Surgical Pathology Quality Assurance Program Using Robotic Real-time Telepathology
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Transcript of Surgical Pathology Quality Assurance Program Using Robotic Real-time Telepathology
Ronald S. Weinstein, M.D.
Professor, Pathology
Head, Pathology 1990 – 2007
Director, Arizona Telemedicine Program
Disclosure
DMetrix – Tucson, AZMedical Director
Apollo Telemedicine – Falls Church, VAShareholder
Telepathology
The use of telecommunications technology to facilitate the transfer of image-rich pathology data between remote locations for the purposes of diagnosis, education, and research.
Telepathology systems are divided into three major types: static image-based systems, real-time systems, and virtual slide systems.1. Static image systems have major benefits of being the
most reasonably priced and usable in the widest range of settings, but have the significant drawback in only being able to capture a selected subset of microscopic fields.
2. Real-time systems and virtual slides allow a consultant pathologist the opportunity to evaluate the entire specimen. With real-time systems, the consultant actively operates a microscope located at a distant site -- changing focus, illumination, magnification, and field of view at will.
3. Virtual slide systems utilize an automated scanner that takes a visual image of the entire slide, which can then be forwarded to another location for diagnosis.
Table 1. Arizona-International Telemedicine Network
Location Population Distance from Tucson (km
[miles])
No. of beds in hospital*
United States - AZ
Tucson 405,000 - 312
Phoenix 983,000 178 (111) 350
Cottonwood 6,000 350 (217) 99
Yuma 55,000 386 (240) 350
Kingman 13,000 478 (297) 50
China
Hangzhou 1,200,000 12,800 (7,900) 600
Mexico
Hermosillo 449,000 381 (237) 250
*Hospital housing the telepathology workstation.The Hospital General del Estado in Hermosillo served as the hub for a network of regional hospitals whose pathologists brought cases to the referring site for transmission to Tucson and teleconsultation.
University of Arizona Telepathology ServicesUniversity of Arizona Telepathology Servicesaa
Modality Classb QASecond opinion
Frozen sections
Deferred casesc
Static image telepathology
2A --- 239 --- 17
Robotic dynamic telepathology
3B 3064d 81 142 228
Virtual slide telepathology
5C 329 --- --- ---
Total 3393 320 142 245
a University of Arizona telepathology services, initial 4100 cases, 1993-2008.b Weinstein Classification of Telepathology Systems [2].c For special studies, such as immunohistochemistry, or for glass slide reviewd Includes some second-opinion cases.
TELEMEDICINE JOURNALVolume 1, Number 1, 1995Mary Ann Liebert, Inc., Publishers
Case Triage Model for the Practice of Telepathology
A.K. BHATTACHARYYA, M.D., JOHN R. DAVIS, M.D., BRADFORD E. HALLIDAY M.D., ANNA R. GRAHAM, M.D., S. ANNE LEAVITT, M.D., RALPH MARTINEZ, Ph.D.,
RICARDO A. RIVAS, and RONALD S. WEINSTEIN, M.D.
ReferringPathologist
SubspecialtyPathologist
Triage Pathologist
CaseSign-out
PATHWAY A PATHWAY B
Case Triage Model
CaseSign-out
Triage Pathologist
AFIP ModelReferring Pathologist
Triage Clerk
GI Path GYN Path Renal Path Derm Path Etc.
Case Sign-out
CaseSign-out
CaseSign-out
CaseSign-out
CaseSign-out
University of Arizona Telepathology Servicesa
Modality Classb QASecond opinion
Frozen sections
Deferred casesc
Static image telepathology
2A --- 239 --- 17
Robotic dynamic telepathology
3B 3064 81 142 228
Virtual slide telepathology
5C 329 --- --- ---
Total 3393 320 142 245
a University of Arizona telepathology services, initial 4100 cases, 1993-2008.b Weinstein Classification of Telepathology System [2].c For special studies, such as immunohistochemistry, or for glass slide review
Havasu Regional Medical Center
University Medical Center Tucson, AZ
316 Miles
Quality Assurance Program
HRMC processes approximately 3500 surgical pathology cases annually
One pathologist, on-site, between July 2005 and October 2009.
All new cancer cases and challenging non-malignant cases were selected by the HRMC pathologist for telepathology re-review.
Case Read-Outs # of Cases
% of Cases
Average Time
UMC on-service telepathologist
1692 90.87% 3.78(1-33 minutes)
Deferred for glass slide review
170 9.13% 6.12(1-18 minutes)
Total 1862
Deferral Rate
Pathologists
Total cases in general
Deferred cases
Total cases excluding the pathologist’s subspecialty
Total deferred cases
excluding the pathologist’s subspecialty
Deferral rate in general
Deferral rate excluding
pathologist’s subspecialty
Gastro Intestinal 501 24 344 17 4.79% 4.94%
Heart and Lung 369 30 321 25 8.13% 7.78%
Renal 188 24 150 22 14.79% 14.67%
Soft Tissue 174 37 165 36 21.26% 21.81%
GYN 166 12 161 12 7.23% 7.45%
Renal 139 12 109 10 8.63% 9.17%
Endocrine 85 9 83 9 10.59% 10.84%
ENT Path 84 6 76 6 7.14% 7.89%
Dermatology 58 7 50 5 12.07% 10%
Breast 51 4 50 4 7.84% 8%
Deferral Rate
Pathologists
Total cases in general
Deferred cases
Total cases excluding the pathologist’s subspecialty
Total deferred cases
excluding the pathologist’s subspecialty
Deferral rate in general
Deferral rate excluding
pathologist’s subspecialty
Gastro Intestinal 501 24 344 17 4.79% 4.94%
Heart and Lung 369 30 321 25 8.13% 7.78%
Renal 188 24 150 22 14.79% 14.67%
Soft Tissue 174 37 165 36 21.26% 21.81%
GYN 166 12 161 12 7.23% 7.45%
Renal 139 12 109 10 8.63% 9.17%
Endocrine 85 9 83 9 10.59% 10.84%
ENT Path 84 6 76 6 7.14% 7.89%
Dermatology 58 7 50 5 12.07% 10%
Breast 51 4 50 4 7.84% 8%
Deferral Rate
Pathologists
Total cases in general
Deferred cases
Total cases excluding the pathologist’s subspecialty
Total deferred cases
excluding the pathologist’s subspecialty
Deferral rate in general
Deferral rate excluding
pathologist’s subspecialty
Gastro Intestinal 501 24 344 17 4.79% 4.94%
Heart and Lung 369 30 321 25 8.13% 7.78%
Renal 188 24 150 22 14.79% 14.67%
Soft Tissue 174 37 165 36 21.26% 21.81%
GYN 166 12 161 12 7.23% 7.45%
Renal 139 12 109 10 8.63% 9.17%
Endocrine 85 9 83 9 10.59% 10.84%
ENT Path 84 6 76 6 7.14% 7.89%
Dermatology 58 7 50 5 12.07% 10%
Breast 51 4 50 4 7.84% 8%
Deferral Rate
The case deferral rates for individual telepathologists ranged from
4.79% to 21.26% The deferral rates were not significantly
changed by exclusion of cases within the individual pathologists’ subspecialty area. These deferral rates ranged from
4.94% to 21.81%
• The triage pathologist completed the telepathology consultation without any assistance of a subspecialty pathologist in 66% of the cases.
• A review panel examined the original glass slides
from 134 cases by light microscopy.
• Concordance rates of the telepathologists’ provisional diagnosis or review panel’s diagnoses with the referring pathologists’ diagnoses were not statistically different ( P > 0.05).
Conclusions: Deferral rates were minimally impacted by
pathologist subspecialty.
Overall diagnostic discordance rate,
comparing on-site light microscopy and telepathology diagnoses, was 5.73%.
Deferrals for glass-slide review represented less than 10% of
telepathology QA cases.
Conclusions: Deferral rates were minimally impacted by
pathologist subspecialty.
Overall diagnostic discordance rate,
comparing on-site light microscopy and telepathology diagnoses, was 5.73%.
Deferrals for glass-slide review represented less than 10% of
telepathology QA cases.
Telepathology Practice Models
Thank you!