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Digital Imaging in Education and Distributed Pathology Practice

Digital Imaging in Education and Distributed Pathology Practice. Elizabeth H Hammond MD Professor of Pathology University of Utah and Intermountain Healthcare Executive Editor for Pathology Amirsys, Inc. Is Digital Imaging Critical or Is it Just a New Toy?.

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Digital Imaging in Education and Distributed Pathology Practice

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  1. Digital Imaging in Education andDistributed Pathology Practice Elizabeth H Hammond MD Professor of Pathology University of Utah and Intermountain Healthcare Executive Editor for Pathology Amirsys, Inc.

  2. Is Digital Imaging Critical or Is it Just a New Toy? • Value in Pathologist Education • Value in Pathology Practice

  3. Pathology Education Deficiencies • Teaching methods limited in teaching certain disciplines and skills • Some skills cannot be taught by current methods • Some skills not examined by self assessment, a requirement of MOC. • Pathologists accessibility requires better electronic tools

  4. Skills Required in Diagnostic Pathology • Searching • Identification • Classification • Comparison with previous experience by observer

  5. Searching Skill • Searching • Finding areas of interest • Skill developed by experience • Strategies are not taught but are learned • Time to diagnosis less for skilled versus unskilled observers • Can be detected by evaluating and comparing eye movements of novices and experts • Not taught or glossed over because of limits of time

  6. Whole Slide Imaging is Highly Valuable in Searching • Static images are often poor at low magnification where searching occurs. • Since static images include the lesion, the searching skill is bypassed. • Observation of skillful observer by a novice promotes learning of searching skills

  7. Whole Slide Image Heart Transplant Biopsy

  8. Identification Skill • Skills needed to identify areas of interest using low power visual clues • Visual clues may not be obvious without training • Areas on IHC exam to select for HER2 FISH • Vascular lesions in transplant biopsies • Areas of lobular carcinoma in breast

  9. Value in Identification • Skilled observer can be instructed to define in words how the identification occurs while the less skilled observer is watching • Areas of confusion or misidentification can be carefully reviewed and discussed • Artifacts can be defined • Limited preselected images do not fill this need

  10. Whole Slide Image HER2 Stained Slide

  11. Classification Skill • Ability to compare test object with correctly classified objects reproducibly • Can be combined with identification skill in learning • Requires many high quality images of variously classified objects

  12. Value in Classification • Combination of identification and classification skills is enabled • Based on interaction with learners, various classification clues can be focused on • Quality of static imaging is improved for documentation or teaching • Number of images that can be easily obtained is high.

  13. Whole Slide Image HER2 Stained Slide

  14. How Can Such New Technology Be Deployed Effectively? • Video microscopy sessions at meetings • Use unknowns to enhance conversation • Describe process while doing it • Webcasts with other members of department as intradepartmental consults • Sessions with resident and staff at time of diagnosis.

  15. Accessibility • Digital Imaging allows pathologist to practice skills • Any place • Any time • Method can be incorporated for self assessment to help pathologist define their areas of deficiency

  16. Whole Slide Image Heart Transplant Biopsy

  17. Distributed Practice Issues • Consistent interpretation required because Intermountain is a quality healthcare system • Variable skill and knowledge by group members • Variable availability of expert resources • Occasional manpower issues • Wide geographic separation

  18. Practice Demographics • 5 pathology groups • Distributed over 450 miles • Group sizes: • 17: most specialties (4 hospitals) • 4: Dermpath, Hematopath (2 hospitals) • 3 (x2): Hematopath • 2: None

  19. Process • Pathology groups are separate entities • Intermittent consultation • Sharing of expert resources for technical functions and some professional functions • Sharing during manpower shortages • Communication via phone and courier • Collegial environment

  20. Potential Utilities of Whole Slide Microscopy • Intragroup consultation of specialists • Intergroup consultation between sites and for double read situations • Intergroup consultation for frozen sections • Professional sign out of immunohistochemistry with or without expert consultation • Tumor board presentations to clinicians • Education sessions to improve consistency of interpretation and speed of integration on new members

  21. Specialty Consultations • Faster turn around time because couriers not involved • More common consultation because of increased availability • Opportunity for learning of others because of multiple viewing options

  22. Intragroup Consultation • Requirement for double reading in many cases • New diagnosis of cancer • Prostate needle biopsies • Difficult cases which might benefit from consultation • Difficult with multisite groups so that appropriate second reader might not be used

  23. Frozen Section Consultation • Difficult frozens benefit from second opinions • If no other pathologist on site, this is not utilized • Diagnoses could be improved by having this capacity at each hospital

  24. Sign Out of IHC • Currently, all IHC done in three sites and slides shipped to other sites • Turn around time 24 hours for off site locations • Could consolidate technical functions if virtual microscopy was available • No option for dual viewing in difficult cases • No option to educate new members of group

  25. Tumor Boards And Clinical Conferences • One or two each day in largest group • Slides that need to be included may not be available • Lost in pathologist office • Only at another hospital • In process of filing • Significant time required by pathologist to take required static images or drag photoscope to conference room

  26. Education of Group Pathologists • Intermountain operates by developing standards which are transmitted throughout the system using data on provider behavior • Pathologists expected to be consistent and complete in reports (data system) • Education of pathologists required • Nottingham Score • HER2 scoring

  27. Summary • Digital imaging has great value in improving pathology education • Improving diagnostic skills • Improving accessibility • Digital imaging has great value in practice • Allowing flexibility in sign out and consultation • Allowing distributed conference functions • Decreasing courier related process delays

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