Interinstitutional and interstate teleneuropathology Clayton A. Wiley, MD/PhD [email protected] Disclosures
• None – Employee of UPMC and U Pittsburgh – Clinical evaluation board for OMNYX • But I remain receptive if anyone has any great ideas ….. History
• 1973: Washington, DC pathologists diagnosed lymphosarcoma/leukemia via satellite in a patient on a ship docked in Brazil • 1986: “telepathology” coined • 1993: first teleneuropathology paper (Becker et al.) – High error rate (27%) – Static imaging system • 2001: Szymas et al. – Robotic dynamic system – 83 paraffin-embedded neurosurgical cases – 95% accuracy
Telepathology systems
• Static versus dynamic – Static images dependent on proper selection of diagnostic fields • Dynamic: Robotic versus non-robotic – Non-robotic requires two pathologists, one at each end • Whole Slide Imaging 2001
• Dynamic non-robotic for IO consults • Teleconferencing between 2 pathologists at 2 hospitals 18 blocks apart • Problems – Inadequate image quality (NTSC 640 X 480) – No remote control – Required 2 pathologists – Frequent technical glitches, also required presence of IT techs to assist
2002: Nikon DN100
• Static, non-robotic • High-resolution imaging (1280 X 960) • Broadcast every 2 seconds • No remote control • No whole-slide image available
2003: Nikon Coolscope
• Dynamic-robotic system • High resolution • Full remote control by consulting neuropathologist • Trained PA to make specimens
Our Analysis
• Compared error and deferral rates between conventional and telepathology IO cases over 5 years 2002-2006 • 1,629 intraoperative consults – 402 teleneuropathology consults # of Cases Summary results
• Conventional error rate: 39/1227 (3%) • Telepathology error rate: 13/402 (3%)
• Conventional deferral rate: 5% • Telepathology deferral rate: 16% Conclusions
• Telepathology for intraoperative consultations is a reasonable means of distributing Neuropathological expertise • Technology is NOT the limiting factor – Need EMR and good communication • Training PA & NP – Think about what you don’t know – Definition of Ass-U-Me Discussion • Plan backup for system failure • Volume- Opening Pandora’s Box • Busy times – Plan ahead – Professional backup
Trestle 2008
Concordance rates February 2008
• Approached by a large commercial pathology firm about the feasibility of providing teleneuropathology in Indiana – Despite busy neurosurgical service (17 neurosurgeons) difficult to support a solitary neuropathologist • Provide remote expert neuropathology advice during intra-operative consultation April 2009
• Contract with Ameripath / QUEST – Subcontracts – 5 days a week, 8AM-6PM on call coverage – Price per case • Onsite Ameripath Pathologist remains the intraoperative pathologist – Indiana medical licenses – Hospital privileges What we do from Pittsburgh? • Review operative schedule afternoon before • Review provided clinical information • Review available neuroradiology • Be available on pager during standard hours • Be available on phone before, during and after specimen received • Recommend intraoperative specimen preparation and further processing • Use robotic microscope to view specimen • Provide expert opinion
Legal issues of interstate telepathology
Medical vs Legal advances
Legal issues of interstate telepathology • Get counsel • Licensing and patient safety – By state • Credentialing – By institution • Insurance and Indemnification – Who is making the diagnosis? • If it is available must you use it?
126 intraops Discrepant cases
How is teleneuropathology for intraops different then initially imagined? • Nature of consultation – Clinical experience • Neuroradiology • Clinical setting of rare entities – Pathology experience • Pattern matching • e.g. spindle cell lesion to AP versus NP Things we didn’t think of
• Work out all issues locally and be prepared to rework them out • What is it we are really providing? – Eyes versus medical expertise • How much of what we do is based in trust • Murphey’s Law at a distance • Law of assumptions • Little things matter……………
Things we didn’t think of
Questions? Questions?
Clayton A. Wiley, MD/PhD University of Pittsburgh Medical Center [email protected]