Combined robotic and nonrobotic telepathology as an integral service component of a geographically dispersed laboratory network

doi:10.1053/hupa.2001.29644

Human Pathology

Volume 32, Issue 12, December 2001, Pages 1300-1303

https://doi.org/10.1053/hupa.2001.29644 Get rights and content

Abstract

To achieve real-time connectivity between its 8 hopital-based laboratories, Veterans Integrated Service Network (VISN) 12, headquartered in Chicago, IL, has implemented a hybrid dynamic store-and-forward (HDSF) telepathology network that extends across portions of 3 states. The majority of diagnostic telepathology functions are provided to the 3 hospitals (Iron Mountain, MI; Tomah, WI; and North Chicago, IL), which lack on-site pathologists and are serviced by the 4 pathologists located in Milwaukee, WI. In surgical pathology, routine primary diagnosis, frozen section diagnosis, and clinical consultation are provided with telepathology. In addition, autopsy and specialty clinical conferences are frequently performed by using telepathology. Telepathology has been applied to a variety of areas within clinical pathology as well, including protein electrophoresis, immunoelectrophoresis, peripheral blood smears, body fluids, microbiology, and distance learning. Implementation of telepathology has allowed VISN 12 to reach the goal of providing a single standard of accurate and timely pathology service, even at small sites that lack an on-site pathologist. HUM PATHOL 32:1300-1303. Copyright © 2001 by W.B. Saunders Company

Section snippets

Telecommunications

VISN 12 has implemented a WAN that allows integration of data, voice, video, and diagnostic imaging systems. In addition to telepathology, the WAN enables real-time teleradiology (general, computed tomography scan, and ultrasound), telefluoroscopy, telenuclear medicine imaging, telepsychiatry, and teleconsultation.

When initially installed, software allowed only point-to-point connections between any 2 sites on the WAN.¹³ In May 2001, software was upgraded to allow multisite connectivity between

Telepathology applications

Current applications of telepathology in VISN 12 are outlined in Table 1 and described as follows.

. Summary of uses of telepathology in VISN 12

Anatomic pathology

Surgical pathology

Frozen section diagnoses

Routine primary diagnoses

Clinical consultation

Autopsy pathology

Autopsy conferences conducted remotely

Gross and microscopic images sent electronically to attending physician

Gross images to be entered into VistA imaging system (future function)

Clinical conference support

Specialty conferences

Discussion

Telepathology networking is an essential tool in the VISN 12 P&LMS product line, in which the clinical laboratories are separated by distances of up to 320 miles. Experience in VISN 12 shows that telepathology is useful not only for anatomic pathology, but for all areas of the clinical laboratory in which viewing of macroscopic or microscopic images is important.¹¹ In VISN 12, use of telepathology is not limited to pathologists; skilled technologists in areas such as microbiology, hematology,

Summary

In summary, telepathology serves as an integral service component within the geographically dispersed multihospital laboratory network that composes VISN 12. Increased access to pathologists has proven especially valuable at the rural VAMC laboratories, where it is difficult to recruit pathologists because of geographic isolation and increasing cost constraints. By increasing access to pathologists and technologists within the P&LMS product line, telepathology networking has become an essential

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Cited by (31)

Precise identification of cell and tissue features important for histopathologic diagnosis by a whole slide imaging system
2020, Journal of Pathology Informatics
Background: Previous studies have demonstrated the noninferiority of pathologists’ interpretation of whole slide images (WSIs) compared to microscopic slides in diagnostic surgical pathology; however, to our knowledge, no published studies have tested analytical precision of an entire WSI system. Methods: In this study, five pathologists at three locations tested intra-system, inter-system/site, and intra- and inter-pathologist precision of the Aperio AT2 DX System (Leica Biosystems, Vista, CA, USA). Sixty-nine microscopic slides containing 23 different morphologic features suggested by the Digital Pathology Association as important to diagnostic pathology were identified and scanned. Each of 202 unique fields of view (FOVs) had 1-3 defined morphologic features, and each feature was represented in three different tissues. For intra-system precision, each site scanned 23 slides at three different times and one pathologist interpreted all FOVs. For inter-system/site precision, all 69 slides were scanned once at each of three sites, and FOVs from each site were read by one pathologist. To test intra- and inter-pathologist precision, all 69 slides were scanned at one site, FOVs were saved in three different orientations, and the FOVs were transferred to a different site. Three different pathologists then interpreted FOVs from all 69 slides. Wildcard (unscored) slides and washout intervals were included in each study. Agreement estimates with 95% confidence intervals were calculated. Results: Combined precision from all three studies, representing 606 FOVs in each of the three studies, showed overall intra-system agreement of 97.9%; inter-system/site agreement was 96%, intra-pathologist agreement was 95%, and inter-pathologist agreement was 94.2%. Conclusions: Pathologists using the Aperio AT2 DX System identified histopathological features with high precision, providing increased confidence in using WSI for primary diagnosis in surgical pathology.
Primary frozen section diagnosis by robotic microscopy and virtual slide telepathology: the University Health Network experience
2009, Seminars in Diagnostic Pathology
Citation Excerpt :
A more contemporary definition of TP would include the use of the internet to link a pathologist to a glass slide. Some centers have used TP extensively for routine surgical pathology,3-6 whereas others have used it more selectively for pathologist-to-pathologist consultation with frozen sections.7,8 TP was first used for primary frozen section diagnosis in 1989 in Norway,9 where video telemicroscopy was used to provide intra-operative coverage with 100% accuracy to five remote hospitals.
Although telepathology (TP) has not been widely implemented for primary frozen section diagnoses, interest in its use is growing as we move into an age of increasing sub-specialization and centralization of pathology services. University Health Network (UHN) is a 3-site academic institution in downtown Toronto. The pathology department is consolidated at its Toronto General Hospital (TGH) site. The Toronto Western Hospital (TWH), located 1 mile to west of TGH, has no on-site pathologist and generates 5-10 frozen section cases per week. Over 95% of these frozen sections are submitted by neurosurgeons, in most cases to confirm the presence of lesional tissue and establish a tissue diagnosis. In 2004, we implemented a robotic microscopy (RM) TP system to cover these frozen sections. In 2006, we changed to a virtual slide (VS) TP system. Between November 2004 and September 2006, 350 primary frozen section diagnoses were made by RM. An additional 633 have been reported by VS TP since October 2006, giving a total of 983 frozen sections from 790 patients. Eighty-eight percent of these cases have been single specimens with total turnaround times averaging 19.98 and 15.68 minutes per case by RM and VS TP, respectively (P < 0.0001). Pathologists required an average of 9.65 minutes to review a slide by RM. This decreased 4 fold to 2.25 minutes following the change to VS TP (P < 0.00001). Diagnostic accuracy has been 98% with both modalities and our overall deferral rate has been 7.7%. Mid-case technical failure has occurred in 3 cases (0.3%) resulting in a delay where a pathologist went to TWH to report the frozen section. Discrepant cases have typically involved minor interpretive errors related to tumor type. None of our discrepant TP diagnoses have had clinical impact to date. We have found TP to be reliable and accurate for frozen section diagnoses. In addition to its superior speed and image quality, the VS approach readily facilitates consultation with colleagues on difficult cases. As a result, there has been greater overall pathologist satisfaction with VS TP.
Robotic surgical telepathology between the Iron Mountain and Milwaukee Department of Veterans Affairs Medical Centers: a twelve year experience
2009, Seminars in Diagnostic Pathology
Citation Excerpt :
In our previous analysis, approximately half of the deferrals occurred because the special stain requested was not performed at Iron Mountain VAMC while the other half were deferred because of the perceived difficulty of the case.4 In contrast, in the present report, all pathologists, including senior Pathologist B, have stated that the main reason for deferral of cases to LM was the perception of recurrent pathologist shortages relative to workload coupled with the longer time required to read cases by TP, as noted previously.3,5 Of interest, the overall deferral rate of Pathologist B increased approximately four-fold from 2.5% in our original report4 to 10.7% (Table 5) in the present analysis.
Since mid-1996 we have operated a diagnostic robotic telepathology (TP) system at the Iron Mountain, Michigan, Department of Veterans Affairs Medical Center (VAMC) from the Milwaukee, Wisconsin VAMC, located some 220 miles away. No on-site pathologist is present in Iron Mountain. Instead, an experienced, well-trained pathologist assistant, under direction of pathologists located in Milwaukee, is responsible for tissue grossing and sectioning. The pathologist assistant places slides onto the stage of the robotic microscope, which is then controlled by pathologists in Milwaukee. Each case read by TP is subsequently read by light microscopy (LM) by the same pathologist. Three distinct phases of TP have been recognized. Our experience during Phase I (mid-1996 through early 1999) has been published previously. During Phase II (early 1999 through mid-2004), one of the two senior telepathologists in Phase I retired and three junior pathologists were hired. During Phase III (mid-2004 though June 2008), two new junior pathologists were hired and ASAP Imaging (Apollo Telemedicine, Inc., Falls Church, VA) was implemented. The number of TP case opportunities in Phases I, II and III was 2,200; 5,841 and 3,512; respectively resulting in a total of 11,553. A total of 1,834 cases were deferred to LM for a variety of reasons. The number of TP diagnoses rendered in Phases I, II and III was 2,144; 4,636 and 2,939; respectively, for a total of 9,719. The major discordance rates in Phases I, II and III were 0.33%, 0.45% and 0.20%, respectively with an overall rate of 0.35%. Pathologist-specific discordance rates were not significantly different and ranged from a low of 0.12% to a high of 0.77%, while case deferral rates were significantly different (P < 0.0001) and ranged from 2.5% to 28.7%. In general, no relationship between deferral rate and discordance rate was noted. Iron Mountain clinicians have expressed great satisfaction with the services provided by their off-site pathologist colleagues.
Robotic surgical telepathology between the Iron Mountain and Milwaukee Department of Veterans Affairs Medical Centers: a 12-year experience
2009, Human Pathology
Citation Excerpt :
During phases I, II, and III of this analysis, a total of 2200, 5841, and 3512 case opportunities for TP were available, respectively (Table 1). Cases were deferred to LM for a variety of reasons including case difficulty, requirement for consultation from another pathologist, requirement for special or immunostains not performed at Iron Mountain, and “short staffing” because in our experience reading cases by TP requires more time than reading by LM [2-5]. The overall deferral rates during phases I, II, and III were 2.5%, 20.6%, and 16.3%, respectively.
Since mid-1996, we have operated a diagnostic robotic telepathology (TP) system at the Iron Mountain, MI, Department of Veterans Affairs Medical Center (VAMC) from the Milwaukee, WI, VAMC, located some 220 miles away. No on-site pathologist is present in Iron Mountain. Instead, an experienced, well-trained pathologist assistant, under direction of pathologists located in Milwaukee, is responsible for tissue grossing and sectioning. The pathologist assistant places slides onto the stage of the robotic microscope, which is then controlled by pathologists in Milwaukee. Each case read by TP is subsequently read by light microscopy (LM) by the same pathologist. Three distinct phases of TP have been recognized. Our experience during phase I (mid-1996 to early 1999) has been published previously. During phase II (early 1999 to mid-2004), 1 of the 2 senior telepathologists in phase I retired, and 3 junior pathologists were hired. During phase III (mid-2004 to June 2008), 2 new junior pathologists were hired, and ASAP Imaging (Apollo Telemedicine, Inc., Falls Church, VA) was implemented. The number of TP case opportunities in phases I, II, and III was 2200, 5841, and 3512, respectively, resulting in a total of 11 553. A total of 1834 cases were deferred to LM for a variety of reasons. The number of TP diagnoses rendered in phases I, II, and III was 2144, 4636, and 2939, respectively, resulting in a total of 9719. The major discordance rates in phases I, II, and III were 0.33%, 0.45%, and 0.20%, respectively, with an overall rate of 0.35%. Pathologist-specific discordance rates were not significantly different and ranged from a low of 0.12% to a high of 0.77%, whereas case deferral rates were significantly different (P < .0001) and ranged from 2.5% to 28.7%. In general, no relationship between deferral rate and discordance rate was noted. Iron Mountain clinicians have expressed great satisfaction with the services provided by their off-site pathologist colleagues.
Primary frozen section diagnosis by robotic microscopy and virtual slide telepathology: the University Health Network experience
2009, Human Pathology
Citation Excerpt :
A more contemporary definition of TP would include the use of the internet to link a pathologist to a glass slide. Some centers have used TP extensively for routine surgical pathology [3-6], whereas others have used it more selectively for pathologist-to-pathologist consultation with frozen sections [7,8]. TP was first used for primary frozen section diagnosis in 1989 in Norway [9], where videotelemicroscopy was used to provide intraoperative coverage with 100% accuracy to 5 remote hospitals.
Although telepathology (TP) has not been widely implemented for primary frozen section diagnoses, interest in its use is growing as we move into an age of increasing subspecialization and centralization of pathology services. University Health Network is a 3-site academic institution in downtown Toronto. The pathology department is consolidated at its Toronto General Hospital (TGH) site. The Toronto Western Hospital (TWH), located 1 mile to west of TGH, has no on-site pathologist, and generates 5 to 10 frozen section cases per week. More than 95% of these frozen sections are submitted by neurosurgeons, in most cases to confirm the presence of lesional tissue and establish a tissue diagnosis. In 2004, we implemented a robotic microscopy (RM) TP system to cover these frozen sections. In 2006, we changed to a virtual slide (VS) TP system. Between November 2004 and September 2006, 350 primary frozen section diagnoses were made by RM. An additional 633 have been reported by VS TP since October 2006, giving a total of 983 frozen sections from 790 patients. Of these cases, 88% have been single specimens with total turnaround times averaging 19.98 and 15.68 minutes per case by RM and VS TP, respectively (P < .0001). Pathologists required an average of 9.65 minutes to review a slide by RM. This decreased 4-fold to 2.25 minutes after the change to VS TP (P < .00001). Diagnostic accuracy has been 98% with both modalities, and our overall deferral rate has been 7.7%. Midcase technical failure has occurred in 3 cases (0.3%) resulting in a delay, where a pathologist went to TWH to report the frozen section. Discrepant cases have typically involved minor interpretive errors related to tumor type. None of our discrepant TP diagnoses has had clinical impact to date. We have found TP to be reliable and accurate for frozen section diagnoses. In addition to its superior speed and image quality, the VS approach readily facilitates consultation with colleagues on difficult cases. As a result, there has been greater overall pathologist satisfaction with VS TP.
An array microscope for ultrarapid virtual slide processing and telepathology. Design, fabrication, and validation study
2004, Human Pathology
This paper describes the design and fabrication of a novel array microscope for the first ultrarapid virtual slide processor (DMetrix DX-40 digital slide scanner). The array microscope optics consists of a stack of three 80-element 10 x 8-lenslet arrays, constituting a “lenslet array ensemble.” The lenslet array ensemble is positioned over a glass slide. Uniquely shaped lenses in each of the lenslet arrays, arranged perpendicular to the glass slide constitute a single “miniaturized microscope.” A high-pixel-density image sensor is attached to the top of the lenslet array ensemble. In operation, the lenslet array ensemble is transported by a motorized mechanism relative to the long axis of a glass slide. Each of the 80 miniaturized microscopes has a lateral field of view of 250 microns. The microscopes of each row of the array are offset from the microscopes in other rows. Scanning a glass slide with the array microscope produces seamless two-dimensional image data of the entire slide, that is, a virtual slide. The optical system has a numerical aperture of N.A. = 0.65, scans slides at a rate of 3 mm per second, and accrues up to 3,000 images per second from each of the 80 miniaturized microscopes. In the ultrarapid virtual slide processing cycle, the time for image acquisition takes 58 seconds for a 2.25 cm² tissue section. An automatic slide loader enables the scanner to process up to 40 slides per hour without operator intervention. Slide scanning and image processing are done concurrently so that post-scan processing is eliminated. A virtual slide can be viewed over the Internet immediately after the scanning is complete.
A validation study compared the diagnostic accuracy of pathologist case readers using array microscopy (with images viewed as virtual slides) and conventional light microscopy. Four senior pathologists diagnosed 30 breast surgical pathology cases each using both imaging modes, but on separate occasions. Of 120 case reads by array microscopy, there were 3 incorrect diagnoses, all of which were made on difficult cases with equivocal diagnoses by light microscopy. There was a strong correlation between array microscopy vs. “truth” diagnoses based on surgical pathology reports. The kappa statistic for the array microscopy vs. truth was 0.96, which is highly significant (z = 10.33, p < 0.001). There was no statistically significant difference between rates of agreement with truth between array microscopy and light microscopy (z = 0.134, p > 0.05). Array microscopy and light microscopy did not differ significantly with respect to the number/percent of correct decisions rendered (t = 0.552, p = 0.6376) or equivocal decisions rendered (t = 2.449, p = 0.0917). Pathologists rated 95.8% of array microscopy virtual slide images as good or excellent. None were rated as poor. The mean viewing time for a DMetrix virtual slide was 1.16 minutes.
The DMetrix virtual slide processor has been found to reduce the virtual slide processing cycle more than 10 fold, as compared with other virtual slide systems reported to date. The virtual slide images are of high quality and suitable for diagnostic pathology, second opinions, expert opinions, clinical trials, education, and research.

View all citing articles on Scopus

^*: Address correspondence and reprint requests to Bruce E. Dunn, MD, Zablocki VA Medical Center, Pathology and Laboratory Medicine Service (113), 5000 West National Ave, Milwaukee, WI 53295-1000.

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Telepathology SymposiumCombined robotic and nonrobotic telepathology as an integral service component of a geographically dispersed laboratory network*

Abstract

Section snippets

Telecommunications

Telepathology applications

Discussion

Summary

Hum Pathol

Hum Pathol

Hum Pathol

Current status of telepathology

APMIS

Telepathology in Europe. Its practical use

Arch Anat Cytol Pathol

Experience and present status of telepathology in the National Cancer Center Hospital, Tokyo

Zentralbl Pathol

Telepathology

Telepathology

Am J Surg Pathol

Dynamic robotic telepathology on-line: Summary of first 200 cases

Cell Vision

Telepathology Symposium
Combined robotic and nonrobotic telepathology as an integral service component of a geographically dispersed laboratory network*