Transcript Surgical Pathology Quality Assurance Program Using Robotic

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