Combined robotic and nonrobotic telepathology as an integral service component of a geographically dispersed laboratory network

Combined Robotic and Nonrobotic Telepathology as an Integral Service Component of a Geographically Dispersed Laboratory Network BRUCE E. DUNN, MD, HONGYUNG CHOI, MD, URIAS A. ALMAGRO, MD, AND DANIEL L. RECLA, MT (ASCP), PA (AAPA) To achieve real-time connectivity between its 8 hopital-based laboratories, Veterans Integrated Service Network (VISN) 12, headquartered in Chicago, IL, has implemented a hybrid dynamic store-and-forward (HDSF) telepathology network that extends across portions of 3 states. The majority of diagnostic telepathology functions are provided to the 3 hospitals (Iron Mountain, MI; Tomah, WI; and North Chicago, IL), which lack on-site pathologists and are serviced by the 4 pathologists located in Milwaukee, WI. In surgical pathology, routine primary diagnosis, frozen section diagnosis, and clinical consultation are provided with telepathology. In addition, autopsy and specialty clinical conferences are frequently performed by using telepathology. Telepathology has been applied to a variety of areas within clinical pathology as well,

including protein electrophoresis, immunoelectrophoresis, peripheral blood smears, body fluids, microbiology, and distance learning. Implementation of telepathology has allowed VISN 12 to reach the goal of providing a single standard of accurate and timely pathology service, even at small sites that lack an on-site pathologist. HUM PATHOL 32: 1300-1303. Copyright © 2001 by W.B. Saunders Company Key words: telepathology, VISN 12, robotic microscope, hybrid dynamic store-and-forward telepathology. Abbreviations: VHA, Veterans Health Administration; VISN, Veterans Integrated Service Network; VAMC, Veterans Affairs Medical Center; HDSF, hybrid dynamic store-and-forward; WAN, wide area network; ID, infectious disease; PTEE, full-time employee equivalent.

Telepathology is the practice of pathology at a distance.1-4 This technology has facilitated reorganization of the Veterans Health Administration (VHA) in several regions of the United States. In late 1995, the VHA of the United States Department of Veterans Affairs was organized into 22 Veterans Integrated Service Networks (VISNs). The 8 Veterans Affairs Medical Centers (VAMCs) in VISN 12 (headquartered in Chicago, IL) are located in a corridor measuring approximately 320 miles in north–south and 100 miles east–west in the upper Midwest. The VAMCs include Iron Mountain, MI; Tomah, WI; Madison, WI; Milwaukee, WI; North Chicago, IL; Hines (Maywood), IL; and VA Chicago Health Care System Westside and Lakeside Divisions. The Iron Mountain and Tomah VAMCs are located in rural settings, are not affiliated directly with medical schools, and have no on-site pathologists. The North Chicago VAMC is affiliated with a medical school but does not have an on-site pathologist. The remaining VAMCs are affiliated with medical schools and have on-site pathologists. The Tomah and North Chicago VAMCs do not maintain inpatient surgery programs, whereas the other 6 medical centers support inpatient surgery. The VHA has made a significant commitment to telepathology.5-15 In 1996, VISN 12 implemented a Pathology and

Laboratory Medicine Service (P&LMS) “product line,” strategic goals of which are (1) centralization of leadership and administration; (2) improved cost effectiveness; and (3) establishment of a single standard of pathology and laboratory service throughout the VISN. To achieve real-time connectivity for its 8 hospital laboratories and reach the goal of having a single standard of accurate and timely pathology and laboratory service, VISN 12 has implemented a 3-state hybrid dynamic store-and-forward (HDSF) telepathology network using commercially available equipment (Apollo Telemedicine, Falls Church, VA).10,13 Each laboratory has 1 telepathology workstation linked to a dedicated, private telecommunications network-wide system. The system uses a combination of nonrobotic HDSF (class 3A) and robotic HDSF (class 3B) telepathology systems.16 Two network sites have HDSF systems with robotic microscopes (located at the Iron Mountain and Hines VAMCs), and HDSF systems with nonrobotic microscopes are at the other six VISN 12 hospital laboratories (and at the pathology department of Loyola University Medical School) linked by an economical, high-speed wide area network (WAN), as shown in Fig 1. Each of the microscopes is equipped with a computercontrolled Sony DKC 5000 3CCD camera that allows transmission of either dynamic (real-time) images or high-resolution static images, as described previously.7,9 In addition to the microscopes and associated computer units, each of the VISN 12 telepathology units has a document reader and/or gross examination station to capture both dynamic and static macroscopic images of surgical pathology specimens, microbiology culture plates, photographs, electrophoresis gels, or other items. Gross tissue examination stations8 are installed in the histology suites at Iron Mountain, North Chicago,

From the Department of Pathology, Medical College of Wisconsin, Milwaukee, WI; Pathology and Laboratory Medicine Services, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI; and the Iron Mountain Veterans Affairs Medical Center, Iron Mountain, MI. Address correspondence and reprint requests to Bruce E. Dunn, MD, Zablocki VA Medical Center, Pathology and Laboratory Medicine Service (113), 5000 West National Ave, Milwaukee, WI 53295-1000. Copyright © 2001 by W.B. Saunders Company 0046-8177/01/3212-0002$35.00/0 doi:10.1053/hupa.2001.29644

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FIGURE 1. Configuration of the VISN 12 HDSF telepathology network as of May 2001. Computer-based control units with imaging screens are present at all sites, including Loyola Medical School. Robotic microscopes (RM) with gross tissue examination stations (GS) and document readers (DR) are present at Iron Mountain and Hines. Nonrobotic microscopes (NRM) are present at the Tomah, Madison, North Chicago, Milwaukee, and VA Chicago Health Care System Westside and Lakeside Division VAMCs and at Loyola Medical School, which also have either DR or GS, as shown. The 8 VISN 12 telepathology units are interconnected via the WAN, allowing dynamic and static imaging at speeds up to 786 kbps. Static images can be sent as e-mail attachments outside of VISN 12 through the VHA WAN or the Internet via routers located at Hines and North Chicago VAMCs. However, connection between Loyola Medical School and Hines VAMC will continue via a point-to-point ISDN connection.

and Hines. Document scanners and hand-held digital cameras are also available at selected sites. TELECOMMUNICATIONS VISN 12 has implemented a WAN that allows integration of data, voice, video, and diagnostic imaging systems. In addition to telepathology, the WAN enables real-time teleradiology (general, computed tomography scan, and ultrasound), telefluoroscopy, telenuclear medicine imaging, telepsychiatry, and teleconsultation. When initially installed, software allowed only point-to-point connections between any 2 sites on the WAN.13 In May 2001, software was upgraded to allow multisite connectivity between most of the VISN 12 telepathology units. However, connections between Loyola University Medical School and Hines VAMC will continue via a point-to-point ISDN connection. A technical overview of the WAN has been published previously.13 Briefly, an IGX 8400 series wide-area switching platform switch (Cisco Systems, San Jose, CA) is de-

ployed at each of the eight VISN 12 hospitals. The 4 Chicago area switches are connected via DS3 connections to an OC-12/STM-4 Synchronous Optical Network (SONET) ring, the speed of which is scaleable up to 622 Mbs. Multiple T1 trunks extend to Milwaukee, Madison, Tomah, and Iron Mountain. The data network uses Cisco 7500 series routers connected via OC3 interfaces to the asynchronous transfer mode WAN backbone. The data switching network is designed as a full redundant mesh, eliminating any single point of failure.13 Since the VISN 12 telepathology units have been connected via the WAN, there has been essentially no limit to the extent or duration of telepathology connectivity because VISN 12 pays a single fee for all monthly communications services. Thus, no significant financial limitations are imposed on telepathology user connectivity within the VISN 12 WAN. TELEPATHOLOGY APPLICATIONS Current applications of telepathology in VISN 12 are outlined in Table 1 and described as follows.

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TABLE 1. Summary of Uses of Telepathology in VISN 12

time of case sign out.8 Gross tissue examination stations have also been installed within the North Chicago and Hines histology suites. It is anticipated that similar stations will be installed at all of the sites performing gross tissue examination within VISN 12 to allow uploading of digitized images into the VistA imaging package of the VHA-wide computerized patient record system.13 Currently, pathologists from Milwaukee travel to Iron Mountain and North Chicago to perform autopsies. Digitized images of key gross findings are generated using hand-held digital cameras or gross tissue imaging workstations. Upon completion of an autopsy, digitized images are sent to the attending clinician using the VISN 12 Microsoft Outlook computer network. In addition, virtual autopsy conferences are conducted at Iron Mountain using electronic images of specimens.

Anatomic pathology Surgical pathology Frozen section diagnoses Routine primary diagnoses Clinical consultation Autopsy pathology Autopsy conferences conducted remotely Gross and microscopic images sent electronically to attending physician Gross images to be entered into VistA imaging system (future function) Clinical conference support Specialty conferences (gastroenterology, pulmonary) Clinician consultations Clinical pathology Protein electrophoresis (serum and urine) and immunoelectrophoresis Microbiology Diagnostic (viewing of gram stains and culture plates) Teaching (ID staff and fellows and laboratory staff) Peripheral blood smears (diagnostic and educational functions) Body fluids (diagnostic and educational functions) Distance learning

Interpretation of Protein Electrophoresis and Immunofixation Gels

Primary Diagnosis and Clinical Consultation in Surgical Pathology The robotic telepathology connection between Iron Mountain and Milwaukee has been used since mid-1996 to render more than 4,000 diagnoses in routine surgical pathology and intraoperative frozen section cases. For primary diagnoses, we have reported a deferral rate of 2.5%. Approximately half of these cases were deferred because pathologists requested special studies not performed at the Iron Mountain laboratory. A diagnostic accuracy (clinically significant) of 99.7% was achieved in nondeferred cases.10 Since early 2000, a pathologist at Hines VAMC in Maywood, IL, near Chicago, has also routinely rendered surgical pathology diagnoses at Hines VAMC using the robotic HDSF system. In addition, clinicians at Iron Mountain, North Chicago, and Tomah have used the distributed telepathology system to review cases with Milwaukee pathologists just as if they were using a “multiheaded” microscope at a single institution. Since establishment of the Iron Mountain–Milwaukee telepathology service in mid-1996, telepathology services for rendering routine surgical pathology and/or intraoperative frozen section diagnoses have been described in other VISNs of the VHA,14,15 as well as in the private sector.17 Gross Examination and Documentation of Surgical Pathology and Autopsy Specimens Since the inception of the Iron Mountain–Milwaukee telepathology service in mid-1996, a gross tissue examination station has been present in the Iron Mountain histology suite to allow pathologists in Milwaukee to view complicated gross specimens in real time.7,9 In addition, the system allows annotation of digitized images of gross specimens for review at the

Electrophoresis of serum, urine, and cerebrospinal fluid samples is performed at the Hines VAMC core laboratory, where images of gels are scanned, then sent electronically to a Chicago VAMC or the Milwaukee VAMC to be interpreted by a telepathologist. This process has been in place since the late 1999 retirement of the Hines pathologist responsible for overseeing protein electrophoresis. More than 1,000 gels have been interpreted successfully by telepathology. There have been no detectable decreases in quality or turn-around time of diagnoses. Support for Consolidated Microbiology Laboratories Clinical microbiology has been consolidated to the laboratory at Milwaukee from the Tomah and North Chicago VAMCs, located 170 and 55 miles away, respectively. Gram stains are performed and read in Tomah and North Chicago, where culture plates are set up and incubated. Plates are transported to Milwaukee in portable incubators. Dynamic and static images of culture plates and smears are shared between the primary laboratories and the core laboratory in Milwaukee using the telepathology system. An important function of clinical microbiology laboratories is the provision of training for infectious disease (ID) fellows. Using the telepathology system. Milwaukee microbiology staff are able to provide 2-way interaction between laboratory and ID staff at North Chicago. Gram stains generated at either site are reviewed. Dynamic images of culture plates showing colony morphology and growth characteristics can be demonstrated. Weekly training sessions are held for ID fellows, residents, and medical students. Static images of “hot” cultures (plates, smears, or both) can be emailed directly to the ID attending physician and fellow daily using the Microsoft Outlook network. We have previously reported on the feasibility of reading Gram stains using static electronic imaging.18

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Review of Problematic Peripheral Blood Smears and Body Fluids

SUMMARY

Telepathology is used to review peripheral blood smears as needed at Iron Mountain, Tomah, and North Chicago by hematopathologists located at Milwaukee or Hines. By providing same-day service, rather than incurring delays by shipping smears to a core laboratory, a single standard of accurate and rapid diagnosis in hematopathology can be achieved. Distance Learning Finally, telepathology is used as a distance learning tool to support the subdisciplines of clinical pathology among all sites within VISN 12. This is especially important at the 3 laboratories that lack on-site pathologists, where training has emphasized analysis of peripheral blood smears and body fluids.

DISCUSSION Telepathology networking is an essential tool in the VISN 12 P&LMS product line, in which the clinical laboratories are separated by distances of up to 320 miles. Experience in VISN 12 shows that telepathology is useful not only for anatomic pathology, but for all areas of the clinical laboratory in which viewing of macroscopic or microscopic images is important.11 In VISN 12, use of telepathology is not limited to pathologists; skilled technologists in areas such as microbiology, hematology, and clinical chemistry routinely use HDSF telepathology as both a diagnostic and an educational tool. As we have shown previously, telepathology can be cost effective compared with maintaining an on-site pathologist at a remote site.10,12 Cost of the hardware making up the VISN 12 telepathology network shown in Fig 1 has been leveraged against a reduction in total pathologist salaries. In 1996, there were more than 30 pathologist full-time employee equivalents (FTEEs) in VISN 12; approximately 16 pathologist FTEEs and 300 nonpathologist FTEEs are currently employed in the VISN 12 P&LMS product line. Implementation of telepathology has not completely eliminated the need for pathologists to travel between sites within VISN 12. For example, pathologists based in Milwaukee travel to other sites to attend Medical Executive Committee meetings, selected administrative meetings, and clinical conferences and to perform autopsies. Although it is possible that several of these functions could be “attended” by videoconferencing or teleconferencing, it is essential for pathologists to interact face-to-face with clinicians and key administrative staff at other sites periodically to promote mutual understanding and respect.19 Clinicians and chiefs of staff have strongly supported the high quality of shared pathology services provided in VISN 12.

In summary, telepathology serves as an integral service component within the geographically dispersed multihospital laboratory network that composes VISN 12. Increased access to pathologists has proven especially valuable at the rural VAMC laboratories, where it is difficult to recruit pathologists because of geographic isolation and increasing cost constraints. By increasing access to pathologists and technologists within the P&LMS product line, telepathology networking has become an essential strategic component of the VISN 12 staffing plan. REFERENCES 1. Eide TJ, Nordrum I: Current status of telepathology. APMIS 102:88-90, 1994 2. Kayser K: Telepathology in Europe. Its practical use. Arch Anat Cytol Pathol 43:196-199, 1995 3. Shimosato Y, Yagi Y, Yamagishi K, et al: Experience and present status of telepathology in the National Cancer Center Hospital, Tokyo. Zentralbl Pathol 138:413-417, 1992 4. Weinstein RS, Bhattacharyya A, Davis JR, et al: Telepathology, in Bashshur RL, Sanders JH, Shannon GW, (eds): Telemedicine. Theory and Practice. Springfield IL, Charles C. Thomas, 1997, pp 79-209 5. Almagro UA, Dunn BE, Choi H, et al: Telepathology. Am J Surg Pathol 22:1161-1163, 1998 (letter) 6. Dunn BE, Almagro UA, Choi H, et al: Dynamic robotic telepathology on-line: Summary of first 200 cases. Cell Vision 3:467-469, 1996 7. Dunn BE, Almagro UA, Choi H, et al: Use of telepathology for routine surgical pathology review in a test bed in the Department of Veterans Affairs. Telemed J 3:1-10, 1997 8. Almagro UA, Dunn BE, Choi H, et al: The gross pathology workstation: An essential component of a dynamic-robotic telepathology system. Cell Vision 3:470-473, 1996 9. Dunn BE, Almagro UA, Choi H, et al: Dynamic robotic telepathology: Department of Veterans Affairs feasibility study. HUM PATHOL 28:8-12, 1997 10. Dunn BE, Choi H, Almagro UA, et al: Routine surgical telepathology in the Department of Veterans Affairs: Experiencerelated improvements in pathologist performance in 2200 cases. Telemed J 5:323-337, 1999 11. Dunn BE, Chejfec G, Weinstein RS: Progress toward development of a full-service, telepathology-based laboratory. Cell Vision 3:463-466, 1996 12. Agha Z, Weinstein RS, Dunn BE: Cost minimization analysis of telepathology. Am J Clin Pathol 112:470-478, 1999 13. Dunn BE, Choi H, Almagro UA, et al: Telepathology networking in VISN-12 of the Veterans Health Administration. Telemed J e-Health 6:349-354, 2000 14. Weisz-Carrington P, Blount M, Kipreos B, et al: Telepathology between Richmond and Beckley Veterans Affairs Hospitals: Report on the first 1000 cases. Telemed J 5:367-373, 1999 15. Dawson PJ, Johnson JG, Edgemon LJ, et al: Outpatient frozen sections by telepathology in a Veterans Administration Medical Center. HUM PATHOL 31:786-788, 2000 16. Weinstein RS, Descour MR, Liang C, et al: Telepathology overview: From concept to implementation. HUM PATHOL 32:12831299, 2001 17. Callas PW, Leslie KO, Mattia AR, et al: Diagnostic accuracy of a rural live video telepathology system. Am J Surg Pathol 21:812-819, 1997 18. McLaughlin WJ, Schifman RB, Ryan KJ, et al: Telemicrobiology: Feasibility study. Telemed J 4:11-17, 1998 19. Weinstein RS, Dunn BE, Graham AR: Telepathology networks as models of telemedical services by cybercorps. New Med 1:235-241, 1997

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