Pathology Visions 2010

1. Pathology Visions 2010 Regional Telepathology in Fraser Health Authority: A multisite, multimodality, multidiscipline deployment. Dr. I. Scott Cornell Medical Lead, FHA Telepathology Project

2. Project Team Sponsor: Minnie Downey IT: David Izzard Gagan Atwal Technical Coordinator: James Owen Lab Scientists: Janet Tunnicliffe – Anatomic Path Val Horak – Hematology Kulvinder Mannan – Microbiology Physicians: Scott Cornell – AP & Medical Lead Lawrence Haley - Hematology Dale Purych - Microbiology Project Manager: Julie Harrison

3. Introduction • Presentation of our 5 year project • Results and conclusions to date. • Our current deployment. • Our take on the future.

4. Fraser Health AuthorityLocation FHA

5. Map of Fraser Health Authority • 12 Hospital sites. • 150km or 95 miles wide • Serving 1.5 million people • Over 1750 acute care beds

6. 11,500 Pathology Hub Sites Surgical Pathology Total Accessions 92,000 19,500 37,000 24,000

7. The Promise of Digital Pathology • Diagnostics • Consultations • Conferencing • Teaching • Quality Assurance • Archiving • Image Analysis • Efficiencies

8. FHA IOC’s for 1 Year

9. 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.

10. Potential Telepathology Application

11. 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

12. LIS Manager Financial aspects IT Liaison AP Lab Scientist Technical requirements Work flow IT Input IT Manager Hardware Specialist Privacy & Security Specialist Technical Architect Business Case Specialist Building the Team:Preparing for RFP

13. IM/IT Pathology Admin

14. IM/IT: Project Needs • Image Quality & Workflow • Hardware & Software Evaluation • Compatibility with Enterprise • Business Case & RFP Development • Provincial Advisory Group & Standards Group

15. IM/IT: Enterprise Needs • Streaming Impact • Storage Impact – integrate with PACS • Server Requirements: • Standard • Compatible with FHA desktop • Compatible with “Live Meeting” & “Communicator” • Security & Privacy Impact

16. IM/IT: Specifics Tasks • Hardware & Software Evaluations: • Standards • Security • Impact on network • Authentication compatibility • Scaleable across our enterprise

17. Phase 2a Focus Image Quality • WSI • Streaming • Still

18. 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

19. Building the Team Technical Coordinator • Histopathology skills • IT skills • Project experience • Motivated • Interpersonal skills • Enthusiasm for concept

20. 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

21. Frozen Section Room in the OR

22. ELMO & Microscope Set up

23. Whole Slide Scans • Slide scanner: Aperio • Image management software: Apollo PathPACs

24. Streaming Image • Live video • Gross (macro) image presenter • Microscope camera • Capture FOV

25. Action on the gross table…

26. Assessing the margins…

29. Correlation of TP to IOC and Final Diagnosis

30. Image Quality vs. Concordance level (for TP vs. IOC) Image Score 1=Unacceptable, 2=Below Average, 3=Acceptable, 4=Exceeds expectations

31. Image Quality Score of Less Than 3 Out of 54 cases, 21 cases had image score <3

32. IOC Case Mix

33. Case Type for Major and Minor Disagreement

34. Phase 2a Findings • Concordance of WSI to glass was promising • Technical issues identified: • 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

35. Conclusions We are unable to recommend at this time implementation of this technology for provision of routine frozen sections during intraoperative consultations.

36. 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

37. 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

38. Phase 2b Goals Heme & Micro • Deploy to multiple sites • Evaluate role for • consultations • teaching • conferencing/rounds

39. Equipment Deployment

40. TP vs IOC & TP vs Final

41. Review Pathologist Discordance Rate

42. Raw Case Mix Numbers

43. Case Mix/Concordance Discordance

44. Image Quality as related to TP & IOC Concordance Level

45. Image Quality of Less than Three(3)

46. AP Conclusions • Diagnostic Accuracy WSI • Acceptable • Image Quality • Acceptable

47. AP Conclusions • Software: • Well acceptable • Minimal training • Easy to operate • Well Trained Technical Coordinator Essential • Technical quality • Hardware/software expertise • Time efficiency

48. AP Conculsions • Remote Gross Specimen Viewing • Well accepted • Time efficient • Education & QA Rounds • Enhanced plus • Continue & expand

49. Evaluation Forms

50. Hematopathology • Case Review Rounds (6 pathologists at 3 sites) • Pathologist to Pathologist Consultations • Tech to Tech Consultations • Educational Rounds