Telepathology for Frozen Section Analysis: A Validation of Remote Meeting Technologies (RMT)TM Software

Samuel Barasch MD1, Zhanhai Li PhD2 and Jimmie Stewart III, MD1 School of Medicine 1 and Public Health Department of and Laboratory Medicine, University of Wisconsin School of Medicine and Public Health, Madison WI UNIVERSITY OF WISCONSIN-MADISON 2 Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health, Madison WI

ABSTRACT INTRO MATERIALS ReSULTS CONCLUSIONS Background: Telepathology can expand laboratory efficiency in a time of AND Methods All pathologists had acceptable accuracy with In pathology informatics, there are many products of A private Wide Area Network connection is needed The University of Wisconsin Hospital and tightening budgets and simultaneous need to expand services. both methods; and telepathology. variable utility. The product studied here has been to transmit data between geographically divided Clinics is supporting frozen section (FS) Telepathology was considered after the University of Wisconsin effective and also simple to use, implement, and organizations. Telepathology fits well with the Validation was performed through competency There is no difference detected between capability at a partner institution over 40 Hospital and Clinics (UWHC) formed a strategic partnership support. Given institutional support of the technology organizational plan to provide telemedicine services assessments of frozen section slides viewed on telepathology diagnoses and microscopic miles away. The Department of Pathology with the Watertown Regional Medical Center (WRMC) to extend and network infrastructure required for transmission including telestroke, remote telemetry monitors, and telepathology and by light microscopy. The diagnoses. The Cochran-Mantel-Haenszel (CMH) was tasked with finding the most efficient specialty medical care, surgical services, neurologic care, of images, RMT real-time imaging product has great cytologic specimen adequacy evaluation. Without competency assessments on each method test (Table 1) found outstanding correlation solution providing this service. Cost and pathology within the region. As part of medical services potential to expand a pathologist’s efficiency. RMT institutional investment in technology infrastructure, were then compared for accuracy between between telepathology and direct microscopy effectiveness and accuracy were our most extended to the WRMC, UWHC needed to find a way to serve the with a p value of <0.0001. The null hypothesis in software product provides diagnostic quality video this system would not be possible. pressing concerns. After review of many the methods. Acceptable accuracy was intraoperative consultation needs of this hospital. However, the this analysis was that there was no correlation streaming capabilities which require little training and techniques, including virtual scanning, determined to be 90% of cases receiving the intraoperative consultation volume was not sufficient to justify between the two methods. The exceedingly low minimal technical support following implementation. Developing and troubleshooting new computer real time imaging was chosen. To prove correct diagnosis for both light microscopy and travel of over an hour (one way) for an anatomic faculty member. 1 p value gives extremely strong evidence against systems is a challenge, even more so when two this method was just as effective as direct telepathology. No difference between diagnostic capability using disparate organizations with different IT staff microscopy, a validation/correlation study A telepathology solution utilizing dynamic imaging would allow that null hypothesis. telepathology and direct microscopy could be hierarchies seek integration. Excellent communication was performed. This also functioned as a surgical pathologist to conduct remote consultation alongside A selection of 20 FS slides was chosen based detected in our study. Similar studies in other between IT staff within partnering organizations a training/competency assessment for daily signout activities. Telepathology allows pathologists to on the type of specimens seen at WRMC. institutions have also found dynamic real-time is essential for the long term maintenance of participating pathologists allowing them evaluate specimens and make diagnoses in geographically Specimens were chosen such that they TABLE 1. CMH Test to Compare Telepath telepathology to be diagnostically equivalent to light a telepathology system. Even with excellent to become familiar with making diagnoses disparate areas without the logistical complications of travel. represented the most diagnostically challenging with Direct Microscopy Controlling for microscopy.2-6 Therefore, telepathology can be judged communication, weekly “system checks” are from digital images. Telepathology has been used by pathologists in the Veterans material, including cases of lobular breast Pathologists as an effective and efficient method of extending performed to assure images can be transmitted Health Administration system in this region for more than 15 carcinoma in a sentinel lymph node. The more Design: 2 Cochran-Mantel- pathology services to cover wide geographic areas. between hospitals and through firewalls. The system years. Also, the UWHC section has been using difficult cases were favored to show that the Comments Six pathologists were given a set of 20 FS Haenszel test checks allow changes to network security that would telepathology since 2005 to allow cytopathologists the ability to RMT system could accurately display diagnostic slides and asked to interpret them via our For hypothesis that P-value<.0001 There is a Without full remote control of the slide for the remotely evaluate fine needle aspirate specimens for adequacy. halt image transmission to be detected prior to an chosen telepathology system, Remote features in a digitized image. correlation=0. significant pathologists in the main laboratory, an experienced UWHC now sought to use dynamic imaging telepathology for urgent intraoperative consultation or FNA procedure. Meeting Technologies (RMT). The slides correlation PA or other technical staff is needed at the remote site. intraoperative frozen section consults. Six pathologists were given the same set of slides were chosen after a review of common between This staff should be able to scan the frozen section Although there was some concern about system and asked to interpret them via the RMT system. telepathology FS slides seen in the partner institution. slide through the imaging system and show the entire reliability, we have not had any technical issues at Because technical staffing After a period of 3 months or more of lag time, and direct The more difficult cases were favored to slide to the pathologist. At the same time, there must time of frozen section. Each person involved in this was needed at the remote the slides were reordered and presented to microscopy. show that the RMT system could accurately be excellent communication between the two areas implementation was asked to comment on an issue display diagnostic features in a digitized site for preparation of the the same pathologists for direct microscopy in telepathology. The pathologist needs to be certain with the system they had noted since its first usage in image. After 3 months or more of lag time, tissue, sectioning, and staining examination. The answers from each exam were that if there are unusual features with a given case that March of 2012. There were two user errors noted. In the slides were reordered and presented to of the slide, a pathology then correlated to determine if any difference the PA can communicate and show those features. the first case, the PA at the remote site had not started the same pathologists for direct microscopy assistant(PA) was needed to existed between the two methods of diagnosis. The PA needs to be comfortable with histology and the image broadcast. In the second case, the faculty examination. The answers from each scan the frozen section slide TABLE 2. Overall Kappa coefficients and test basic dissection, and be able to understand any member at the university had not started the imaging exam were then correlated to determine under the at The RMT system transmitted via a leased line of equal Kappa coefficients if any difference existed between the two from Charter Communications with bandwidth concerns that a pathologist might have regarding a client software. Technical support staff had five issues the remote location or show Figure 1: Pathologist at Main Overall Kappa Coefficient Comment given case. Future plans include developing human to resolve; four of these issues were fixed by rebooting methods of diagnosis. gross specimens that needed Sign Out Facility of 10 Mbps from the WRMC to the UWHC which allowed safe and reliable transmission through a Kappa=.73 There is an resources at the remote site to train qualified staff the telepathology server at the remote site. One Results: dissection. With technical private network (rather than the public ). excellent or hire more qualified staff for the PA portion of the technical issue was related to changes in the firewall The Cochran-Mantel-Haenszel (CMH) test staff available at the remote IT staff from both UWHC and WRMC had detailed agreement. process. Also, there are plans for implementation at the WRMC without awareness of the need for the found outstanding correlation between location, a dynamic, real-time, communication with each other to allow the 95% CI (.60, .85) of a remote robotic system for slide control if and telepathology system to be permitted to transmit. telepathology and direct microscopy with imaging system from Remote Test of equal Kappa when developed. This would allow for greater control These issues were all detected during system checks a p value of <0.0001. The null hypothesis Meeting Technologies (RMT), system to pass the visual data through hospital coefficients among all of the slide by the surgical pathologist at the main or during use of the system during procedures other in this analysis was that there was no was chosen, as opposed firewalls securely in compliance with the Health pathologists laboratory, but a trained PA or staff would still be than intraoperative consultation. correlation between the two methods. to whole slide imaging, for Information Portability and Accountability Act Chi-square test P-value=.98 All kappa The exceedingly low p value gives (HIPAA) regulations. needed for dissection and histologic sectioning. simplicity of implementation coefficients The authors would like to thank Rob Rohrer for extremely strong evidence against that null Figure 2: Camera at Remote Site; Grossing Station and lower capital expenditures. are equal. Although there was an initial reluctance to work with his assistance in developing and maintaining the hypothesis. the telepathology system, faculty soon recognized the computer system described above. A pathologist at the main Conclusions: productivity benefits. All faculty involved in frozen The RMT system provides 1920 x 1080 pixels laboratory is in contact with sections from March 2012 thru Dec 2012 requested References of resolution which is the equivalent to high the PA at all points in the at the remote location used the telepathology and 1. Moser PL, Stadlmann S, Heinzle G, et al. A cost comparison of TABLE 3. McNemar’s test for each pathologist telepathology and a visiting pathologist service J Telemed Telecare definition. This provides the diagnosing intraoperative consultation found it to be adequate for rendering a diagnosis. 2003;9:200-3. pathologist with an exceptionally sharp (Fig. 1) process via phone. High Pathologist p_value from McNemar’s test Comment No faculty involved in frozen section diagnoses view of diagnostic features. Our study definition grossing cameras are were needed at the remote location. When a frozen 2. Dunn B, Hongyung C, Recla D, Wisniewski T. Telepathology as an shows that our telepathology system is used to allow for pathologist D 1 Telepath and direct agree. Essential Networking Tool in WISN 12 of the Veterans section is necessary, PAs and lab techs begin the Health Administration. In: Kumar S, Dunn B, ed. Telepathology. Berlin valid for interpreting FS. The collected input into the tissue dissection F .083 Telepath and direct agree. connection from the remote camera stations to the Heidelberg: Springer-Verlag, 2009:19. data provides excellent evidence of a high Figure 3: Camera at Remote Site; Microscopy (Fig. 2). This allows for issues Station viewing station in the reading room at the UW, and degree of correlation between the two 3. Gifford AJ, Colebatch AJ, Litkouhi S, et al. Remote frozen section related to tissue sampling G .083 Telepath and direct agree. the pathologist routinely assigned to frozen section methods. More studies of this type need examination of breast sentinel lymph nodes by telepathology ANZ J (in a large specimen) or tissue orientation to be discussed as these services makes the diagnosis. Surg 2012;82:803-8. to be performed on other systems being may be critical in margin assessment. When the slide is ready, it is H 1 Telepath and direct agree. developed to prove their validity in FS 4. Li X, Gong E, McNutt MA, et al. Assessment of diagnostic accuracy scanned manually by the PA via a full 1080p microscopic camera Many systems have resolution that is better at lower diagnosis and the pathologists’ competency I .083 Telepath and direct agree. and feasibility of dynamic telepathology in China Hum Pathol (Fig. 3) with instruction by the pathologist to assure all aspects of power and worse at higher power. Paradoxically, the in using them. 2008;39:236-42. the slide are examined. J .16 Telepath and direct agree. RMT system has resolution noted to be superior at 5. Liang WY, Hsu CY, Lai CR, Ho DM, Chiang IJ. Low-cost telepathology 10x rather than at 4x by several of the pathologists system for intraoperative frozen-section consultation: our experience As with all newly implemented laboratory methods, validation was participating in the study. We are unable to pinpoint and review of the literature Hum Pathol 2008;39:56-62. necessary. Validation goals were to conform to Clinical Laboratory the technical component of the system to alter 6. Weinstein RS, Graham AR, Richter LC, et al. Overview of Improvement Amendment act of 1988 and College of American resolution. Though surgical pathologists tend to telepathology, virtual microscopy, and whole slide imaging: prospects Pathology regulations, to train staff, and to test technology. use the 4x objective heavily, resolution was overall for the future Hum Pathol 2009;40:1057-69. Acknowledgement: No relationship exists that represents a possible conflict of interest with respect to the content of this presentation. excellent and entirely adequate for diagnostic need.