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Whole-slide imaging-based telepathology in geographically dispersed Healthcare Networks. The Eastern Québec Telepathology project
MINI-SYMPOSIUM: WHOLE-SLIDE IMAGING IN PATHOLOGY
Whole-slide imaging-based telepathology in geographically dispersed Healthcare Networks. The Eastern Quebec Telepathology project
comprised primary diagnosis (including intraoperative consultations (IOC)), expert opinions between two pathologists, continuing education and assistance to macroscopic description. A concordance rate of 98% was found between IOC diagnosis and the final report and the average turnaround time was 20 minutes. Expert opinion reports were completed within 24 hours in 68% of cases. An evaluation of the benefits demonstrates that telepathology prevented interruption of IOC, two-stage surgeries and patient transfers. It also shows that retention and recruitment of surgeons in remote hospitals were facilitated and that professional isolation among pathologists was reduced. Wider adoption of telepathology would require technological improvements and appropriate change management policies. A second phase is underway to expand the service to other regions across the province.
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Keywords expert opinion; frozen section; intraoperative consultation; network; telepathology; virtual pathology; whole-slide image
Bernard Tetu Guy Pare Marie-Claude Trudel Julien Meyer
History of telepathology in Canada
Peter V Gould
Digital pathology has been successfully implemented in many countries around the world for education, clinical pathological conferences, and research.1 Despite a constant increase in adoption of digital pathology for diagnostic purposes, there are still too few examples of structured clinical networks. Canada has been a world leader in the implementation of telepathology. The large geographic size of the country combined with its relatively small population, extreme heterogeneity in population density and a shortage of anatomical pathologists played a critical role in the adoption of this technology but the country also benefited from the initiative of a few leading pathologists and the financial support of provincial governments and Canada Health Infoway, a not-for-profit federally funded health information technology agency. A recent survey reveals that up to 71% of Canadian anatomical pathologists, residents and fellows believe there is a need for telepathology in their practice.2 In Canada, healthcare delivery and management are a provincial responsibility. Ontario and Quebec have been the first two provinces to adopt telepathology for diagnostic purposes. The University Health Network (UHN) in Toronto pioneered the development of diagnostic telepathology and has demonstrated, since 2004, the feasibility and advantages of using virtual microscopy to cover intraoperative consultations (IOC) between two hospitals 1.5 km apart.3 UHN has since expanded its telepathology program to provide sub-speciality support for its transplant pathology programs as well as sub-speciality services to several other hospitals in the province and even in Kuwait. In 2004, the “Eastern Quebec Telepathology Network” (called “Reseau de Telepathologie de l’Est du Quebec” in French) was also created. A detailed description of the Network is the main focus of this article. Elsewhere in Canada, the province of British Columbia has developed expertise in standards and is using digital microscopy for consultations, education and quality assurance since 2007. Currently, Diagnostic Services Manitoba Inc. (DSM), a not-forprofit corporation with funding support from the Manitoba Health and Canada Health Infoway, is in a process of implementing a digital pathology solution in five sites in the province of Manitoba with a main focus on consultations, tumour boards, quality assurance, education and research. Once the implementation is completed, Manitoba expects to connect with the University Health Network in Toronto, Ontario and
Stephan Saikali Michele Orain Lyne Nadeau Bich N Nguyen
Abstract This study reports the first 3-year experience of the Eastern Quebec Telepathology Network. Clinical activities started in January 2011 and involved 18 hospitals practicing oncologic surgery in the region. Clinical activities
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Bernard Tetu MD Professor, Service d’Anatomopathologie et de Cytologie, CHU de Qu ebec, Hopital du St-Sacrement, Quebec, Canada. Conflicts of interest: none. ˇ
Ph.D. Chair in Information Technology in Health Care, HEC Guy Pare Montreal, Montreal, Canada. Conflicts of interest: none. Marie-Claude Trudel PhD Associate Professor, HEC Montreal, Montreal, Canada. Conflicts of interest: none. Julien Meyer MSc PhD Student HEC Montreal, Montreal, Canada. Conflicts of interest: none. Peter V Gould MD FRCPC Neuropathologist, Service d’Anatomopathologie, CHU de Quebec, Hopital de l’Enfant-Jesus, Quebec, Canada. Conflicts of interest: none. Stephan Saikali MD PhD Neuropathologist, Service d’Anatomopathologie, CHU de Qu ebec, Hopital de l’Enfant-Jesus, Quebec, Canada. Conflicts of interest: none. ˇ
le Orain RT Research Assistant, Service d’Anatomopathologie et Miche de Cytologie, CHU de Quebec, Hopital du St-Sacrement, Quebec, Canada. Conflicts of interest: none. ˇ
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Lyne Nadeau CT RT Chief Technologist, CT RT, Hopital de Sept-Iles, Sept-ıˆles, Canada. Conflicts of interest: none. Bich N. Nguyen M.D. Professor, Centre Hospitalier de lUniversite de Montr eal, Montreal, Canada. Conflicts of interest: none.
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In contrast to other Canadian provinces, the Quebec telepathology project counts no single responding site to which community hospitals turn for pathology services. No single site has the mandate to provide pathology services across the entire service area. Rather, the architecture of the Network was purposely designed to encourage decentralization and the development of a regional organization of pathology services.
Newfoundland & Labrador. The Eastern Ontario Regional Laboratory Association in Ottawa is also in the process of implementing a 17-hospital Network. Finally, the province of Alberta has trained 300 users who use digital pathology for conferences and some in-house clinical services. Streaming is used routinely in hematopathology for consultations between sites, conferences and presentations, and some users use streaming from the operating room to their office to guide grossing.
Sites and equipment C C
The Network comprises 24 hospitals providing oncologic surgery services. Of the 24 hospitals, seven have no pathology laboratory. Of the 17 sites with a pathology laboratory, four have no onsite pathologist, while six have only one pathologist and seven have 2 pathologists or more. Eighteen sites are currently fully operational (4 with no pathology laboratory, 4 with a pathology laboratory but no on-site pathologist, 4 with one pathologist and 6 with 2 or more pathologists). Additional backup equipment has also been supplied to one hospital in the Montreal area, outside of our Network territory, to relieve a temporary interruption of service. IOC and urgent biopsies were covered by the pathologists at the University of Montreal Academic Hospital, located 10 km farther. This Network is currently the most ambitious telepathology project in Canada and ranks among the most important in the world in terms of both the number of sites and geographic coverage.4 To fulfil the objectives of the project, the same equipment was implemented at each participating hospital (Figure 1). It includes a macroscopy station (PathStand 40, Diagnostic Instruments, Sterling Height, USA) and two videoconferencing devices (PCS-XG80DS Codec, Sony, Minato, Tokyo, Japan) equipped with a drawing tablet (Bamboo CTE-450K, WACOM, Otone, Saitama, Japan). Those pieces of equipment were provided by Olympus Canada Inc. (Markham, Canada). Digital images of the slides for both the IOC and expert opinions are scanned at a 20 magnification on a Nanozoomer 2.0 RS (Hamamatsu Photonics, Shizuoka Prefecture, Japan) and the images are saved on a local dedicated telepathology server. The visualisation is performed at a 1680 x 1050 pixels resolution with the mScope v.3.6.1 (Aurora Interactive Ltd., Montreal, Canada) software. With respect to project governance, a steering committee has been created to oversee all activities of the Network, including quality assurance. Before any implementation, all targeted users are trained to use the technology. Policies regarding the indications and contra-indications of telepathology have been developed by a committee of expert pathologists. A checking process for both the macroscopy station and the scanning system is performed every morning before the beginning of IOC. Performance parameters (turnaround time, concordance studies and number of deferred cases) are tracked on a regular basis.
Canada is a world leader in telepathology. Telepathology is mainly used for clinical services, conferences and continuing medical education.
Scope and objectives of the Eastern Quebec Telepathology Network The Eastern Quebec Telepathology Network aims at providing uniform diagnostic telepathology services to pathologists and surgeons in a territory of 408,760 km2 with 1.7 million inhabitants where the density, in certain areas, is as low as 0.4 inhabitans/ km2. It was financially supported by the Quebec ministry of health and Canada Health Infoway. The project was initiated because of the lack of consistent pathology coverage in several smaller community hospitals in the territory covered by the Network. Inhouse surveys performed among surgeons and pathologists of the concerned territory revealed an urgent need for surgeons practicing in hospitals without a full-time on-site pathologist to have access to more consistent pathology coverage. Without an on-site pathologist, pathology cases are either being examined by a travelling pathologist or sent to a remote laboratory. Surgeries requiring an IOC have to be grouped on the days the pathologist is visiting, which significantly limits the flexibility of the operating room schedule. Therefore, when no pathologist is available on-site and an IOC is needed, surgeries are postponed, patients are transferred to larger cities or two-step surgeries are performed. This situation also proved to be a major barrier in recruiting young surgeons trained in centres with an easy access to expert pathologists. Furthermore, it was clear that younger pathologists in early practice felt insecure and were often reluctant to work alone with no possibility of rapidly obtaining an expert opinion. Practicing pathologists also complained that they could hardly be absent without disturbing the surgical workflow. Finally, the survey confirmed that certain community hospitals did not have enough surgical activities to justify the presence of a full-time pathologist or even of a pathology laboratory. Essentially, the Eastern Quebec Telepathology Network was developed to meet the priorities and needs expressed in the surveys. Its overarching goal was to provide or improve access to pathology services in all remote community hospitals. More precisely, the first objective of the project was to offer a continuous coverage in IOC within the Network. The second objective was to improve time to diagnosis and quality of care, and prevent two-stage surgeries. The third objective was to facilitate the recruitment and retention of surgeons in remote hospitals. The fourth and last objective was to facilitate access to second opinions and, hence, reduce professional isolation and insecurity among pathologists working alone.
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Activities Figure 2 shows the different interactions between the Network’s sites. As initially planned, the Network favours a decentralized organisation of the IOC service in order to foster a voluntary collaboration between sites with regional affinities and to involve professionals who already developed mutual trust. It was also felt that academic sites would be most helpful at providing expert
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MINI-SYMPOSIUM: WHOLE-SLIDE IMAGING IN PATHOLOGY
Figure 1 Equipment deployed in each participating site.
opinions to pathologists working alone and to act as a safety net for sites with temporary interruption of IOC service. As per March 2014, more than 7440 slides have been scanned for primary diagnosis, (1329 IOC and the rest mostly as urgent biopsies), 2308 for expert opinions between two pathologists and 14,369 for medical education. In addition, a total of 1260 macroscopy sessions have been supervised using the system. Several smaller laboratories in community hospitals without full immunohistochemical facilities request immunohistochemical analyses from larger laboratories and, for faster results, images are returned through telepathology. Telecytology has not been performed yet for diagnostic purposes in the Network. This form of usage is currently seen as technologically challenging but recent advances are encouraging and live video streaming seems to be favoured by many users.5 Furthermore, during the eight weeks of activities between the two centres in Montreal, 13 IOC (61 slides scanned) and 10 urgent analyses (75 slides) were performed.
pathologist supervising gross description and sectioning by videoconference. Sections to be taken are selected on the screen by the remote pathologist via the drawing tablet. Complex cases requiring orientation are brought to the pathology laboratory directly by the on-site surgeon. The equipment allows live discussion between the remote pathologist and the on-site technician and/or surgeon as if they were collocated. Once the sample is selected for the IOC, the technician proceeds to the cryosectioning, staining and scanning of the slides. Digital images are accessed electronically by the remote pathologist who examines them and communicates the result to the surgeon. Figure 2 shows that IOC are originating from 13 of the 18 operational sites and that there are seven referral sites. Most IOC are from breast cancers (sentinel lymph nodes, margin close to breast cancer), lung cancers (bronchial margins, mediastinal lymph nodes), ovarian, pleural, peritoneal, omental lesions, or from stomach and head and neck cancers (Moh’s surgery).
Intraoperative consultations (frozen sections) As mentioned earlier, one of the major goals of the Network is to provide IOC (frozen sections) to community hospitals lacking onsite pathologists. In one hospital devoid of pathology laboratory, where the surgeons never had access to IOC, over 136 slides have been scanned for IOC, less than one year after implementation, confirming the need for such an expertise. For the IOC, the grossing is performed on the macroscopy station by either an onsite pathologists’ assistant or a technician with the remote
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Intraoperative consultations proved to be among the most useful applications of telepathology in the Eastern Quebec Telepathology Network. Thanks to telepathology, surgical activities in remote hospitals were maintained despite the absence of a pathologist on-site and prevented transfer of patients and two-stage surgeries.
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MINI-SYMPOSIUM: WHOLE-SLIDE IMAGING IN PATHOLOGY
Figure 2 Map of the territory covered by the Eastern Quebec Telepathology Network. The arrows indicate the sites of origin and destination of the requests.
validated by more than one pathologist6 and some quality assurance programs require that 10% of cases be reviewed by more than one pathologist.7 As expected, experts located in academic hospitals are mainly solicited. One of us (BT) received 236 consultation cases over a 3-year period and, as shown in Figure 2, the requests came from eight different sites. As an expert in gynaecologic and urologic oncologic pathology, requests mainly concerned endometrium, ovary, cervix, prostate, testis and urinary bladder. The details of these cases are presented in Table 1. When requesting an expert opinion, the on-site pathologist provides clinical information, gross and microscopic description along with additional information or attaches a cover letter to the on-line request. Once sent out electronically via the system, the expert pathologist receives an e-mail confirming the request for an opinion. Once the examination of the images is completed, the expert pathologist can either type his own report or dictate a report to be transcribed by either the local or a remote secretary. Once signed electronically, an e-mail is sent to inform the on-site pathologist that the report, in a pdf format, is available in the system.
Expert opinions Another major objective of the Network was to allow pathologists practicing alone to easily ask for expert opinions. In the literature, it is estimated that 10e20% of oncologic cases must be
Consultation cases to one pathologist of the network by telepathology Organ
Number of cases
Gynaecology Endometrial biopsy Ovary Cervix Uterus Vulva Fallopian tube Others (vagina, perineum, Bartholin’s gland, placenta) Genitourinary Urinary bladder Prostate Testis Kidney Others (urethra, pelvic region, adrenal) Miscellaneous (inguinal, colon, rectum)
e 69 32 24 23 3 3 6
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e 30 19 10 9 4 4
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Obtaining a quick opinion from an expert through telepathology has been found to be extremely supportive and reassuring, especially for pathology practicing alone.
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MINI-SYMPOSIUM: WHOLE-SLIDE IMAGING IN PATHOLOGY
Macroscopy supervision Macroscopic supervision constitutes another major component of the Network. In order to avoid sending large specimens to a central laboratory, generating delays and risk of poor fixation, several pathologists elected to distantly supervise qualified technicians or pathologists’ assistants to describe gross specimens and select the sections to be histologically examined. Table 2 shows a 1-year experience of the site having the broadest experience supervising macroscopic descriptions at a distance. Overall, of the 290 supervised cases, most were colectomies (62 cases), hysterectomies (60 cases) and mastectomies (56 cases).
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The ability of technicians to scan slides for IOC on-site permits the neuropathologist to perform IOC from elsewhere in the Network, or even from home for evening or weekend calls, in which case Network access is provided over a secure network connection via the Quebec Ministry of Health’s network (in French: Reseau integre de Telecommunications Multimedias (RITM)). Remote login to the Network is provided either via the Windows Secure Application Manager for computers using Microsoft Windows, or via Citrix XenApp. Access to the RITM is controlled by an RSA security token. Whole slide images (WSI) are also extensively used by the neuropathologists for routine diagnostic work to demonstrate colocalisation of features seen on special stains with features identified on preliminary haematoxylin and eosin (H&E) sections. WSI has replaced traditional photomicroscopy when preparing images for clinicopathologic correlations and tumour boards. In these cases the ability to display the entire tissue sample on one slide before proceeding to higher magnifications provides a clinical and radiological correlation difficult to provide prior to the implementation of WSI.
Support to macroscopy is a major activity in hospitals with absence of pathologist but requires the presence of a qualified well-trained technician or a pathologists’ assistant. Telepathology avoided the transfer of large specimens with the risk of delays and poor fixation.
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Teleneuropathology Two neuropathologists from one of the participating academic sites are very active at using telepathology for diagnostic purposes. As shown in Table 3, in 2012, 25 cases (35 slides) were scanned and, in 2013, 18 additional cases (19 slides) were scanned for IOC. Most IOC were aimed at confirming the presence of tumour in cases of suspected glioblastoma, meningioma, or brain metastases. For such cases, telepathology is more than adequate, even for physicians who are not familiar with this technology.8 Other cases included a variety of inflammatory lesions including cerebral angiitis, as well as radionecrosis following radiotherapy. These cases are potentially more challenging than the clear cut tumour cases, but review of permanent sections in all cases was concordant with the IOC diagnosis by telepathology. An advantage of teleneuropathology over other telepathology activities is that it rarely requires macroscopic examination.
Distant marker analyses (HER, skin fluorescence) Telepathology also allows pathologists to read WSI at a distance from where the analysis is performed. One of the network’s pathologist interpreted distantly a large number of scanned HER2 immunohistochemical cases. Another pathologist interpreted, via telepathology, skin immunofluorescence which technical preparation was done in a different site. Continuing medical education Teaching cases have also been shared through the mScope academic module to allow pathologists across the Network to participate in continuing medical education and quality assurance activities. Representative WSI along with appropriate clinical information are being placed on the academic mScope and shared with all participants before discussion through videoconference.
Macroscopic supervision data in one participating site in 2013 Gross description
Number of cases
Colectomies Hysterectomy Mastectomy Salpingo-oophorectomy Thyroid and parathyroid Lung (lobectomy, wedge) Dermatopathology excision for melanoma Other gastro-intestinal resections (gastrectomies, appendix, liver) Genitourinary (testis, penis) Others
62 60 56 31 22 14 11 8
Teleneuropathology is among the most convenient telepathology activities because it rarely requires macroscopic examination. WSI are used extensively by neuropathologists for IOC, routine diagnostic work and tumour boards.
Evaluation
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Concordance and turnaround time for IOC We recently reported our experience on the diagnostic concordance and turnaround time of the Network’s first 104 IOC cases.9,10 The turnaround time for an IOC by telepathology was 20 minutes including macroscopic examination and compares favourably with the situation when both the surgeon and the pathologist are on-site. Furthermore, 15 minutes were required for IOC without macroscopy, which is comparable to a reported average of 15.7 minutes by Evans et al.3 Finally, our concordance rate of 98.1% between the diagnosis rendered in the IOC and in the final report, based on the microscopic examination of glass
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slides, is comparable to prior reports3,11 and to that obtained for IOC when both pathologist and surgeon are on the same site.12 Our study also confirms the experience from different groups demonstrating, on routine material13 or on difficult consultation cases14 instead of IOC, an overall diagnostic accuracy rendered by telepathology comparable to that obtained with a conventional microscope. One of our discordant cases was a micrometastasis which has been missed by telepathology. Our results are consistent with those reported by Gifford et al.15 who found a similar false-negative rate (12%) when searching for micrometastases with telepathology compared to a conventional light microscope. This confirms the reliability of telepathology diagnosis except for some specific instances.
before a long holiday, two were ambiguous cases that required consultation of a third expert, one was received at the early implementation phase of the Network when users were not familiar with the technology and no clear reason was found for the delay of the last case. As reported elsewhere, it is rarely required to go back to glass slides to make a final diagnosis by telepathology.18 In our hands, they were requested in five instances only (2%) because of the complexity of the cases but the slide review did not provide additional information. Benefits of telepathology The Eastern Quebec Telepathology Network has been recently submitted to a multi-method evaluation19 study to better understand the expected and unexpected effects of telepathology on healthcare professionals and patients as well as on the regional organization and delivery of care services. Four major benefits of the introduction of telepathology have been identified. First, the study confirmed our expectation that telepathology would prevent interruption of IOC service in hospitals with no on-site pathologist. In two community pathology laboratories, a pathologist has been on-site for more than 10 years and moved to another laboratory in two months of notice. In both situations, the only option to maintain the surgical activities requiring IOC was to obtain support from a remote pathologist through telepathology. A similar situation happened in Montreal where an interruption of IOC occurred suddenly and required the support of an academic pathology laboratory. In the latter situation, the two hospitals were only 10 km apart but it was judged more efficient to cover IOC by telepathology rather than by sending a pathologist daily to the remote site. In all those situations, telepathology allowed the continuation of the surgical activities. Second, surgeons and pathologists who were interviewed mentioned that two-stage surgeries, aggressive surgeries and patient transfers were prevented by telepathology. Third, retention and recruitment of surgeons in remote hospitals were facilitated. Two surgeons mentioned that telepathology was instrumental in their decision. One was planning to leave because of the departure of the on-site pathologist and the second accepted an appointment, thanks to the availability of IOC through telepathology. Fourth, professional isolation and insecurity among pathologists working alone was reduced. Over 2000 WSI were submitted for expertise from such pathologists since the beginning of the Network activities, confirming the need of such a service among the remote pathologist community.
Turnaround time for expert opinions We recently updated the results of our experience that we reported on the turnaround time required between the time the onsite pathologist sends the request and receives the report.9,10 Of the 236 consultation cases presented above, 91 (38.5%) were signed out within 12 hours, 160 (67.8%) within 24 hours, 204 (86.4%) within 72 hours and 223 (94.5%) within seven days. The median turnaround time of expert opinion via telepathology was 32 hours, which is well within the median of six days reported in a study by the College of American Pathologists for consultations sent through regular mail16 and is well within the recommended time proposed by the Association of Directors of Anatomic and Surgical Pathology.17 Such rapid access to an expert opinion by telepathology is clearly an advantage over traditional work practice. Of the 13 cases that required more than seven days, none exceeded 15 days. Of them, six were difficult cases that required either additional literature review, discussion with the on-site pathologist or request of additional tests, three were received
Neuropathology cases examined in intraoperative consultations by telepathology in one site in 2012e2013 Final diagnosis
Number of cases
Glioblastoma (WHO grade IV) Metastasis Meningioma (WHO grade I) Giant cell glioblastoma (WHO grade IV) Atypical meningioma (WHO grade II) Radionecrosis Pituitary adenoma Anaplastic oligodendroglioma (WHO grade III) Disc hernia Angiitis Lymphoma Chronic inflammation Mucocele Fibrous dysplasia No inflammation Schwannoma Secondary glioblastoma (WHO grade II)
12 10 4 2 2 2 1 1 1 1 1 1 1 1 1 1 1
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The evaluation of benefits of telepathology in our Network confirmed that our initial goals were met and that the population in these remote sites clearly benefited of the usage of the technology.
Future challenges Despite all the benefits above, this multi-method study and the first-hand experience of several of the authors also highlight a number of challenges that have to be addressed to improve adoption and sustainability of such a decentralized telepathology network.
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Barriers and facilitators Evaluation studies identified technological, organizational and human factors which may explain in part the relative resistance of pathologists and technicians to use telepathology. As we previously reported,20 human factors remain among the most important challenges to using telepathology. For one thing, the technology has not reached the same level of maturity as for teleradiology since glass slides are still available to pathologists once the implementation of telepathology is completed. Further, many pathologists are reluctant to abandon their comfort zone as glass slides are still available. In the Network, to be successful, telepathology had to target well defined niches with a clear advantage for the pathologist or the patient, IOC being one of them. Success relied on efficient change management strategies including close tutorship and a highly coordinated effort between medical, laboratory staff, biomedical, administrative and IT support teams working on different sites. A central coordination centre has been created to provide logistic and technical support and each site is being visited regularly or invited to participate to follow-up videoconferences. The recently released guidelines on “validating whole-slide imaging for diagnostic purposes in pathology” by the College of American Pathologists21 and the Canadian guidelines for establishing a telepathology service for anatomic pathology using whole-slide imaging22 are among the strategies aimed at encouraging mainstream adoption of the technology by the North American pathology community. Despite all those supportive efforts, it became clear that telepathology also requires pathologists and surgeons to change their work practices, and distant technologists, pathologists and surgeons to build relationships based on trust. Technological advances in digital pathology have been significant in recent years and a large number of clinical studies confirm the accuracy of clinical diagnoses by telepathology for routine pathology cases13 and that pathologists are increasingly comfortable with the use of the technology.18 However, additional technological improvements are needed to reach wider adoption of telepathology for clinical use. Current technological challenges are largely related to image archiving and retrieval and to software application ergonomics, more specifically to the speed of user interfaces that many feel inadequate to support high-volume practice.1,23 Furthermore, most commercially available digital pathology solutions cannot be easily integrated with local laboratory information systems making their use laborious. The inability to easily perform real-time focus adjustments, especially for cytology slides, represents another technological challenge for WSI systems. Finally, difficulties at clearly visualizing micro-organisms and the need to rescan up to 13% of slides for varying technical reasons24 represent other barriers to a more widespread use of the technology in the routine practice. Those issues are however currently addressed by most vendors and major improvements in ergonomics and large volume storage will be achieved in the near future.
as Canada and in unions of independent countries such as the European Union. In Canada, health is a provincial jurisdiction and pathologists must hold a provincial licence to practice. However, liability insurances generally assist pathologists in the event of medico-legal difficulties as a result of professional work, provided that both the patient and the pathologist are in Canada. Pathologists using telehealth for a patient located outside of Canada will generally not be assisted. Other issues with respect to WSI retention are currently addressed in the Network. Current regulation and national policies require that images and patient records be saved at both the local and remote sites and that all WSI be saved for at least 20 years, which requires huge storage capacities. Nevertheless, it is expected that decreasing costs of digital storage will allow such massive storage to be economically viable. Organizational issues The recent evaluation of the network pointed out the gap between the overall objective of the network to offer consistent pathology coverage in a region and the necessity for each institution to prioritize its own in-house cases and to meet predefined turnaround times. Nevertheless, the information system architecture of the Network has broader networking capabilities and might allow pathologists from any of the participating sites, through a structured coordination mechanism, to prioritize the pathology material in a region. However, several factors such as tradition of practice, institutional regulations, shortage of pathologists and the lack of financial incentives to read distant cases, are among the major barriers to the development of such integration. The affordances of telepathology will force healthcare networks around the world to redefine the routing of surgical pathology cases and adopt a more integrated and comprehensive pathology coverage. Our experience also demonstrated that university hospitals don’t always have all the human resources to accommodate all telepathology activities in a region and that regional laboratories must be actively involved. Furthermore, as illustrated in Figure 2, in remote hospitals, surgeons declared a clear preference to work with a limited number of pathologists in their vicinity with whom they developed mutual trust over time. Licensure Whereas the US Food and Drug Administration (FDA) currently has not granted approval to any digital pathology vendor to market WSI systems for primary diagnosis, Canada granted at least three companies a Health Canada Class II Medical Device Licensure for creating, managing, storing, annotating, measuring, and viewing digital whole-slide images for routine pathology use.25 This is a major step toward the wider acceptance and adoption of digital technology in the daily practice of pathologists in this country.
Conclusion
Legal issues Telepathology also raises unique liability issues because of its capability to transcend jurisdictions. Physician multijurisdictional licensure is a major issue in the United States where pathologists may be involved in several states requiring a different license. It is also an issue in other federal countries such
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In conclusion, our experience shows that the diagnostic accuracy of IOC by telepathology falls well within that reported by conventional light microscopy and provides turnaround times respecting the most accepted standards. The “Eastern Quebec Telepathology Network” has allowed to maintain a quality IOC
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12 Novis DA, Gephardt GN, Zarbo RJ. Interinstitutional comparison of frozen section consultation in small hospitals: a College of American Pathologists Q-probes study of 18,532 frozen section consultation diagnoses in 233 small hospitals. Arch Pathol Lab Med 1996; 120: 1087e93. 13 Bauer TW, Schoenfield L, Slaw RJ, Yerian L, Sun Z, Henricks WH. Validation of whole slide imaging for primary diagnosis in surgical pathology. Arch Pathol Lab Med 2013; 137: 518e24. 14 Bauer TW, Slaw RJ. Validating whole-slide imaging for consultation diagnoses in surgical pathology. Arch Pathol Lab Med 2014; 138: 1459e65. 15 Gifford AJ, Colebatch AJ, Litkouhi S, et al. Remote frozen section examination of breast sentinel lymph nodes by telepathology. ANZ J Surg 2012; 82: 803e8. 16 Azam M, Nakhleh RE. Surgical pathology extradepartmental consultation practices. Arch Pathol Lab Med 2002; 126: 405e12. 17 Simpson PR, Tschang TP. ADASP recommendations: consultations in surgical pathology. Association of Directors of Anatomic and Surgical Pathology. Hum Pathol 1993; 24: 1382. 18 Evans AJ, Perez-Ordonez B, Asa SL. Primary diagnosis by whole slide imaging (WSI) telepathology: University Health Network (UHN) goes live. Lab Invest 2014; 94(suppl 1): 399A. 19 Trudel MC, Pare G, Tetu B, Sicotte C. The effects of a regional telepathology project: a study protocol. BMC Health Serv Res 2012; 12: 64. 20 Tetu B, Fortin JP, Gagnon MP, Louahlia S. The challenges of implementing a “patient-oriented” telepathology network; the Eastern Quebec telepathology project experience. Anal Cell Pathol (Amst) 2012; 35: 11e8. 21 Pantanowitz L, Sinard JH, Henricks WH, et al. Validating whole slide imaging for diagnostic purposes in pathology: guideline from the college of American pathologists pathology and laboratory quality center. Arch Pathol Lab Med 2013; 137: 1710e22. 22 Bernard C, Cornell IS, Dalton J, et al. Guidelines from the Canadian Association of Pathologists for establishing a telepathology service for anatomic pathology using whole-slide imaging. J Pathol Inform 2014; 5: 15. 23 Weinstein RS, Graham AR, Lian F, et al. Reconciliation of diverse telepathology system designs. Historic issues and implications for emerging markets and new applications. APMIS 2012; 120: 256e75. 24 Campbell WS, Lele SM, West WW, Lazenby AJ, Smith LM, Hinrichs SH. Concordance between whole-slide imaging and light microscopy for routine surgical pathology. Hum Pathol 2012; 43: 1739e44. 25 Tetu B, Evans A. Canadian licensure for the use of digital pathology for routine diagnoses: one more step toward a new era of pathology practice without borders. Arch Pathol Lab Med 2014; 138: 302e4.
service in hospitals where no pathologist was available on-site and to provide fast inter-institutional expert opinions for pathologists working alone. It is our experience that telepathology allows greater flexibility in practice, avoids unnecessary travel and facilitates a better organisation of pathology services in a vast territory suffering from a shortage of specialists. In view of the success of the current telepathology Network, the Quebec ministry of health and Canada Health Infoway recently initiated a second phase of the project, which is aimed at connecting 7 to 10 additional sites across the province. Considering all the ongoing initiatives in Canada, it is not unrealistic to expect for the next few years the development of a pan-Canadian Multi-Jurisdictional Telepathology Network, resulting in something resembling a nation-wide virtual pathology department. More globally, for a growing number of pathologists, the day is not so distant where light microscope will no longer be needed in pathology laboratories. It is the responsibility of the pathology profession to see that this transition occurs in a safe and orderly manner. A REFERENCES 1 Pantanowitz L, Valenstein PN, Evans AJ, et al. Review of the current state of whole slide imaging in pathology. J Pathol Inform 2011; 2: 36. 2 Bellis M, Metias S, Naugler C, Pollett A, Jothy S, Yousef GM. Digital pathology: attitudes and practices in the Canadian pathology community. J Pathol Inform 2013; 4: 3. 3 Evans AJ, Chetty R, Clarke BA, et al. Primary frozen section diagnosis by robotic microscopy and virtual slide telepathology: the University Health Network experience. Hum Pathol 2009; 40: 1070e81. 4 Tetu B, Gagnon MP, Roch G, Fortin JP. The Eastern Quebec Telepathology Network: a support to the improvement to the public health care system. Diagn Pathol Diagn Pathol 2013; 8(suppl 1): S8. 5 Pantanowitz L, Wiley CA, Demetris A, et al. Experience with multimodality telepathology at the University of Pittsburgh Medical Center. J Pathol Inform 2012; 3: 45. 6 Dietel M, Nguyen-Dobinsky TN, Hufnagl P. The UICC TELEPATHOLOGY Consultation Center. International Union against Cancer. A global approach to improving consultation for pathologists in cancer diagnosis. Cancer 2000; 89: 187e91. 7 Nakhleh RE, Bekeris LG, Souers RJ, Meier FA, Tworek JA. Surgical pathology case reviews before sign-out: a College of American Pathologists Q-Probes study of 45 laboratories. Arch Pathol Lab Med 2010; 134: 740e3. 8 Gould PV, Saikali S. A comparison of digitized frozen section and smear preparations for intraoperative neurotelepathology. Anal Cell Pathol (Amst) 2012; 35: 85e91. 9 Perron E, Tetu B. Intraoperative pathologic consultation by telepathology: an accuracy study of 104 analysis performed by the Eastern Quebec Telepathology Network. Mod Pathol 2013; 26(suppl 2): 499A. 10 Perron E, Louahlia S, Nadeau L, Boilard F, Orain M, Tetu B. Telepathology for intraoperative consultations and expert opinions: the experience of the Eastern Quebec Telepathology Network. Arch Pathol Lab Med 2014; 138: 1223e8. 11 Ribback S, Flessa S, Gromoll-Bergmann K, Evert M, Dombrowski F. Virtual slide telepathology with scanner systems for intraoperative frozen-section consultation. Pathol Res Pract 2014; 210: 377e82. ˇ
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Acknowledgements The authors are thankful to Mrs. Linda Hunter, Project Manager, Diagnostic Services Manitoba, for useful information on the Manitoba telepathology project. They are also thankful to Dr I Ian Scott Cornell for information on the Alberta Network.
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Whole-slide imaging-based telepathology in geographically dispersed Healthcare Networks. The Eastern Quebec Telepathology project
comprised primary diagnosis (including intraoperative consultations (IOC)), expert opinions between two pathologists, continuing education and assistance to macroscopic description. A concordance rate of 98% was found between IOC diagnosis and the final report and the average turnaround time was 20 minutes. Expert opinion reports were completed within 24 hours in 68% of cases. An evaluation of the benefits demonstrates that telepathology prevented interruption of IOC, two-stage surgeries and patient transfers. It also shows that retention and recruitment of surgeons in remote hospitals were facilitated and that professional isolation among pathologists was reduced. Wider adoption of telepathology would require technological improvements and appropriate change management policies. A second phase is underway to expand the service to other regions across the province.
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Keywords expert opinion; frozen section; intraoperative consultation; network; telepathology; virtual pathology; whole-slide image
Bernard Tetu Guy Pare Marie-Claude Trudel Julien Meyer
History of telepathology in Canada
Peter V Gould
Digital pathology has been successfully implemented in many countries around the world for education, clinical pathological conferences, and research.1 Despite a constant increase in adoption of digital pathology for diagnostic purposes, there are still too few examples of structured clinical networks. Canada has been a world leader in the implementation of telepathology. The large geographic size of the country combined with its relatively small population, extreme heterogeneity in population density and a shortage of anatomical pathologists played a critical role in the adoption of this technology but the country also benefited from the initiative of a few leading pathologists and the financial support of provincial governments and Canada Health Infoway, a not-for-profit federally funded health information technology agency. A recent survey reveals that up to 71% of Canadian anatomical pathologists, residents and fellows believe there is a need for telepathology in their practice.2 In Canada, healthcare delivery and management are a provincial responsibility. Ontario and Quebec have been the first two provinces to adopt telepathology for diagnostic purposes. The University Health Network (UHN) in Toronto pioneered the development of diagnostic telepathology and has demonstrated, since 2004, the feasibility and advantages of using virtual microscopy to cover intraoperative consultations (IOC) between two hospitals 1.5 km apart.3 UHN has since expanded its telepathology program to provide sub-speciality support for its transplant pathology programs as well as sub-speciality services to several other hospitals in the province and even in Kuwait. In 2004, the “Eastern Quebec Telepathology Network” (called “Reseau de Telepathologie de l’Est du Quebec” in French) was also created. A detailed description of the Network is the main focus of this article. Elsewhere in Canada, the province of British Columbia has developed expertise in standards and is using digital microscopy for consultations, education and quality assurance since 2007. Currently, Diagnostic Services Manitoba Inc. (DSM), a not-forprofit corporation with funding support from the Manitoba Health and Canada Health Infoway, is in a process of implementing a digital pathology solution in five sites in the province of Manitoba with a main focus on consultations, tumour boards, quality assurance, education and research. Once the implementation is completed, Manitoba expects to connect with the University Health Network in Toronto, Ontario and
Stephan Saikali Michele Orain Lyne Nadeau Bich N Nguyen
Abstract This study reports the first 3-year experience of the Eastern Quebec Telepathology Network. Clinical activities started in January 2011 and involved 18 hospitals practicing oncologic surgery in the region. Clinical activities
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Bernard Tetu MD Professor, Service d’Anatomopathologie et de Cytologie, CHU de Qu ebec, Hopital du St-Sacrement, Quebec, Canada. Conflicts of interest: none. ˇ
Ph.D. Chair in Information Technology in Health Care, HEC Guy Pare Montreal, Montreal, Canada. Conflicts of interest: none. Marie-Claude Trudel PhD Associate Professor, HEC Montreal, Montreal, Canada. Conflicts of interest: none. Julien Meyer MSc PhD Student HEC Montreal, Montreal, Canada. Conflicts of interest: none. Peter V Gould MD FRCPC Neuropathologist, Service d’Anatomopathologie, CHU de Quebec, Hopital de l’Enfant-Jesus, Quebec, Canada. Conflicts of interest: none. Stephan Saikali MD PhD Neuropathologist, Service d’Anatomopathologie, CHU de Qu ebec, Hopital de l’Enfant-Jesus, Quebec, Canada. Conflicts of interest: none. ˇ
le Orain RT Research Assistant, Service d’Anatomopathologie et Miche de Cytologie, CHU de Quebec, Hopital du St-Sacrement, Quebec, Canada. Conflicts of interest: none. ˇ
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Lyne Nadeau CT RT Chief Technologist, CT RT, Hopital de Sept-Iles, Sept-ıˆles, Canada. Conflicts of interest: none. Bich N. Nguyen M.D. Professor, Centre Hospitalier de lUniversite de Montr eal, Montreal, Canada. Conflicts of interest: none.
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In contrast to other Canadian provinces, the Quebec telepathology project counts no single responding site to which community hospitals turn for pathology services. No single site has the mandate to provide pathology services across the entire service area. Rather, the architecture of the Network was purposely designed to encourage decentralization and the development of a regional organization of pathology services.
Newfoundland & Labrador. The Eastern Ontario Regional Laboratory Association in Ottawa is also in the process of implementing a 17-hospital Network. Finally, the province of Alberta has trained 300 users who use digital pathology for conferences and some in-house clinical services. Streaming is used routinely in hematopathology for consultations between sites, conferences and presentations, and some users use streaming from the operating room to their office to guide grossing.
Sites and equipment C C
The Network comprises 24 hospitals providing oncologic surgery services. Of the 24 hospitals, seven have no pathology laboratory. Of the 17 sites with a pathology laboratory, four have no onsite pathologist, while six have only one pathologist and seven have 2 pathologists or more. Eighteen sites are currently fully operational (4 with no pathology laboratory, 4 with a pathology laboratory but no on-site pathologist, 4 with one pathologist and 6 with 2 or more pathologists). Additional backup equipment has also been supplied to one hospital in the Montreal area, outside of our Network territory, to relieve a temporary interruption of service. IOC and urgent biopsies were covered by the pathologists at the University of Montreal Academic Hospital, located 10 km farther. This Network is currently the most ambitious telepathology project in Canada and ranks among the most important in the world in terms of both the number of sites and geographic coverage.4 To fulfil the objectives of the project, the same equipment was implemented at each participating hospital (Figure 1). It includes a macroscopy station (PathStand 40, Diagnostic Instruments, Sterling Height, USA) and two videoconferencing devices (PCS-XG80DS Codec, Sony, Minato, Tokyo, Japan) equipped with a drawing tablet (Bamboo CTE-450K, WACOM, Otone, Saitama, Japan). Those pieces of equipment were provided by Olympus Canada Inc. (Markham, Canada). Digital images of the slides for both the IOC and expert opinions are scanned at a 20 magnification on a Nanozoomer 2.0 RS (Hamamatsu Photonics, Shizuoka Prefecture, Japan) and the images are saved on a local dedicated telepathology server. The visualisation is performed at a 1680 x 1050 pixels resolution with the mScope v.3.6.1 (Aurora Interactive Ltd., Montreal, Canada) software. With respect to project governance, a steering committee has been created to oversee all activities of the Network, including quality assurance. Before any implementation, all targeted users are trained to use the technology. Policies regarding the indications and contra-indications of telepathology have been developed by a committee of expert pathologists. A checking process for both the macroscopy station and the scanning system is performed every morning before the beginning of IOC. Performance parameters (turnaround time, concordance studies and number of deferred cases) are tracked on a regular basis.
Canada is a world leader in telepathology. Telepathology is mainly used for clinical services, conferences and continuing medical education.
Scope and objectives of the Eastern Quebec Telepathology Network The Eastern Quebec Telepathology Network aims at providing uniform diagnostic telepathology services to pathologists and surgeons in a territory of 408,760 km2 with 1.7 million inhabitants where the density, in certain areas, is as low as 0.4 inhabitans/ km2. It was financially supported by the Quebec ministry of health and Canada Health Infoway. The project was initiated because of the lack of consistent pathology coverage in several smaller community hospitals in the territory covered by the Network. Inhouse surveys performed among surgeons and pathologists of the concerned territory revealed an urgent need for surgeons practicing in hospitals without a full-time on-site pathologist to have access to more consistent pathology coverage. Without an on-site pathologist, pathology cases are either being examined by a travelling pathologist or sent to a remote laboratory. Surgeries requiring an IOC have to be grouped on the days the pathologist is visiting, which significantly limits the flexibility of the operating room schedule. Therefore, when no pathologist is available on-site and an IOC is needed, surgeries are postponed, patients are transferred to larger cities or two-step surgeries are performed. This situation also proved to be a major barrier in recruiting young surgeons trained in centres with an easy access to expert pathologists. Furthermore, it was clear that younger pathologists in early practice felt insecure and were often reluctant to work alone with no possibility of rapidly obtaining an expert opinion. Practicing pathologists also complained that they could hardly be absent without disturbing the surgical workflow. Finally, the survey confirmed that certain community hospitals did not have enough surgical activities to justify the presence of a full-time pathologist or even of a pathology laboratory. Essentially, the Eastern Quebec Telepathology Network was developed to meet the priorities and needs expressed in the surveys. Its overarching goal was to provide or improve access to pathology services in all remote community hospitals. More precisely, the first objective of the project was to offer a continuous coverage in IOC within the Network. The second objective was to improve time to diagnosis and quality of care, and prevent two-stage surgeries. The third objective was to facilitate the recruitment and retention of surgeons in remote hospitals. The fourth and last objective was to facilitate access to second opinions and, hence, reduce professional isolation and insecurity among pathologists working alone.
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Activities Figure 2 shows the different interactions between the Network’s sites. As initially planned, the Network favours a decentralized organisation of the IOC service in order to foster a voluntary collaboration between sites with regional affinities and to involve professionals who already developed mutual trust. It was also felt that academic sites would be most helpful at providing expert
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Figure 1 Equipment deployed in each participating site.
opinions to pathologists working alone and to act as a safety net for sites with temporary interruption of IOC service. As per March 2014, more than 7440 slides have been scanned for primary diagnosis, (1329 IOC and the rest mostly as urgent biopsies), 2308 for expert opinions between two pathologists and 14,369 for medical education. In addition, a total of 1260 macroscopy sessions have been supervised using the system. Several smaller laboratories in community hospitals without full immunohistochemical facilities request immunohistochemical analyses from larger laboratories and, for faster results, images are returned through telepathology. Telecytology has not been performed yet for diagnostic purposes in the Network. This form of usage is currently seen as technologically challenging but recent advances are encouraging and live video streaming seems to be favoured by many users.5 Furthermore, during the eight weeks of activities between the two centres in Montreal, 13 IOC (61 slides scanned) and 10 urgent analyses (75 slides) were performed.
pathologist supervising gross description and sectioning by videoconference. Sections to be taken are selected on the screen by the remote pathologist via the drawing tablet. Complex cases requiring orientation are brought to the pathology laboratory directly by the on-site surgeon. The equipment allows live discussion between the remote pathologist and the on-site technician and/or surgeon as if they were collocated. Once the sample is selected for the IOC, the technician proceeds to the cryosectioning, staining and scanning of the slides. Digital images are accessed electronically by the remote pathologist who examines them and communicates the result to the surgeon. Figure 2 shows that IOC are originating from 13 of the 18 operational sites and that there are seven referral sites. Most IOC are from breast cancers (sentinel lymph nodes, margin close to breast cancer), lung cancers (bronchial margins, mediastinal lymph nodes), ovarian, pleural, peritoneal, omental lesions, or from stomach and head and neck cancers (Moh’s surgery).
Intraoperative consultations (frozen sections) As mentioned earlier, one of the major goals of the Network is to provide IOC (frozen sections) to community hospitals lacking onsite pathologists. In one hospital devoid of pathology laboratory, where the surgeons never had access to IOC, over 136 slides have been scanned for IOC, less than one year after implementation, confirming the need for such an expertise. For the IOC, the grossing is performed on the macroscopy station by either an onsite pathologists’ assistant or a technician with the remote
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Intraoperative consultations proved to be among the most useful applications of telepathology in the Eastern Quebec Telepathology Network. Thanks to telepathology, surgical activities in remote hospitals were maintained despite the absence of a pathologist on-site and prevented transfer of patients and two-stage surgeries.
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MINI-SYMPOSIUM: WHOLE-SLIDE IMAGING IN PATHOLOGY
Figure 2 Map of the territory covered by the Eastern Quebec Telepathology Network. The arrows indicate the sites of origin and destination of the requests.
validated by more than one pathologist6 and some quality assurance programs require that 10% of cases be reviewed by more than one pathologist.7 As expected, experts located in academic hospitals are mainly solicited. One of us (BT) received 236 consultation cases over a 3-year period and, as shown in Figure 2, the requests came from eight different sites. As an expert in gynaecologic and urologic oncologic pathology, requests mainly concerned endometrium, ovary, cervix, prostate, testis and urinary bladder. The details of these cases are presented in Table 1. When requesting an expert opinion, the on-site pathologist provides clinical information, gross and microscopic description along with additional information or attaches a cover letter to the on-line request. Once sent out electronically via the system, the expert pathologist receives an e-mail confirming the request for an opinion. Once the examination of the images is completed, the expert pathologist can either type his own report or dictate a report to be transcribed by either the local or a remote secretary. Once signed electronically, an e-mail is sent to inform the on-site pathologist that the report, in a pdf format, is available in the system.
Expert opinions Another major objective of the Network was to allow pathologists practicing alone to easily ask for expert opinions. In the literature, it is estimated that 10e20% of oncologic cases must be
Consultation cases to one pathologist of the network by telepathology Organ
Number of cases
Gynaecology Endometrial biopsy Ovary Cervix Uterus Vulva Fallopian tube Others (vagina, perineum, Bartholin’s gland, placenta) Genitourinary Urinary bladder Prostate Testis Kidney Others (urethra, pelvic region, adrenal) Miscellaneous (inguinal, colon, rectum)
e 69 32 24 23 3 3 6
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e 30 19 10 9 4 4
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Obtaining a quick opinion from an expert through telepathology has been found to be extremely supportive and reassuring, especially for pathology practicing alone.
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Macroscopy supervision Macroscopic supervision constitutes another major component of the Network. In order to avoid sending large specimens to a central laboratory, generating delays and risk of poor fixation, several pathologists elected to distantly supervise qualified technicians or pathologists’ assistants to describe gross specimens and select the sections to be histologically examined. Table 2 shows a 1-year experience of the site having the broadest experience supervising macroscopic descriptions at a distance. Overall, of the 290 supervised cases, most were colectomies (62 cases), hysterectomies (60 cases) and mastectomies (56 cases).
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The ability of technicians to scan slides for IOC on-site permits the neuropathologist to perform IOC from elsewhere in the Network, or even from home for evening or weekend calls, in which case Network access is provided over a secure network connection via the Quebec Ministry of Health’s network (in French: Reseau integre de Telecommunications Multimedias (RITM)). Remote login to the Network is provided either via the Windows Secure Application Manager for computers using Microsoft Windows, or via Citrix XenApp. Access to the RITM is controlled by an RSA security token. Whole slide images (WSI) are also extensively used by the neuropathologists for routine diagnostic work to demonstrate colocalisation of features seen on special stains with features identified on preliminary haematoxylin and eosin (H&E) sections. WSI has replaced traditional photomicroscopy when preparing images for clinicopathologic correlations and tumour boards. In these cases the ability to display the entire tissue sample on one slide before proceeding to higher magnifications provides a clinical and radiological correlation difficult to provide prior to the implementation of WSI.
Support to macroscopy is a major activity in hospitals with absence of pathologist but requires the presence of a qualified well-trained technician or a pathologists’ assistant. Telepathology avoided the transfer of large specimens with the risk of delays and poor fixation.
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Teleneuropathology Two neuropathologists from one of the participating academic sites are very active at using telepathology for diagnostic purposes. As shown in Table 3, in 2012, 25 cases (35 slides) were scanned and, in 2013, 18 additional cases (19 slides) were scanned for IOC. Most IOC were aimed at confirming the presence of tumour in cases of suspected glioblastoma, meningioma, or brain metastases. For such cases, telepathology is more than adequate, even for physicians who are not familiar with this technology.8 Other cases included a variety of inflammatory lesions including cerebral angiitis, as well as radionecrosis following radiotherapy. These cases are potentially more challenging than the clear cut tumour cases, but review of permanent sections in all cases was concordant with the IOC diagnosis by telepathology. An advantage of teleneuropathology over other telepathology activities is that it rarely requires macroscopic examination.
Distant marker analyses (HER, skin fluorescence) Telepathology also allows pathologists to read WSI at a distance from where the analysis is performed. One of the network’s pathologist interpreted distantly a large number of scanned HER2 immunohistochemical cases. Another pathologist interpreted, via telepathology, skin immunofluorescence which technical preparation was done in a different site. Continuing medical education Teaching cases have also been shared through the mScope academic module to allow pathologists across the Network to participate in continuing medical education and quality assurance activities. Representative WSI along with appropriate clinical information are being placed on the academic mScope and shared with all participants before discussion through videoconference.
Macroscopic supervision data in one participating site in 2013 Gross description
Number of cases
Colectomies Hysterectomy Mastectomy Salpingo-oophorectomy Thyroid and parathyroid Lung (lobectomy, wedge) Dermatopathology excision for melanoma Other gastro-intestinal resections (gastrectomies, appendix, liver) Genitourinary (testis, penis) Others
62 60 56 31 22 14 11 8
Teleneuropathology is among the most convenient telepathology activities because it rarely requires macroscopic examination. WSI are used extensively by neuropathologists for IOC, routine diagnostic work and tumour boards.
Evaluation
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Concordance and turnaround time for IOC We recently reported our experience on the diagnostic concordance and turnaround time of the Network’s first 104 IOC cases.9,10 The turnaround time for an IOC by telepathology was 20 minutes including macroscopic examination and compares favourably with the situation when both the surgeon and the pathologist are on-site. Furthermore, 15 minutes were required for IOC without macroscopy, which is comparable to a reported average of 15.7 minutes by Evans et al.3 Finally, our concordance rate of 98.1% between the diagnosis rendered in the IOC and in the final report, based on the microscopic examination of glass
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slides, is comparable to prior reports3,11 and to that obtained for IOC when both pathologist and surgeon are on the same site.12 Our study also confirms the experience from different groups demonstrating, on routine material13 or on difficult consultation cases14 instead of IOC, an overall diagnostic accuracy rendered by telepathology comparable to that obtained with a conventional microscope. One of our discordant cases was a micrometastasis which has been missed by telepathology. Our results are consistent with those reported by Gifford et al.15 who found a similar false-negative rate (12%) when searching for micrometastases with telepathology compared to a conventional light microscope. This confirms the reliability of telepathology diagnosis except for some specific instances.
before a long holiday, two were ambiguous cases that required consultation of a third expert, one was received at the early implementation phase of the Network when users were not familiar with the technology and no clear reason was found for the delay of the last case. As reported elsewhere, it is rarely required to go back to glass slides to make a final diagnosis by telepathology.18 In our hands, they were requested in five instances only (2%) because of the complexity of the cases but the slide review did not provide additional information. Benefits of telepathology The Eastern Quebec Telepathology Network has been recently submitted to a multi-method evaluation19 study to better understand the expected and unexpected effects of telepathology on healthcare professionals and patients as well as on the regional organization and delivery of care services. Four major benefits of the introduction of telepathology have been identified. First, the study confirmed our expectation that telepathology would prevent interruption of IOC service in hospitals with no on-site pathologist. In two community pathology laboratories, a pathologist has been on-site for more than 10 years and moved to another laboratory in two months of notice. In both situations, the only option to maintain the surgical activities requiring IOC was to obtain support from a remote pathologist through telepathology. A similar situation happened in Montreal where an interruption of IOC occurred suddenly and required the support of an academic pathology laboratory. In the latter situation, the two hospitals were only 10 km apart but it was judged more efficient to cover IOC by telepathology rather than by sending a pathologist daily to the remote site. In all those situations, telepathology allowed the continuation of the surgical activities. Second, surgeons and pathologists who were interviewed mentioned that two-stage surgeries, aggressive surgeries and patient transfers were prevented by telepathology. Third, retention and recruitment of surgeons in remote hospitals were facilitated. Two surgeons mentioned that telepathology was instrumental in their decision. One was planning to leave because of the departure of the on-site pathologist and the second accepted an appointment, thanks to the availability of IOC through telepathology. Fourth, professional isolation and insecurity among pathologists working alone was reduced. Over 2000 WSI were submitted for expertise from such pathologists since the beginning of the Network activities, confirming the need of such a service among the remote pathologist community.
Turnaround time for expert opinions We recently updated the results of our experience that we reported on the turnaround time required between the time the onsite pathologist sends the request and receives the report.9,10 Of the 236 consultation cases presented above, 91 (38.5%) were signed out within 12 hours, 160 (67.8%) within 24 hours, 204 (86.4%) within 72 hours and 223 (94.5%) within seven days. The median turnaround time of expert opinion via telepathology was 32 hours, which is well within the median of six days reported in a study by the College of American Pathologists for consultations sent through regular mail16 and is well within the recommended time proposed by the Association of Directors of Anatomic and Surgical Pathology.17 Such rapid access to an expert opinion by telepathology is clearly an advantage over traditional work practice. Of the 13 cases that required more than seven days, none exceeded 15 days. Of them, six were difficult cases that required either additional literature review, discussion with the on-site pathologist or request of additional tests, three were received
Neuropathology cases examined in intraoperative consultations by telepathology in one site in 2012e2013 Final diagnosis
Number of cases
Glioblastoma (WHO grade IV) Metastasis Meningioma (WHO grade I) Giant cell glioblastoma (WHO grade IV) Atypical meningioma (WHO grade II) Radionecrosis Pituitary adenoma Anaplastic oligodendroglioma (WHO grade III) Disc hernia Angiitis Lymphoma Chronic inflammation Mucocele Fibrous dysplasia No inflammation Schwannoma Secondary glioblastoma (WHO grade II)
12 10 4 2 2 2 1 1 1 1 1 1 1 1 1 1 1
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The evaluation of benefits of telepathology in our Network confirmed that our initial goals were met and that the population in these remote sites clearly benefited of the usage of the technology.
Future challenges Despite all the benefits above, this multi-method study and the first-hand experience of several of the authors also highlight a number of challenges that have to be addressed to improve adoption and sustainability of such a decentralized telepathology network.
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Barriers and facilitators Evaluation studies identified technological, organizational and human factors which may explain in part the relative resistance of pathologists and technicians to use telepathology. As we previously reported,20 human factors remain among the most important challenges to using telepathology. For one thing, the technology has not reached the same level of maturity as for teleradiology since glass slides are still available to pathologists once the implementation of telepathology is completed. Further, many pathologists are reluctant to abandon their comfort zone as glass slides are still available. In the Network, to be successful, telepathology had to target well defined niches with a clear advantage for the pathologist or the patient, IOC being one of them. Success relied on efficient change management strategies including close tutorship and a highly coordinated effort between medical, laboratory staff, biomedical, administrative and IT support teams working on different sites. A central coordination centre has been created to provide logistic and technical support and each site is being visited regularly or invited to participate to follow-up videoconferences. The recently released guidelines on “validating whole-slide imaging for diagnostic purposes in pathology” by the College of American Pathologists21 and the Canadian guidelines for establishing a telepathology service for anatomic pathology using whole-slide imaging22 are among the strategies aimed at encouraging mainstream adoption of the technology by the North American pathology community. Despite all those supportive efforts, it became clear that telepathology also requires pathologists and surgeons to change their work practices, and distant technologists, pathologists and surgeons to build relationships based on trust. Technological advances in digital pathology have been significant in recent years and a large number of clinical studies confirm the accuracy of clinical diagnoses by telepathology for routine pathology cases13 and that pathologists are increasingly comfortable with the use of the technology.18 However, additional technological improvements are needed to reach wider adoption of telepathology for clinical use. Current technological challenges are largely related to image archiving and retrieval and to software application ergonomics, more specifically to the speed of user interfaces that many feel inadequate to support high-volume practice.1,23 Furthermore, most commercially available digital pathology solutions cannot be easily integrated with local laboratory information systems making their use laborious. The inability to easily perform real-time focus adjustments, especially for cytology slides, represents another technological challenge for WSI systems. Finally, difficulties at clearly visualizing micro-organisms and the need to rescan up to 13% of slides for varying technical reasons24 represent other barriers to a more widespread use of the technology in the routine practice. Those issues are however currently addressed by most vendors and major improvements in ergonomics and large volume storage will be achieved in the near future.
as Canada and in unions of independent countries such as the European Union. In Canada, health is a provincial jurisdiction and pathologists must hold a provincial licence to practice. However, liability insurances generally assist pathologists in the event of medico-legal difficulties as a result of professional work, provided that both the patient and the pathologist are in Canada. Pathologists using telehealth for a patient located outside of Canada will generally not be assisted. Other issues with respect to WSI retention are currently addressed in the Network. Current regulation and national policies require that images and patient records be saved at both the local and remote sites and that all WSI be saved for at least 20 years, which requires huge storage capacities. Nevertheless, it is expected that decreasing costs of digital storage will allow such massive storage to be economically viable. Organizational issues The recent evaluation of the network pointed out the gap between the overall objective of the network to offer consistent pathology coverage in a region and the necessity for each institution to prioritize its own in-house cases and to meet predefined turnaround times. Nevertheless, the information system architecture of the Network has broader networking capabilities and might allow pathologists from any of the participating sites, through a structured coordination mechanism, to prioritize the pathology material in a region. However, several factors such as tradition of practice, institutional regulations, shortage of pathologists and the lack of financial incentives to read distant cases, are among the major barriers to the development of such integration. The affordances of telepathology will force healthcare networks around the world to redefine the routing of surgical pathology cases and adopt a more integrated and comprehensive pathology coverage. Our experience also demonstrated that university hospitals don’t always have all the human resources to accommodate all telepathology activities in a region and that regional laboratories must be actively involved. Furthermore, as illustrated in Figure 2, in remote hospitals, surgeons declared a clear preference to work with a limited number of pathologists in their vicinity with whom they developed mutual trust over time. Licensure Whereas the US Food and Drug Administration (FDA) currently has not granted approval to any digital pathology vendor to market WSI systems for primary diagnosis, Canada granted at least three companies a Health Canada Class II Medical Device Licensure for creating, managing, storing, annotating, measuring, and viewing digital whole-slide images for routine pathology use.25 This is a major step toward the wider acceptance and adoption of digital technology in the daily practice of pathologists in this country.
Conclusion
Legal issues Telepathology also raises unique liability issues because of its capability to transcend jurisdictions. Physician multijurisdictional licensure is a major issue in the United States where pathologists may be involved in several states requiring a different license. It is also an issue in other federal countries such
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In conclusion, our experience shows that the diagnostic accuracy of IOC by telepathology falls well within that reported by conventional light microscopy and provides turnaround times respecting the most accepted standards. The “Eastern Quebec Telepathology Network” has allowed to maintain a quality IOC
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MINI-SYMPOSIUM: WHOLE-SLIDE IMAGING IN PATHOLOGY
12 Novis DA, Gephardt GN, Zarbo RJ. Interinstitutional comparison of frozen section consultation in small hospitals: a College of American Pathologists Q-probes study of 18,532 frozen section consultation diagnoses in 233 small hospitals. Arch Pathol Lab Med 1996; 120: 1087e93. 13 Bauer TW, Schoenfield L, Slaw RJ, Yerian L, Sun Z, Henricks WH. Validation of whole slide imaging for primary diagnosis in surgical pathology. Arch Pathol Lab Med 2013; 137: 518e24. 14 Bauer TW, Slaw RJ. Validating whole-slide imaging for consultation diagnoses in surgical pathology. Arch Pathol Lab Med 2014; 138: 1459e65. 15 Gifford AJ, Colebatch AJ, Litkouhi S, et al. Remote frozen section examination of breast sentinel lymph nodes by telepathology. ANZ J Surg 2012; 82: 803e8. 16 Azam M, Nakhleh RE. Surgical pathology extradepartmental consultation practices. Arch Pathol Lab Med 2002; 126: 405e12. 17 Simpson PR, Tschang TP. ADASP recommendations: consultations in surgical pathology. Association of Directors of Anatomic and Surgical Pathology. Hum Pathol 1993; 24: 1382. 18 Evans AJ, Perez-Ordonez B, Asa SL. Primary diagnosis by whole slide imaging (WSI) telepathology: University Health Network (UHN) goes live. Lab Invest 2014; 94(suppl 1): 399A. 19 Trudel MC, Pare G, Tetu B, Sicotte C. The effects of a regional telepathology project: a study protocol. BMC Health Serv Res 2012; 12: 64. 20 Tetu B, Fortin JP, Gagnon MP, Louahlia S. The challenges of implementing a “patient-oriented” telepathology network; the Eastern Quebec telepathology project experience. Anal Cell Pathol (Amst) 2012; 35: 11e8. 21 Pantanowitz L, Sinard JH, Henricks WH, et al. Validating whole slide imaging for diagnostic purposes in pathology: guideline from the college of American pathologists pathology and laboratory quality center. Arch Pathol Lab Med 2013; 137: 1710e22. 22 Bernard C, Cornell IS, Dalton J, et al. Guidelines from the Canadian Association of Pathologists for establishing a telepathology service for anatomic pathology using whole-slide imaging. J Pathol Inform 2014; 5: 15. 23 Weinstein RS, Graham AR, Lian F, et al. Reconciliation of diverse telepathology system designs. Historic issues and implications for emerging markets and new applications. APMIS 2012; 120: 256e75. 24 Campbell WS, Lele SM, West WW, Lazenby AJ, Smith LM, Hinrichs SH. Concordance between whole-slide imaging and light microscopy for routine surgical pathology. Hum Pathol 2012; 43: 1739e44. 25 Tetu B, Evans A. Canadian licensure for the use of digital pathology for routine diagnoses: one more step toward a new era of pathology practice without borders. Arch Pathol Lab Med 2014; 138: 302e4.
service in hospitals where no pathologist was available on-site and to provide fast inter-institutional expert opinions for pathologists working alone. It is our experience that telepathology allows greater flexibility in practice, avoids unnecessary travel and facilitates a better organisation of pathology services in a vast territory suffering from a shortage of specialists. In view of the success of the current telepathology Network, the Quebec ministry of health and Canada Health Infoway recently initiated a second phase of the project, which is aimed at connecting 7 to 10 additional sites across the province. Considering all the ongoing initiatives in Canada, it is not unrealistic to expect for the next few years the development of a pan-Canadian Multi-Jurisdictional Telepathology Network, resulting in something resembling a nation-wide virtual pathology department. More globally, for a growing number of pathologists, the day is not so distant where light microscope will no longer be needed in pathology laboratories. It is the responsibility of the pathology profession to see that this transition occurs in a safe and orderly manner. A REFERENCES 1 Pantanowitz L, Valenstein PN, Evans AJ, et al. Review of the current state of whole slide imaging in pathology. J Pathol Inform 2011; 2: 36. 2 Bellis M, Metias S, Naugler C, Pollett A, Jothy S, Yousef GM. Digital pathology: attitudes and practices in the Canadian pathology community. J Pathol Inform 2013; 4: 3. 3 Evans AJ, Chetty R, Clarke BA, et al. Primary frozen section diagnosis by robotic microscopy and virtual slide telepathology: the University Health Network experience. Hum Pathol 2009; 40: 1070e81. 4 Tetu B, Gagnon MP, Roch G, Fortin JP. The Eastern Quebec Telepathology Network: a support to the improvement to the public health care system. Diagn Pathol Diagn Pathol 2013; 8(suppl 1): S8. 5 Pantanowitz L, Wiley CA, Demetris A, et al. Experience with multimodality telepathology at the University of Pittsburgh Medical Center. J Pathol Inform 2012; 3: 45. 6 Dietel M, Nguyen-Dobinsky TN, Hufnagl P. The UICC TELEPATHOLOGY Consultation Center. International Union against Cancer. A global approach to improving consultation for pathologists in cancer diagnosis. Cancer 2000; 89: 187e91. 7 Nakhleh RE, Bekeris LG, Souers RJ, Meier FA, Tworek JA. Surgical pathology case reviews before sign-out: a College of American Pathologists Q-Probes study of 45 laboratories. Arch Pathol Lab Med 2010; 134: 740e3. 8 Gould PV, Saikali S. A comparison of digitized frozen section and smear preparations for intraoperative neurotelepathology. Anal Cell Pathol (Amst) 2012; 35: 85e91. 9 Perron E, Tetu B. Intraoperative pathologic consultation by telepathology: an accuracy study of 104 analysis performed by the Eastern Quebec Telepathology Network. Mod Pathol 2013; 26(suppl 2): 499A. 10 Perron E, Louahlia S, Nadeau L, Boilard F, Orain M, Tetu B. Telepathology for intraoperative consultations and expert opinions: the experience of the Eastern Quebec Telepathology Network. Arch Pathol Lab Med 2014; 138: 1223e8. 11 Ribback S, Flessa S, Gromoll-Bergmann K, Evert M, Dombrowski F. Virtual slide telepathology with scanner systems for intraoperative frozen-section consultation. Pathol Res Pract 2014; 210: 377e82. ˇ
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Acknowledgements The authors are thankful to Mrs. Linda Hunter, Project Manager, Diagnostic Services Manitoba, for useful information on the Manitoba telepathology project. They are also thankful to Dr I Ian Scott Cornell for information on the Alberta Network.
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