robotic telepathology: practical applications
DESCRIPTION
Robotic Telepathology: Practical Applications. Bruce E. Dunn, M.D. Chief Pathologist, Veterans Integrated Service Network (VISN) 12 Professor and Vice-Chair, Dept of Pathology, Medical College of Wisconsin. Conflict-of-interest statement. - PowerPoint PPT PresentationTRANSCRIPT
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Robotic Telepathology: Practical Applications
Bruce E. Dunn, M.D.
Chief Pathologist, Veterans Integrated Service Network (VISN) 12
Professor and Vice-Chair, Dept of Pathology, Medical College of Wisconsin
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Conflict-of-interest statement
Bruce E. Dunn, MD has no financial interest in any commercially-available telepathology system
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21 Veterans Integrated Service Networks (VISNs)
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Hospitals and CBOCs in VISN 12
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Robotic Telepathology (TP) at Iron Mtn
• Iron Mountain is an active, rural DVA hospital with a general surgery program– 1000 - 1500 surgical pathology cases per year– Occasional frozen sections requested
• 1996: part-time Iron Mountain pathologist retired• Full implementation of commercial hybrid
dynamic store/forward system operated by two senior pathologists in Milwaukee
• Feasibility study performed - published in 1997
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Three Phases of Robotic TP at Iron Mtn
• Phase I: mid-1996 – early 1999– Two senior surgical pathologists exclusively read cases with
extensive documentation– 2,200 cases available for TP– Summary published in 1999
• Phase II: early 1999 – end of 2004– One senior pathologist retired; three junior pathologists hired– Consolidation in VISN resulted in increased AP workload– 5,841 cases available for TP
• Phase III: 2005 – present (through July 2006)– One original senior pathologist and two new pathologists– ASAP ImagingTM implemented– 2,015 cases available for TP through July 2006
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Objectives
• Compare rates of case deferral and major TP discordance with light microscopy (LM) among seven pathologists during three phases of robotic telepathology
• Compare rates of major discordance before and after implementing the ASAP ImagingTM system
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Summary of Cases (1999)
Organ/system Percent of totalGastrointestinal 42.9Skin 27.5Prostate 10.2Hernia sac 3.8Urinary bladder 2.6Bone/synovium/tendon 2.1Penis/testis/spermatic cord 1.9Gallbladder 1.3Extremity amputation 1.1Appendix 0.5Gynecologic 0.5Breast 0.3Miscellaneous 5.2
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Technical Aspects of Workflow
• Tissue grossed in Iron Mtn by experienced PA (tele-gross imaging available)
• Slides processed by Iron Mtn histotechnician
• Telepathology systems “linked up”
• PA places slides onto stage in Iron Mtn
• Pathologist controls robotic microscope remotely from Milwaukee
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Current and Future
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Robotic Microscopy• Commercial hybrid dynamic store/forward system• Olympus microscope with motorized stage, objectives,
lighting control• CODEC used for gross & microscopic imaging and
videoconferencing• 4x,10x, 20x 40x 100 (oil free) objectives• Dynamic imaging: 350 x 288 x 24-bit color• Static imaging: 1520 x 1144 x 24-bit color• Images transmitted at 768 kbps over WAN• 2005: ASAP ImagingTM enables remote access with live
streaming imaging
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VISN 12 Telepathology Network
Hines
Madison
Tomah
NorthChicago
Westside
Milw
IronMtn
VHA WANInternet
VHA WANInternet
DR
DR
GS
RM
DR
GS
NRM
NRM
NRM
GS
NRM
NRM
KEYPOP – point of presenceVistA – VA computerized patient record system
WAN
POP
POP
POP
POP
POP
POP
POP
Multi-siteconferencing
DR
DR
POP
DedicatedServer
Current and Future
Tomah
Madison
Hines
Hines Micro
Iron Mtn
Milwaukee
N. Chicago
Chicago
Interface to HIS
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Current and Future
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Methods• Each of 7 pathologists read cases by TP, completed
reports where appropriate, then read same cases by LM• Over 50% of cases read by second pathologist by LM• Revised reports generated based on LM diagnosis, if
necessary, and clinician notified • Reasons for case deferral to LM documented• Pathologist-specific rates of deferral and discordance
determined • Notes:
– TURP and bone marrow cases deferred automatically– Gastric biopsies reviewed for H. pylori-like organisms by PA
in Iron Mtn by LM
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Current and Future
Non-Robotic Telepathology System
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Deferral to Light Microscopy
• Reasons for deferral: case difficulty, need for consultation, special or immuno stains, “short staffing”
• If case referred to Milwaukee due to computer unavailability (malfunction or upgrade), or the assigned pathologist was not yet competent to use telepathology, then case not counted as a deferral
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Discordance Rates by Pathologist
• Deferred cases not included
• Major discordance– Benign versus malignant– Different patient outcome or therapy
• Report modified and clinician called
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Phase I Individual SummariesPathologist A B Total
Total opportunities 1121 1079 2200
No. deferred 34 22 56
Deferral rate (%) 3.0 2.0 2.5
TP cases 1087 1057 2144
Maj discord 5 2 7
Discordance (%) 0.46 0.19 0.33
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Phase II Individual SummariesPathologist B C D E Total
Total opportunities 2231 1582 1031 997 5841
No. deferred 319 290 270 326 1205
Defer rate (%) 14.3 18.3 26.2 32.7 20.6
TP cases 1912 1292 761 671 4636
Maj discord 7 5 8 1 21
Discordance (%) 0.37 0.39 1.05 0.15 0.45
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Phase III Individual Summaries (ASAP) (July 2006)
Pathologist B D E F G Total
Total opportunities 795 17 185 683 335 2015
No. deferred 40 0 12 78 65 195
Deferral rate (%) 5.0 0 6.5 11.4 19.4 9.7
TP cases 755 17 173 605 270 1820
Maj discord 1 0 0 2 1 4
Discordance (%) 0.13 0 0 0.33 0.37 0.22
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Comparison by Phase (July 2006)
Phase I II III Total
Total opportunities 2,200 5,841 2,015 10,056
No. deferred 56 1,205 195 1,456
Deferral rate (%) 2.5 20.6 9.7 14.5
TP cases 2,144 4,636 1,820 8,600
Maj discord 7 21 4 32
Discordance (%) 0.33 0.45 0.22 0.37
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Pathologist B: Major concordance rate (N=3,724)(July 2006)
95
96
97
98
99
100
0-10
0
201-
300
401-
500
601-
700
801-
900
1001
-110
0
1201
-130
0
1401
-150
0
1601
-170
0
1801
-190
0
2001
-210
0
2201
-230
0
2401
-250
0
2601
-270
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-290
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-310
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3201
-330
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3401
-350
0
3601
-370
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% c
onco
rdan
ce
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Pathologist-Specific Discordance Rates
0.12
0.270.33 0.37 0.39
0.46
1.03
0
0.2
0.4
0.6
0.8
1
1.2
E B F G C A D
Pathologist
Dis
cord
ance
Rat
e (%
)
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Major Discordance Rate by Technology (July 2006)
Pathologist
Technology B E All
Pre-ASAP 0.30 0.15 0.41*
ASAP 0.13 0 0.22
*0.33 excluding pathologist D
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Summary
• Pathologist-specific discordance rates ranged from 0.12% to 1.03%, with median of 0.37% and overall rate of 0.37%
• Despite extensive experience of one senior pathologist, occasional discordances continue to occur
• The rates of discordance using ASAP ImagingTM are lower that those observed previously
• All TP cases continue to be reviewed by LM
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References
• Dunn, B.E., U.A. Almagro, H. Choi, N.K. Sheth, J.S. Arnold, D.L.Recla, E.A. Krupinski, A.R. Graham and R.S. Weinstein. 1997. Dynamic-robotic telepathology: Department of Veterans Affairs feasibility study. Human Pathol. 28:8-1.
• Dunn, B.E., H. Choi, U.A. Almagro, D.L. Recla, and R.S. Weinstein. 1999. Routine surgical telepathology in the Department of Veterans Affairs: Experience-related improvements in pathologist performance in 2200 cases. Telemed J. 5:323-337.