Telepathology - Digital Pathology Association

Report
Pathology Visions 2010
Regional Telepathology in
Fraser Health Authority:
A multisite, multimodality, multidiscipline
deployment.
Dr. I. Scott Cornell
Medical Lead, FHA
Telepathology Project
1
Project Team
Sponsor:
IT:
Technical Coordinator:
Lab Scientists:
Physicians:
Project Manager:
2
Minnie Downey
David Izzard
Gagan Atwal
James Owen
Janet Tunnicliffe – Anatomic Path
Val Horak – Hematology
Kulvinder Mannan – Microbiology
Scott Cornell – AP & Medical Lead
Lawrence Haley - Hematology
Dale Purych - Microbiology
Julie Harrison
2
Introduction
1. Presentation of our 5 year project
2. Results and conclusions to date.
3. Our current deployment.
4. Our take on the future.
3
3
Fraser Health Authority
Location
FHA
4
4
Map of Fraser Health Authority
5
.

12 Hospital sites

150km or 95 miles wide

Serving 1.5 million people

Over 1750 acute care beds
5
Pathology Hub Sites
1
Surgical Pathology Total Accessions 92,000
6
6
The Promise of Digital Pathology








7
Diagnostics
Consultations
Conferencing
Teaching
Quality Assurance
Archiving
Image Analysis
Efficiencies
7
FHA IOC’s for 1 Year
SITE – Hub Site in Red
BH
210
RCH
249
ERH
37
RMH
9
PAH
65
DH
12
ARH
CGH
SMH
LMH
8
Total IOCs (Apr ’08- Mar ’09)
104
46
220
66
Total FHA IOC Cases
1018
Travel IOC Cases
235
8
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.
9
9
Potential Telepathology Application
Anatomic pathology
Frozen Sections
Hematology
Microbiology
Anatomic Pathology
Consultation
Conferencing
Teaching
Archiving
Diagnostics
10
10
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
11
11
Building the Team:
Preparing for RFP
LIS Manager
IT Input
 Financial aspects
 IT Liaison
 IT Manager
 Hardware Specialist
 Privacy & Security
Specialist
 Technical Architect
 Business Case Specialist
AP Lab Scientist
 Technical requirements
 Work flow
12
12
IM/IT
Pathology
13
Admin
13
IM/IT: Project Needs
1.
2.
3.
4.
5.
14
Image Quality & Workflow
Hardware & Software Evaluation
Compatibility with Enterprise
Business Case & RFP Development
Provincial Advisory Group &
Standards Group
14
IM/IT: Enterprise Needs
1. Streaming Impact
2. Storage Impact – integrate with PACS
3. Server Requirements:


Standard
Compatible with FHA desktop
4. Compatible with “Live Meeting” &
“Communicator”
5. Security & Privacy Impact
15
15
IM/IT: Specifics Tasks
 Hardware & Software Evaluations:





16
Standards
Security
Impact on network
Authentication compatibility
Scaleable across our enterprise
16
Phase 2a Focus
Image Quality
 WSI
 Streaming
 Still
17
17
Project
AP IOC: RCH
Single Site Deployment
 Largest FS volume
 Proximity to OR
 Proximity to path lead & team
 Tech training: enroll all Pathologists
Hem & Micro: RCH
Single Site Deployment
 Evaluate all imaging modalities
18
18
Building the Team
Technical Coordinator






19
Histopathology skills
IT skills
Project experience
Motivated
Interpersonal skills
Enthusiasm for concept
19
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
20
20
Frozen Section Room in the OR
21
21
ELMO & Microscope Set up
22
22
Whole Slide Scans
 Slide scanner:
Aperio
 Image management
software: Apollo
PathPACs
23
23
Streaming Image
 Live video
 Gross (macro)
image presenter
 Microscope camera
 Capture FOV
24
24
Action on the gross table…
25
25
Assessing the margins…
26
26
27
27
28
28
Correlation of TP to IOC and Final
Diagnosis
29
54 Cases Total
TP vs. IOC
TP vs. Final
IOC vs. Final
Agree
35 (65%)
37 (69%)
49 (91%)
Minor
Disagreement
17 (31%)
14 (26%)
4 (7%)
Major
Disagreement
2 (4%)
3 (5%)
1 (2%)
29
Image Quality vs. Concordance level
(for TP vs. IOC)
Image Score
Concordance
Level
Agree
Minor
Major
Totals
30
1=Unacceptable,
2=Below Average,
3=Acceptable,
4=Exceeds expectations
1
1
1
2
Image Score
2
3
10
23
8
8
1
19
31
Totals
4
2
2
35
17
2
54/54
30
Image Quality Score of Less Than 3
Out of 54 cases, 21 cases had image score <3
Agree
Image
Score of
<3
(Below average or
Unacceptable.)
31
10 / 35
29%
Minor
Major
Disagreement Disagreement
9 / 17
53%
2/2
100%
31
IOC Case Mix
32
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%
32
Case Type for Major and Minor
Disagreement
33
Tissue type
MINOR
Disagreement
MAJOR
Disagreement
Neuropathology
5
-
Cardio / Thoracic
3
1
Gastrointestinal
1
-
Gynecology
6
1
Other
2
-
33
Phase 2a Findings
 Concordance of WSI to glass was promising
 Technical issues identified:








34
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
34
Conclusions
We are unable to recommend at this time
implementation of this technology for
provision of routine frozen sections
during intraoperative consultations.
35
35
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
36
36
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
37
37
Phase 2b Goals
Heme & Micro
 Deploy to multiple sites
 Evaluate role for
 consultations
 teaching
 conferencing/rounds
38
38
Equipment Deployment
Site
Scanner
Streaming
Camera
Still
Camera
Digital
Presenter
Apollo
software
Trained
users
RCH
2
5
8
2
33
28
7
2
1
14
8
5
2
1
3
3
2
1
1
ARHCC
BH
DH
1
LMH
1
PAH
1
SMH
1
RMH
FHA Total
39
3
1
2
2
1
12
10
1
1
1
2
4
18
14
5
71
58
39
TP vs IOC & TP vs Final
TP vs IOC
Percent of
Total
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%
Agree
Total
40
606
TP vs Final Percent of
Total
606
40
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%
6%
8%
10%
Total
41
41
Raw Case Mix Numbers
Patient Case Mix Types
Total
Percent of Total
Cardiac/Thoracic
Endocrine
Gastrointestinal
Gynecology
Lymph Node
Neuropathology
Other
13
22
9
23
5
132
5
17
226
6%
10%
4%
10%
2%
58%
2%
8%
Pancreatic/Hepatobilliary
Total
42
42
Case Mix/Concordance Discordance
Patient
Case Mix
Types
Major
Total of
% of
Disagreement
Discordance
Discordance
0
0
1
2%
2
1
0
3
6%
4%
1
0
0
1
2%
Gynecology
10%
8
1
2
11
22%
Lymph Node
2%
1
0
1
2
4%
58%
23
2
0
25
49%
Other
2%
0
0
0
0
0%
Pancreatic/Hepato
billiary
8%
5
1
2
8
16%
Cardiac/Thoracic
Endocrine
Gastrointestinal
Neuropathology
43
Concordance
% of
Case
Mix
Minor
Disagreement
6%
1
10%
Disagreement
43
Image Quality as related to TP & IOC
Concordance Level
Image Quality Score
Concordance
Level
44
Total
1
2
3
4
Unaccept
able
Below
Average
Acceptable
Exceeds
Requirements
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
44
Image Quality of Less than Three(3)
Concordance
Level
45
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%
45
AP Conclusions
 Diagnostic Accuracy WSI
 Acceptable
 Image Quality
 Acceptable
46
46
AP Conclusions
 Software:
 Well acceptable
 Minimal training
 Easy to operate
 Well Trained Technical Coordinator
Essential
 Technical quality
 Hardware/software expertise
 Time efficiency
47
47
AP Conculsions
 Remote Gross Specimen Viewing
 Well accepted
 Time efficient
 Education & QA Rounds
 Enhanced plus
 Continue & expand
48
48
Evaluation
Forms
49
49
Hematopathology
1. Case Review Rounds (6 pathologists at 3
sites)
2. Pathologist to Pathologist Consultations
3. Tech to Tech Consultations
4. Educational Rounds
50
50
Heme: Modalities Trialed
 WSI up to 83X oil
 Streaming – dry + oil
 Static: still camera
FOV from streaming
51
51
Heme: Conclusions
1. All modalities unacceptable at this
time for definitive diagnosis
2. Streaming images – images of choice
3. WSI not useful at this time
4. Static images less useful, less flexible
5. Will not currently replace existing
rounds system
52
52
Microbiology
1. Case Review Rounds
2. Pathologist to Pathologist Consultations
3. Educational Rounds
53
53
Micro: Modalities Trialed
1. WSI up to 83X oil
2. Streaming: gross with Elmo
micro to 100X oil
3. Static: still camera
FOV from streaming
54
54
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 best
5. WSI: good for general impression of
specimen quality and general morphology
55
55
Microbiology ELMO Images
56
56
Medical Microbiology
57
57
Medical Microbiology
58
58
Conclusions
1.
2.
3.
59
WSI provides images that satisfy most diagnostic
purposes in AP
WSI does not yet provide images suitable for
diagnostic purposes in routine hematology and
microbiology
WSI - an immature technology not yet suitable for
routine surgical pathology in a practice setting like
ours
59
60
60
61
61
Conclusions
1.
2.
3.
WSI provides images that satisfy most diagnostic
purposes in AP
WSI does not yet provide images suitable for
diagnostic purposes in routine hematology and
microbiology
WSI - an immature technology not yet suitable for
routine surgical pathology in a practice setting like
ours
Issues: Speed
62
62
63
63
Conclusions
1.
2.
3.
WSI provides images that satisfy most diagnostic
purposes in AP
WSI does not yet provide images suitable for diagnostic
purposes in routine hematology and microbiology
WSI - an immature technology not yet suitable for
routine surgical pathology in a practice setting like ours
Issues: Speed
Storage
64
64
65
65
Conclusions
1.
2.
3.
WSI provides images that satisfy most diagnostic
purposes in AP
WSI does not yet provide images suitable for diagnostic
purposes in routine hematology and microbiology
WSI - an immature technology not yet suitable for
routine surgical pathology in a practice setting like ours
Issues: Speed
Storage
Work Flow
66
66
Couldn’t you have
just handed me the
slides?
67
67
Conclusions
1.
2.
3.
WSI provides images that satisfy most diagnostic
purposes in AP
WSI does not yet provide images suitable for diagnostic
purposes in routine hematology and microbiology
WSI - an immature technology not yet suitable for
routine surgical pathology in a practice setting like ours
Issues: Speed
Storage
Work Flow
Redundancy
68
68
69
69
Conclusions
1.
2.
3.
WSI provides images that satisfy most diagnostic
purposes in AP
WSI does not yet provide images suitable for diagnostic
purposes in routine hematology and microbiology
WSI - an immature technology not yet suitable for
routine surgical pathology in a practice setting like ours
Issues: Speed
Storage
Work Flow
Redundancy
Cost
70
70
71
71
Conclusions
1.
2.
3.
4.
5.
72
WSI provides images that satisfy most diagnostic
purposes in AP
WSI does not yet provide images suitable for diagnostic
purposes in routine hematology and microbiology
WSI - an immature technology not yet suitable for
routine surgical pathology in a practice setting like ours
Issues: - Speed
- Work Flow
- Storage - Redundancy
- Cost
WSI is suitable for diagnostic purposes in certain niche
applications
Telepathology in general, using streaming gross &
microscopic images has a broad range of applications
for routine uses that are cost effective and efficient
72
73
73
The Promise of Digital Pathology








74
Diagnostics
Consultations
Conferencing
Teaching
Quality Assurance
Archiving
Image Analysis
Efficiencies
74
The Promise of Digital Pathology
Tomorrow
 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
75
75
The Promise of Digital Pathology
Tomorrow
 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
76
76
The Promise of Digital Pathology
Tomorrow
 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
77
77
THE
END
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