Berle Stratton, MD, FCAP Northwest Pathology, PS ... · TELEPATHOLOGY: REMOTE INTRAOPERATIVE...
Transcript of Berle Stratton, MD, FCAP Northwest Pathology, PS ... · TELEPATHOLOGY: REMOTE INTRAOPERATIVE...
TELEPATHOLOGY: REMOTE INTRAOPERATIVE CONSULTATION
Experience at Ketchikan General Hospital, Ketchikan, Alaska
Berle Stratton, MD, FCAP
Northwest Pathology, PS
Bellingham, Washington
Mission: Stewardship of Community, Hospital, Medical Staff and Pathology Laboratory• Quality & Safety
• Strategic
• Financial
Incentives: Engage Hospital Administrationand Medical Staff
• Improve patient outcomes: Quality and Safety
• Reduce hassles and wasted time
• Understand the organization’s culture
• Understand the legal opportunities and barriers
Engaging Physicians in a Shared Quality Agenda. Innovations Series 2007, Institute for Healthcare Improvement.
Incentives: Telepathology Intraoperative Consultation
• Community• Improve access to local
healthcare
• Consider Critical Access Hospitals
• Hospital Administration• Increase autonomy
• Retain procedures
• Improve efficiency
• Reduce cost
• Medical Staff• Increase autonomy
• Retain procedures
• Improve efficiency
• Improve recruitment
• Pathologist• Improve efficiency
• Reduce cost*
Critical Access Hospitals (CAH)
• Purpose– Certified to receive cost-based reimbursement from Medicare
– Reimbursement program
• improves financial performance
• reduce hospital closures
• Criteria for Eligibility– Rural, and
– one of the following:
• 35 miles distant from another hospital, or
• 15 miles from another hospital in mountainous terrain or areas with only secondary roads
Barriers in North Puget Sound and Southeast Alaska
• Geography
• Distance
• Roadless
Northwest Pathology service area
Infamous Gravina Island “Bridge to Nowhere”
Alaska Factoids: In-State Flight Emergency Kit
• One axe or hatchet
• One knife
• One pistol, revolver, shotgun or rifle and ammunition for same
• Two small signaling devices such as colored smoke bombs, etc.
• Two small boxes of matches
• Food for each occupant sufficient to sustain life for two weeks
• One first aid kit
• One small gill net and an assortment of tackle such as hooks, flies, lines, sinkers, etc.
• One mosquito head net for each occupant
Ketchikan Factoids: Potpourri
• Population: 7,368 (2010); 5th most populous city
• Longest day: 19 hours
• Shortest day: 6 hours
• Rainfall: 152 inches
• Snowfall: 37 inches
• Temperature Average: July 65°F, January 39°F
Ketchikan, Deer Mountain, Tongass Channel
Telepathology
• Technology– Whole slide imaging (WSI)
– Gigabyte pixel resolution
– Submicron resolution corresponds to 20x - 40x microscope objective lenses
• Access anywhere, anytime– WSI on computer monitor
simulates microscope
– Global access via internet
– Primary diagnosis, quantitative comparison, case sharing and collaboration, image analysis, remote intraoperative consults, data mining for decision support, personalized medicine.
– Redefining the standard of care
Tecotzky, R: Benefits of digital pathology. Laboratory, 2008 August;7(8):40.Singh, A: Big picture, big rewards—how to think about digital. CAP Today, October 2009.
Gross Examination
Microscopic Examination
Resources
• Hospital IT department
• Personnel– Histotechnologist
• Gross examination
• Frozen section
• Smear preparation
• Stain
• Scan
– Available 40 hours per week
• Equipment– Telepathology system
– Gross examination system
– Pathologist computer system
Implementation: Training and Validation
• Gross telepathology
• Microscopic telepathology– Scanning technique
– Software i.e. image browser
• Validation– 20 cases in each of six
specimen categories; 120 cases total
– Require 90% concordance with known assessments
– Specimens for diagnosis• Frozen sections
• Sentinel lymph node smears
• Blood smears
• Body fluids
– Specimens for adequacy• CT and US-guided needle
biopsy imprints
• FNA
Management: Quality Assurance
• Quality Assurance Programs– Concordance of intraoperative vs. final diagnosis
– Periodic internal telepathology proficiency cases
• Scanning
• Interpretation
– Turnaround Time
• “Practice” with other programs– Scan/interpret proficiency programs i.e. CAP PIP program
– Conferences i.e. tumor board
Legal: Physician State Licensure
“Pathologist Could Be Held Liable for Remote Review of Biopsy”1
• State license may be required to “practice in the state” from which biopsy originated.
– Washington State pathologist rendered a medical diagnosis for an Idaho resident without holding a license to practice medicine in Idaho.
– [Idaho resident] v. [Washington State Laboratory], W.D. Wash.2, No. C09-1662, 12/30/10
– “ Under Washington law, there are no limits on the practice of an out-of-state physician, provided [the pathologist] does not open an office in Washington.”
– “On the other hand, Idaho has created an aggressive statute to prevent unlicensed out-of-state doctors from practicing on Idaho residents.”
1 G2 Reports, March, 20112 U.S. District Court for the Western District of Washington
Conclusion
• Future of Digital Pathology– Not if, but when
• Your laboratory– Partial vs. complete solution