technology evolution in pathology: the university health network experience across ontario sylvia l....
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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:
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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
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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
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The University Health NetworkThe University Health Network
8
~ 1 mile
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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
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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
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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”
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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
10
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
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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
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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
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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
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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