INTERACTIVE INTERACTIVE MULTIDISCIPLINARY WEB MULTIDISCIPLINARY WEB

CONFERENCING:CONFERENCING:The Use of the Aperio and The Use of the Aperio and

PolyCom PVX SystemsPolyCom PVX SystemsOssama Tawfik, MD, PhD Ossama Tawfik, MD, PhD

ProfessorProfessorDirector of Anatomic and Surgical PathologyDirector of Anatomic and Surgical Pathology

The University of Kansas Medical CenterThe University of Kansas Medical CenterPathology Vision Conf, Oct 2008Pathology Vision Conf, Oct 2008

OBJECTIVESOBJECTIVES

1.1. Why going digital is valuable?Why going digital is valuable?2.2. What is wrong with the current What is wrong with the current

system?system?3.3. Can we do better? And why do we Can we do better? And why do we

have to?have to?

Why Digital Conferencing?Why Digital Conferencing?– Problem...

• Medicine is changing.

• Medical Practice and Teaching is moving away from the Major Medical Centers into Community Settings.

• Medical Centers are redesigning themselves - clinics, surgi-centers, nursing homes and doctor’s practices.

• Great majority of patient care will be outpatient, located outside the main Campus.

Why Telepathology?Why Telepathology?– Problem...

• The growing physical separation between Clinician and Pathologist is problematic in communication...

• Traditional Pathology Reports will have limitations in communication.

• How will we communicate with our clients when they are across town, across the state or across the world?

Why Telepathology?Why Telepathology?– Problem...

• As medicine becomes distributed, it will become incumbent upon us as pathologists to find new ways of communicating for clinical work, research and education.

• The primary mode of communication has always been the pathology report.

• We may now have to rethink the way we report...

• Pathologists, radiologists, and surgeons• digital slide/radiology conferencing on a

weekly basis• 500 breast needle core biopsies• ERROR REDUCTION!!!!• Evaluation of significant

abnormalities/discrepancies• Correlation with treatment plans for each

patient

INTERACTIVE MULTIDISCIPLINARY INTERACTIVE MULTIDISCIPLINARY CONFERENCECONFERENCE

Microcalcifications of the breast: size matters!

A mammographic-histologic correlation studyX Liu, M Inciardi, JP Bradley, F Fan, P Thomas, W Smith, O

TawfikPathologica 2007;99:5-10

Core Needle Biopsy Protocol

Specimen radiography

Calcification Absent

Calcification Present

< 100 um > 100 um

Proceed w Dx

Tissue block radiography

Radiologically negative

Radiologically positive

Malignant DxBenign Dx

Cut deeper in block

Additional studies are required!!

Ca Absent Ca Present

Ca SIZE

Medical Error StatisticsMedical Error Statistics

• Colorado and Utah study– Adverse events (AE) in 2.9% of hospitalizations– 8.8% of AE’s led to death (about 44K

deaths/annually

• New York study– AE’s in 3.7% of hospitalizations– 13.6% of AE’s led to death (98K deaths annually)

• Eighth leading cause of death in USA

Dollar Cost of Medical ErrorDollar Cost of Medical Error

• Between $17 to $29 billion/year– Half directly attributable to health care costs– Other half combination of lost productivity, lost

income and disability

Goals of the IOM reportGoals of the IOM report

• Break “cycle of inaction’ concerning patient safety and medical error

• Enhance knowledge base about medical error• Breakdown legal and cultural barriers which

impede safety improvement• Shift from blaming individuals for past errors to a

focus on preventing future errors by designing safety into the health care system

Goals of the IOM Report (cont.)Goals of the IOM Report (cont.)

• Improve knowledge base about medical error and safety improvement

• Develop tools to improve safety

• Cause significant monetary investments to achieve these goals

Institute of Medicine mandateInstitute of Medicine mandate

• Threshold improvement in quality

– 50% reduction in medical error in five years

““ARE WE LISTENING?”ARE WE LISTENING?”

““OUR PROBLEM”OUR PROBLEM”

““OUR PROBLEM”OUR PROBLEM”

KU Med Ctr isLocated 3 miles From Cancer Center

Man power

Time

Resources

““OUR PROBLEM”OUR PROBLEM”

• Aperio ScanScope System

• PolyCom PVX video conferencing System

““OUR SOLUTION”OUR SOLUTION”

• Pathologists, radiologists and surgeons

• Develop a web based pre-diagnostic work-up conference in which the pathology slides and mammograms could be analyzed together

• Goals: – To insure adequate sampling – To reach a proper diagnosis– To determine the proper surgical/treatment

plans

Aperio/KUMC Pilot ProjectAperio/KUMC Pilot Project

Application Values Tested

Variables Measured

Confirmation Reviews with Digital Conferencing

Quality

Concordance between glass and digital reads

Image quality Comfort level with using digital

slides Ease of use with digital slides

Service and Efficiency

Pathologist/Radiologist/Surgeon satisfaction

Comparison of actions taken based on digital consultations vs. history of actions for the same type of discrepancy

Telepathology/Teleradiology Telepathology/Teleradiology Unit Unit

• Server with high speed internet connection

• Personal computer w web camera

• Digital pathology system (Aperio ScanScope XT)

• Spectrum Plus™ digital pathology information management software

• Web conferencing system (PolyCom PVX)

ValuesValues• Pathology side:Remote viewing and conferencingSimultaneous view of multiple digital slidesArchiving and intelligent retrieval capabilities

• Radiology side:Remote viewing and conferencingSimultaneous view of multiple digital imagesAlive radiologic images w radiologist and pathologist input

• Pathology/Radiology:Audio and Video conferencing while reviewing images

No need to leave officeNo phone calls or typing required

ValuesValues

Cases – Pathologic Diagnosis

• Invasive carcinoma (1 case)• DCIS (1 case)• Fibroadenoma (2 cases)• Fibrocystic changes with microcalcifications (12

cases)• Fat necrosis (1 case)• Fibrosis (3 cases)• Intraductal papilloma (1 case)• Sclerosing adenoma (1 case)

• Microcalcifications (11 cases)

• Abnormal mammogram, mass (6 cases)

• Fibroadenoma (2 cases)

• Abnormal ultrasound, mass (2 cases)

• Spiculated mass (1 case)

Cases – Radiologic Diagnosis

Concordance

No Impact

100% concordance

Minor Impact

Major Impact

13 6 3

• Excise lesion (1)• Re-biopsy patient (2)• Follow up

mammograms (2)• X-ray tissue blocks

(4)

Teleconferencing ChallengesTeleconferencing Challenges

ChallengesChallenges

• It requires some training (learning curve)

• Psychological barrier!!!!

• Limitations in technology (view of small area of slide, length of transmission of images, internet connections, etc.)

• Image resolution, size of files transmitted

Benefits of telepathology Benefits of telepathology (telemedicine)(telemedicine)

• Better medical service

• More specialized service

• Primary diagnosis for frozen sections

• Second opinion and consultations (dermatopathology, neuropathology, cytopathology, etc.)

• Quality control

Benefits of telepathology Benefits of telepathology (telemedicine) cont.(telemedicine) cont.

• Cost saving/Time saving

• Exchange of ideas

• Improved collaboration with opportunity for research

• E-learning, clinicopathological mtg and discussion groups

CONCLUSIONSCONCLUSIONS

• It can be cost effective solution to the our university problem. – It negated the need for an on-site

pathologist to staff the biopsy cases– Provided at-your-desk Telepath diagnosis

Digital photo-graphs

Tele-pathology (remotely controlled scopes)

Time

Sc

op

e o

f U

sa

ge

Before digital slides

After digital slides

Digital Pathology ApplicationsDigital Pathology Applications Adoption will Occur in NichesAdoption will Occur in Niches

Tumor Board, Proficiency

Testing, CME

Archival &

Retrieval

VirtualIHC

Peer Review, QA

ImageAnalysis

Manual Readof Digital

Slide

Remote viewing

Secondary Consults

AcknowledgmentsAcknowledgmentsMarilyn DavisMarilyn Davis

Dennis FriesenDennis Friesen

Mark RedickMark Redick

Ryan SpauldingRyan Spaulding

Dennis SchuckmanDennis Schuckman

Sherri Heffner and Aperio Co.Sherri Heffner and Aperio Co.

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