hospitals

– Other large cities with large, full-service hospitals

– Many small towns with hospitals of varying size

• Each hospital is operated as an independent entity with funding from the Ontario Ministry of Health and Long-term Care

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Historical IssuesHistorical Issues

• 1990s Ontario determined that – Health care costs were too high– Pathology was a dying field – There would be no need for Pathologists in the

next century– Training programs in Pathology were slashed

Outcome: major shortages of Pathologists emerged in late 1990s-2000

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Healthcare Reform 1990sHealthcare Reform 1990s

• Regional planning for healthcare (LHINs)

• Consolidation of hospitals6

The University Health NetworkThe University Health Network

• A consolidation of three U f T affiliated teaching hospitals

• Programmatic restructuring– TGH cardiac care; transplantation; advanced

medicine and surgery– PMH cancer care– TWH neurosciences, musculoskeletal care,

community health

• Laboratory consolidation7

The University Health NetworkThe University Health Network

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~ 1 mile

The Challenge: Lab ConsolidationThe Challenge: Lab Consolidation

• 3 physical sites

• 3 cultures

• 3 missions of the academic institution:– Complex patient care– Education– Research

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Proposed SolutionProposed Solution

• A single core department

• Electronic support for specimen tracking and handling at 3 sites

• Highly subspecialized expertise– Biochemistry - Microbiology– Hematology, Transfusion & Hematopathology– Subspecialty Anatomical Pathology– HLA - Molecular/Genetics

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Solution: Step 1Solution: Step 1

LIS implementation goals:

• Best-of-breed approach to support high volume complex testing

• Integration in e-chart with e-orders

• Specimen tracking and management

• Integration of lab data from all disciplines into a consolidated report

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Solution: Step 1Solution: Step 1

LIS implementations:

• Core Lab automation and middleware

• CoPath solution for Pathology

• Transfusion Medicine LIS

• HLA Histotrack

• Upgrade existing Shire for molecular lab and interface with CoPath

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Solution: Step 2Solution: Step 2• Analyze workflow

and clinical needs

• Build core labs and satellites– State-of-the-art

space and equipment– Tubes where possible– Rapid response labs where required– On-site accessioning and grossing for surgical

pathology with enhanced PA support

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Informatics: Voice RecognitionInformatics: Voice Recognition

• Dragon-speech integrated with LIS

means instant reporting without

the need for dictatyping

Solution: Step 3Solution: Step 3

• Recruit appropriate medical and technical expertise

• Create teams of experts who integrate with clinical staff in priority programs: The Pathologist as Medical Consultant

“As is your pathology, so goes your clinical care.”

Sir William Osler15

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Subspecialty PathologySubspecialty Pathology

• All cases reported by a pathologist with expertise in the specific subspecialty required

• Benefits:– Better quality and faster patient care– Fiscal responsibility: 1 pathologist per case– Pathologist satisfaction – enhanced academic

excellence

• Challenges:– Requirement for appropriate staffing in all areas

and redundancy

Solution: Step 4Solution: Step 4

• Implement telepathology for intraoperative consultations and frozen sections at non-core sites– Phase 1: Robotic microscopy– Phase 2: Digital WSI

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Historical Data: TelepathologyHistorical Data: Telepathology

• 1973: Washington DC diagnosis of leukemia via satellite from Brazil

• 1986: Dr. Ronald Weinstein coins name

• 1990s: Norway implements robotic microscopy to support frozen sections in remote hospitals

• 2003 ? Why Not UHN

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Barriers to TelepathologyBarriers to Telepathology

• Cost – cheaper than another pathologist!• FDA approval – not applicable in Canada• Billing/CPT codes – not applicable• Turnaround time - overcome• Pathologist issues

– learning curve/accuracy– “images are good, but not ready for prime time”

Th Philosophical ResponseTh Philosophical Response

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In a time of drastic change it is the learners who inherit the future. The learned usually find

themselves equipped to live in a world that no

longer exists.Eric Hoffer

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Due Diligence Before Going LiveDue Diligence Before Going Live• Medical Malpractice Insurance Provider

– Canadian Medical Protective Association (CMPA)– telepathology will not affect coverage

• UHN Medical Advisory Committee– SOP presented for approval

• Health Canada – Therapeutic Products Program– telepathology does not involve “medical devices” (no direct contact between

instrument and patient) – no federal approval required

• Surgeon Education– demonstrating the robotic microscope/slide scanner

• essential to get surgeon buy-in!

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The Robotic System:The Robotic System: November 2004-October 2006 November 2004-October 2006

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Toronto GeneralTelepathology Work Station

Toronto WesternSurgical Pathology

The Robotic System:The Robotic System: November 2004-October 2006 November 2004-October 2006

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Whole-Slide Imaging:Whole-Slide Imaging: October 2006-Present October 2006-Present

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Whole-Slide Imaging:Whole-Slide Imaging: System Parameters System Parameters

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UHN Telepathology ProtocolUHN Telepathology Protocol• System test each morning • Pathologist reviews daily O.R. list and communicates

game plan for the day to histotechnologist • Surgeon defines tissue of interest• Histotechnologist contacts Pathologist

- specimen description, processing specimen • Histotechnologist at TWH scans the slide and calls the

Pathologist • Pathologist speaks with the surgeon by telephone• QA the next day

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1003 Frozen Sections from 802 1003 Frozen Sections from 802 Patients (Nov 2004-Sept 2008)Patients (Nov 2004-Sept 2008)

0

200

400

600

800

1000

1200

Robotic Total

# Frozen Sections

653

1003

350

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Performance: 1003 Cases/4 Years Performance: 1003 Cases/4 Years • Accuracy

– 98% concordance with final pathology– Not a function of technology

• Deferral rates– Identical to on-site rates– NOT a function of technology

• Sometimes you just don’t know for sure• Sampling issues in the frozen section biopsy

• Turnaround times– Well within 20 minutes required

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TAT Single Block Frozen SectionsTAT Single Block Frozen Sections

02468

101214161820

Robotic WSIFrozenSection

WSIFrozen +

Smear

Total TAT

**

* p < 0.0001

Receipt of tissue to report of diagnosis

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Pathologist Interpretation TimePathologist Interpretation Time

0123456789

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Robotic WSIFrozen

WSIFrozen +

Smear

Time/slide (min)

4-fold

Pathologists tended to go to TWH site for multi-block cases when using the robotic microscope – not so for whole-slide imaging.

*

*

* p < 0.00001

Receipt of image toReport of diagnosis

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WSI Pathologist Interpretation TimeWSI Pathologist Interpretation Time

0

5

10

15

20

25

30

35

40

< 1 1-2 > 2

% of Cases

Minutes/slide

32%

38%

30%

* 70% of cases reported in < 2 minutes after scan is received

Failure Mode AnalysisFailure Mode Analysis

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• PRE-CASE:– Network failure

– Moving the scanner within the surgical pathology lab• static vs dynamic IP addresses

• discovered on morning test run.

• MID-CASE: – Minute/pale pieces of tissue that the scanner would not

“recognize”

– Excess mounting media causing the cover slip to stick to the scanner objective

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Subspecialty Support for FS Subspecialty Support for FS

Subspecialty Model Subspecialty Model

• How do we get the two liver pathologists to read transplant biopsies and attend all academic meetings?

Telepathology solution– USCAP 2008 all rush biopsies read on laptops

at the meeting

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Subspecialty Model Subspecialty Model

• How do we get the subspecialty support for weekend coverage?

Telepathology solution– Summer 2008 all weekend cases read on

laptops at the home/cottage etc.

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Subspecialty Model Subspecialty Model

• How do we get the pituitary expert to read a tough biopsies when she is in Istanbul?

Telepathology Blackberry solution

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Ontario-Wide ImplementationOntario-Wide Implementation

• Timmins and District Hospital forms an alliance with 9 other hospitals in North East Ontario

• Seeks Laboratory Medical Directorship

• UHN provides a suitable proposal– Team of subspecialists to support all clinical

needs from core in Toronto

• Initiation of a new model

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Google Maps 2008

422 miles

LHIN # 13

***

******

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LHIN # 7

Ontario NE Cluster ImplementationOntario NE Cluster Implementation

Configurations in NE OntarioConfigurations in NE Ontario

• Small hospitals going to POCT only

• Medium hospitals on-site labs with POCT

• Largest hospital with full lab and surgical pathology accessioning, grossing by PA with webcam support– All smaller hospitals send AP specimens to

core in Timmins – Complex testing referred to UHN

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Subspecialty ModelSubspecialty Model

• Requires sign-out of all cases by subspecialist– Slides shipped to Toronto by overnight courier

• FS review by subspecialist must be available

• Ultimately no pathologist on siteTelepathology solution

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The Ultimate SolutionThe Ultimate Solution

• $3M grant from government to implement high resolution digital imaging at all sites– All abnormal blood smears, malaria,

microbiology gram stains, CSFs, etc

• Plan to expand FS service to hospitals that have not had this available

• CoPath integration of digital imaging in future will alleviate need for any slide transportation

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Pros and Cons of LIS IntegrationPros and Cons of LIS Integration

Pros

• Fast

• E-filed into right location

• Integration of gross, micro, EM, molecular

• Remote access and who has (need) access

Cons

• Images “trapped” and need for export for other purposes

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Google Maps 2008

422 miles

LHIN # 13

***

******

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LHIN # 7

Addition of New ClientsAddition of New Clients

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The Future of Pathology?The Future of Pathology?

+

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The Future of PathologyThe Future of Pathology

+

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The Future of PathologyThe Future of PathologyThe best way to predict the future is to invent it

Alan Kay

What About Academia?What About Academia?

• Digital education

• Digital documentation of the biobank– The “Biobank” is the current phraseology for

the “Department of Pathology”

• Scanning and automated analysis of TMAs

• Scientific Advances– Laboratories must evaluate,

develop, and apply the genotypic and phenotypic analyses of specimens

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AcknowledgementsAcknowledgements• Pathologists

– Andrew Evans– Runjan Chetty– Blaise Clarke– Sidney Croul– Bayardo Perez-Ordonez– Rasmus Kiehl

• Surgeons– Mark Bernstein– Abhijit Guha– Fred Gentili– Chris Wallace– Michael Fehlings– Mojgan Hodaie– Jaime Escallon

• Histotechnologists– Suganthi Ilaalagan– Sofia Aguierre– Alfreda Antonio– Carsen Chan– Gordon Chin– Norman Hew-Shue– Pam McCartin– Aparna Pant– Ann Marie Scott– Henry Wu

• IT Support– Greg Lewis– Karen Jaquardt

Vendor SupportLeica MicrosystemsQuorum Technology/Aperio