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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