Digital Morphology and EQA Michelle Brereton, John Burthem, Keith Hyde.

1. (H) Digital Morphology and EQA Michelle Brereton, John Burthem, Keith Hyde. Manchester Royal Infirmary. www.manlab.co.uk UK NEQAS(H) www.ukneqas-haem.org.uk

2. (H) Digital Morphology Imaging Aim of Project To assess the emerging role of digital imaging and web-based technology in morphological education, EQA and CPD NEQAS participant driven – questionnaire feedback

3. (H) United Kingdom External Quality Assessment ServiceHaematology - UK NEQAS (H)Morphology Scheme Started in 1968 – updated in 1979 • >500 participant centres UK (80 non UK labs) • 8 surveys per year - 2 cases per survey. • Age, Sex, Hb and WBC. • Choose 5 morphological features – offer a diagnosis. • Glass slides via post.

4. (H) United Kingdom External Quality Assessment ServiceHaematology - UK NEQAS (H)Morphology Scheme Returns and Reports via post: • Histogram of morphological features (coded) • List of 5 most commonly reported features • Brief case history / medical features/ additional laboratory results • Diagnosis and Expert opinion

6. (H) Web Based Morphology Exercises 2001 • 2 cases from previous surveys. • 5 digital images on each case. • Participants view via web site. • Limited response n = 30

7. (H) Digital Image 2001 More Images per case. Improve picture quality.

8. (H) Web Based Morphology Exercises 2003 • Survey Report: A single case, 12 images with expert opinion and consensus results. • Pilot exercise: Educational element, participant involvement. (Response n = 128)

9. Tutorial: Slide 4 Feature 3 119 giant platelet 3 megakaryocyte fragment

10. Tutorial: Slide 4 Feature 8 101 megakaryocytic fragment 15 giant platelet 4 smear cell

11. Tutorial: Slide 4 Feature 6 67/128 acanthocyte 40/128 echinocyte 11/128 spherocyte

12. (H) Priorities for 2004 (1) Survey Report - Multiple Images with Expert Opinion: via Web • Archive / education record • Images from each survey with results and feedback • Image Library of NEQAS surveys since 2002 • Moving to CPD

13. www.manlab.co.uk Image Library.

14. (H) Priorities for 2004 (2) Electronic slide • Develop larger field of view • Maintain resolution • Use computer software to change field of view • Precious material • All see the same cells

15. Photograph single “high power” images

16. Take multiple “overlapping” fields

17. Computer software matches fields

19. And “stitches” a composite image

20. Assemble many fields to make image larger….

21. And larger…….

22. Etc…..

23. While still retaining details that can be viewed at high power

25. Stitched “digital slide” 2001 www.manlab.co.uk Department of Morphology

26. “stitched” digital slide for 2004 www.ukneqas-haem.org.uk www.manlab.co.uk morphology

27. (H) Exercise for 2004 4 cases from previous surveys • Participants not informed that images were actual surveys. • Cases chosen were 0001BF2 (HbSS), 0002BF1 (Bcell PLL),0403BF1 (CGL) and 0403PA1 (malaria) • 40 images “stitched” per case • Images presented with same basic information given with standard surveys (age, sex, WBC, Hb). • Participants asked to give 5 comments per case Result sheets and questionnaire returned to UK NEQAS(H)

28. (H) Response • 166 returned completed coded morphology forms. • 162 also completed questionnaire

29. (H) Was the image of adequate size to allow an opinion?

30. (H) Rate the Exercise

31. (H) Rate the Exercise (overview) 2.7 Comparison to glass 3.5 Download time 3.8 CPD 4.1 Follow-up 4.2 Archive 4.6 Teaching aid 4.6 “Rare” Image Poor OK Excellent

32. (H) The cases: 0001BF2(HbSS) 0403BF1 (CGL) 0403PA1 (P.Ovale) 0002BF1 (Bcell PLL)

33. (H) 0403BF1 (CGL)

34. (H) 0403BF1 (CGL)

35. (H) 0001BF2 (HbSS) ** ** Responses: Sickle disorder: 84% HA: 4% Splenectomy: 5%

36. (H) 0002BF1 (Bcell PLL) ** ** ** Diagnosis virtual: CLL (33); LPD (26) PLL (25) lymphoma (11) AL (9) CMML (2) viral (2)

37. (H) 0403PA1 (P.Ovale) **

38. (H) Summary Digital Imaging for Morphology in EQA • Participant Driven from digital web exercises. • ???s with survey feedback and expert opinion.

39. Future developments

41. (H) UK NEQAS (H) EQA and Education Continuing Professional Development • Participant Driven from digital web exercises. • Image Library - Multiple images with survey feedback and expert opinion. • UK NEQAS registered with IBMS executive for CPD scheme 2005. • Individuals, rather than centres, react to images of morphology.

42. (H) UK NEQAS (H) CPD Scheme – Pilot via Web • Participant centres asked to nominate and register an individual. • View selected surveys via the web. • Comment on images and provide reflective notes. • Return reports to UK NEQAS. • 250 participants currently registered for phased trial. • First 50 start18th April 2005.

43. (H) UK NEQAS (H) CPD Pilot – Process • Register with UK NEQAS(H) nationally • 2 CPD points for registration • 1 point per case reviewed • Accumulate 18 points per year • Complete Reflective Form, Specific to Pilot. • CPD credits awarded by UK NEQAS(H).

44. (H) Acknowledgements Manchester Royal Infirmary www.manlab.co.uk John Ardern. Michelle Brereton. John Burthem. Lois Hickman. Claire Hutchinson. Keith Hyde. Manchester Metropolitan and Salford Universities. Len Seal. Andrew Serrant. Emma Wells. UK NEQAS (H) www.ukneqas-haem.org.uk Paul McTaggart. Barbara De La Salle. John Parker-Williams. Participants of the NEQAS morphology scheme.