TELEPATHOLOGY: REMOTE INTRAOPERATIVE CONSULTATION

Experience at Ketchikan General Hospital, Ketchikan, Alaska

Berle Stratton, MD, FCAP

Northwest Pathology, PS

Bellingham, Washington

Mission: Stewardship of Community, Hospital, Medical Staff and Pathology Laboratory• Quality & Safety

• Strategic

• Financial

Incentives: Engage Hospital Administrationand Medical Staff

• Improve patient outcomes: Quality and Safety

• Reduce hassles and wasted time

• Understand the organization’s culture

• Understand the legal opportunities and barriers

Engaging Physicians in a Shared Quality Agenda. Innovations Series 2007, Institute for Healthcare Improvement.

Incentives: Telepathology Intraoperative Consultation

• Community• Improve access to local

healthcare

• Consider Critical Access Hospitals

• Hospital Administration• Increase autonomy

• Retain procedures

• Improve efficiency

• Reduce cost

• Medical Staff• Increase autonomy

• Retain procedures

• Improve efficiency

• Improve recruitment

• Pathologist• Improve efficiency

• Reduce cost*

Critical Access Hospitals (CAH)

• Purpose– Certified to receive cost-based reimbursement from Medicare

– Reimbursement program

• improves financial performance

• reduce hospital closures

• Criteria for Eligibility– Rural, and

– one of the following:

• 35 miles distant from another hospital, or

• 15 miles from another hospital in mountainous terrain or areas with only secondary roads

Barriers in North Puget Sound and Southeast Alaska

• Geography

• Distance

• Roadless

Northwest Pathology service area

Puget Sound ferry routes

Washington – Alaska ferry routes

Ketchikan, Tongass Narrows, Gravina Island

Ketchikan, Tongass Narrows ferry

Infamous Gravina Island “Bridge to Nowhere”

Alaska Factoids: In-State Flight Emergency Kit

• One axe or hatchet

• One knife

• One pistol, revolver, shotgun or rifle and ammunition for same

• Two small signaling devices such as colored smoke bombs, etc.

• Two small boxes of matches

• Food for each occupant sufficient to sustain life for two weeks

• One first aid kit

• One small gill net and an assortment of tackle such as hooks, flies, lines, sinkers, etc.

• One mosquito head net for each occupant

Ketchikan Factoids: Potpourri

• Population: 7,368 (2010); 5th most populous city

• Longest day: 19 hours

• Shortest day: 6 hours

• Rainfall: 152 inches

• Snowfall: 37 inches

• Temperature Average: July 65°F, January 39°F

Ketchikan, Deer Mountain, Tongass Channel

Ketchikan General Hospital

Ketchikan General Hospital

Telepathology

• Technology– Whole slide imaging (WSI)

– Gigabyte pixel resolution

– Submicron resolution corresponds to 20x - 40x microscope objective lenses

• Access anywhere, anytime– WSI on computer monitor

simulates microscope

– Global access via internet

– Primary diagnosis, quantitative comparison, case sharing and collaboration, image analysis, remote intraoperative consults, data mining for decision support, personalized medicine.

– Redefining the standard of care

Tecotzky, R: Benefits of digital pathology. Laboratory, 2008 August;7(8):40.Singh, A: Big picture, big rewards—how to think about digital. CAP Today, October 2009.

Gross Examination

Microscopic Examination

Low, medium, high power resolution

Images by Alex Milne

Low, medium, high power resolution

Resources

• Hospital IT department

• Personnel– Histotechnologist

• Gross examination

• Frozen section

• Smear preparation

• Stain

• Scan

– Available 40 hours per week

• Equipment– Telepathology system

– Gross examination system

– Pathologist computer system

Implementation: Training and Validation

• Gross telepathology

• Microscopic telepathology– Scanning technique

– Software i.e. image browser

• Validation– 20 cases in each of six

specimen categories; 120 cases total

– Require 90% concordance with known assessments

– Specimens for diagnosis• Frozen sections

• Sentinel lymph node smears

• Blood smears

• Body fluids

– Specimens for adequacy• CT and US-guided needle

biopsy imprints

• FNA

Management: Quality Assurance

• Quality Assurance Programs– Concordance of intraoperative vs. final diagnosis

– Periodic internal telepathology proficiency cases

• Scanning

• Interpretation

– Turnaround Time

• “Practice” with other programs– Scan/interpret proficiency programs i.e. CAP PIP program

– Conferences i.e. tumor board

Legal: Physician State Licensure

“Pathologist Could Be Held Liable for Remote Review of Biopsy”1

• State license may be required to “practice in the state” from which biopsy originated.

– Washington State pathologist rendered a medical diagnosis for an Idaho resident without holding a license to practice medicine in Idaho.

– [Idaho resident] v. [Washington State Laboratory], W.D. Wash.2, No. C09-1662, 12/30/10

– “ Under Washington law, there are no limits on the practice of an out-of-state physician, provided [the pathologist] does not open an office in Washington.”

– “On the other hand, Idaho has created an aggressive statute to prevent unlicensed out-of-state doctors from practicing on Idaho residents.”

1 G2 Reports, March, 20112 U.S. District Court for the Western District of Washington

Conclusion

• Future of Digital Pathology– Not if, but when

• Your laboratory– Partial vs. complete solution

TELEPATHOLOGY: REMOTE INTRAOPERATIVE CONSULTATION

Experience at Ketchikan General Hospital, Ketchikan, Alaska

Berle Stratton, MD, FCAP

Northwest Pathology, PS

Bellingham, Washington