Different Kinds of Pathological Services

Surgical

Figure 5: Services which could be delivered by telepathology [Weinstein in Dunn, 1996/(2), p. 464].

The figure above shows the main services, which may be served by telepathology. They can be briefly characterized as follows:

6.3.1 Tele-Diagnostics

Primary Diagnostic (Telediagnosis)

One area of telepathology is the utilization of telepathology systems for primary diagnos-tics. This service is often called ‘telediagnosis³⁵’ or ‘telepresence’ [Nelson, 1997, p.

176A]. In the figure above telediagnosis is demonstrated by the first three boxes - surgical pathological diagnoses (including intraoperative frozen section examinations), clinical con-sultation and clinical pathological diagnoses (e.g. cell examinations). Primary diagnosis it

35 At the AITN the term ‘telediagnostic’ is used for second opinion diagnoses. In opposite in most of the literature and in this study, it is used for primary telepathology diagnoses.

Description of Telepathology in General Page: 47

meant to be the first diagnosis that is directly executed by telepathology. Such a diagnosis has immediate therapeutically consequences. Primary case examinations are either done for a specific single case or for a set of multiple ‘en bloc’ cases from different patients in a sequence without any break. Yet, telepathology is actually only performed for single case diagnoses [Kayser, 1996, p. 475].

Primary tele-diagnostic is mainly used between hospitals without pathologists and outside pathology laboratories. Often primary telediagnoses are limited to frozen section examina-tions, like in Basel (Switzerland) or Tromsoe (Norway). One of the few locations where telepathology is not just used for frozen section examinations but on a routine basis for primary diagnostic is in Vermont, USA. All tele-diagnoses are confirmed by direct light microscope examination later.

Second Opinion Consultations (Teleassistance, Secondary Diagnostic)

Pathology has evolved towards enormous complexity. It is a vast and changing field of the medical art, which makes it very difficult for a pathologist, even impossible, to acquire and maintain a keen knowledge in all the fields of organic diseases. It is already impossible for general pathologists to handle the increasing sophistication of diagnostic methods and to cover the entire spectrum of specialized and sub-specialized diagnostic services, e.g. car-diac, dermatology, liver, gynecology, breast, neurology, etc., or even to examine cases out-side their designated subspecialty area. Therefore pathologists become interested in helping one another in providing accurate diagnoses [Martin, 1995, p. 192]. To ask a colleague to have a ‘second look’ on a rare or difficult specimen or to refer cases to subspecialists, to confirm, to infirm, to modify or enrich a diagnosis is a common procedure in pathology.

Not rarely a pathologist is not sure about the stage and grade of a certain disease process, e.g. grading malignancy or estimating degrees of tissue destruction from chronic inflam-mation or other degenerative processes, and wishes to confirm or clarify his result [Allaert, 1995/(2), pp. 599, 600; Kayser, 1995/(1), p. 54; Olsson, 1995, p. 235].

However it is quite time consuming, if there is no second pathologist at the face. The glass microscopic slides together with documentation on the patient’s clinical history and inves-tigation have to be packaged up and send by mail. This means that the average turnaround time by using traditional routes is 1-2 weeks, depending on the distance between the refer-ring and expert’s institution. In addition, not rarely slides get damaged or lost, or there is a contentious issue of the return of the material to the referring pathologist, which may cause problems [Eusebi, 1997, p. 13]. Tele-expert-consultation may be a solution to overcome these difficulties.

”It is difficult to compute the benefit in diagnostic assistance which relies to a high degree on the diagnostic knowledge of the partners and clinical task of the surgeon; however, rough estimations calculate that substantial additional information was achieved in about 35-40 % of cases.” [Kayser, 1995/3]

”Frozen section diagnosis are not regarded as the major potential application of the technology.

Expert on-line consultation in difficult cases may be a more important application.” [Weinstein, 1987, p. 648]

Telepathology systems have proved to be an accurate and cost effective way to support second opinion advises between pathologists. They allow to reduce the risk of generalists to take responsibility for diagnosis and treatment. If they are not certain about a diagnostic outcome, they can easily request an expert for an ‘online’ second opinion. Specimen

Description of Telepathology in General Page: 48

images and case information are sent via the Internet to a consultant pathologist. Then in an interactive situation, the two physicians converse by telephone, showing each other the part of the lesion they find necessary to discuss. Using telepathology systems, pathologists are able to easily communicate and work with colleagues or small professional groups without compulsory links with major hospitals [Allaert, 1995/(2), p. 596].

One can distinguish second look consultations (‘horizontal’ consultation for supportive chats with colleagues), and second opinion consultations or reference consultations with board examination centers (‘vertical’ consultation with experts), where a highly specialized pathologist is contacted [Busch, 1992, p. 430]. At second look consultations the responsi-bility for cases remains at the requesting side. In opposite to second opinion consultations, where the judgement of the consultant has legal impact (see chapter 15.1.2).

Reference consultations are executed by pathologists, who are highly specialized in the examination of specific organs. Consequently the reference pathologist carries the respon-sibility. This is already a routine process in pathology. If a diagnosis is not conclusive or if the diagnosis has drastic therapeutically consequences, the whole specimen is sent to this specialist for a reference diagnosis. This takes in average one to two weeks until the result is available. Since waiting time is lost time for the patient and surgeon, telepathology will speed up this process [Hufnagl, 1999].

6.3.2 Continuing Medical Education and Discussion Groups

Telepathology systems are often employed for online education lessons on a distance, for computerized training and proficiency testing, or for the establishment of discussion groups.

They support the access to databases with rare and interesting registered cases. This way they help to increase competence. Getting access, the pathologist at the periphery has the pos-sibility to take part at the newest research findings and education programs. In the past pathologists discussed difficult or rare lesions by looking through one or more multihead bridge microscopes. With telepathology a color TV camera is linked to a high-quality color TV monitor for image capturing and demonstration. All electronical images can be used for teaching and training. Based on such video images, various experts at different locations can communicate and work on difficult cases that have been prepared through formalized

telepathology systems. Telepathology applications will also improve interdisciplinary cooperation and communication, because colleagues can easily be contacted and case information can be exchanged quickly. Fortunately, pathologists already start to recognize the new communication and training multimedia tools in pathology as a new feature to communi-cate more effectively with colleagues. They also enjoy the continuous education and training lectures that are offered online [Azumi, 1996, p. 451, Rienhoff, 1998, pp. 7-14; Allaert 1999;

Brebner, 1997/(1), pp. 10-12; Brebner, 1997/(2), pp. 48-52; Diebold, 2000].

One example for online-teaching in telepathology had been executed by the Office of Academic Computing for the Pathology Departments of the New York Hospital Cornell Medical Center and the Sloan Kettering Memorial Hospital. Students and teachers tele-communicated in groups, supported by a free Internet conferencing software (CU-SeeMe in connection with AppleScript). Low bandwidth high-resolution images were exchanged over the Internet. Students just had to click on images, manage pointers, manipulate image placement and zooming and were able to download cases [Stensaas, 1996, pp. 484-485].

Similar online-education features are available in Bosnia-Herzegovina and Germany

Description of Telepathology in General Page: 49

[Seiwerth, 2000; Leiner, 2000³⁶]. At the Medical University of Beijing, China, a menu-driven MBES-Pathology system had been introduced for individualized, interactive multi-media self-paced learning. The system has improved the comprehension of learning and teaching in pathology compared to traditional methods [Gong, 1996, p. 486]. And as a last example, at the Department of Pathology at the Robert Wood Jonson Medical School (New Brunswick/Piscataway, NJ, USA) ‘TelemEDUcation’ provides biomedical information, computer-based learning tools for medical education and medical practice support via Internet [Trelstad, 1996, pp. 453-454].

6.3.3 Computer-Aided Diagnoses, Quality Assurance and Research Data

Computer-Aided Diagnoses and Standardization of Exams

Pathological case data, especially rare and difficult ones, can be archived and processed at a (centralized) scientific visual data storage. If such registered diagnostic case data is available, it could be used for diagnostic purposes in the classification of benign and malignant tumors.

Remote pathologist are able to access reference cases for a double-check of a diagnosis decision. They will be alert of any possible abnormalities in the images. Merely conventional telephone lines are sufficient to send visual information of a case to the database. There the original images could be matched with the images stored in the visual database. Then the most congruent one and its diagnosis could be retrieved [Kayser, 1993/(1), pp. 331, 332]. Doing so, highly complex computer image analysis systems are used to screen specimen independently or automated quality control re-screening is offered to compare the patient’s images with reference images [Grohs, 1998, p. 166; Klossa, 1998, p. 209; Martin, 1995, p. 192; Mun, 1995, p. 158]. Computer-aided diagnosis systems with artificial intelligence technology and artificial neural networks for decision support could help to improve the accuracy and consistence of diagnoses, almost as having a second pathologist for double reading at the place. In addition, case databases may become a forcing factor to standardize exam processes and could provide clear guidelines for quality assurance.

To give an example, in a project at Oxford, UK, ‘gold standard’ images are stored in a database, which is accessible via Internet by non-experts as reference point and analysis feature for diagnoses [McGee, 1995, p. 34; Joel, 2000]. Another database of this kind was designed in France³⁷ for hematology [Flandrin, 2000]. The ENAA telematic system (Elec-trodiagnostic Neurophysiological Automated Analysis) at the Bristol Hospital, UK, is an additional example. It also can be accessed for requesting diagnostic support [Papakosto-poulos, 1996, p. 30]. Thinking about executing quality performance tests of pathologists by using ‘virtual cases’, the research approach of the University of Trento is from value [Demichelis, 2000]. Images could be captured and transmitted to all pathologists instead of the real slides have to be mailed. Another useful effect of telepathology in the context of quality assurance is the creation of protocols. Cancer research associations, such as European EORTC, already access telemedicine processes to define and monitor therapeutic protocols.

For the future it is to assume that computer-aided diagnostic assistance tools become a very important component in telepathology.

36 www.mi.med.uni-goettingen.de/PathologieLehre/

37 web: www.adicap.asso.fr; standardized image database for hematology, contact address: 1. ADICAP, Hopital Charles Nicolle, Laboratoire d’anatomopathologie, 76031 Rouen Cedex, France; 2. CRIHAN, Parc technologique de la Vatine, 32 Rue Raymond Aron, 76130 Mont-Saint-Aignan, France; CRIHAN = Center de Ressources Informatiques de Haute-Normandie; ADICAP = Association pour le Développement de I’Informatique en Cytologie et en Anatomie Pathologique

Description of Telepathology in General Page: 50

Technical Diagnostic in Pathology

There are already pathologists who use cell automatic recognition and who generate com-puter-aided diagnoses by automatic cell counting to improve and maintain diagnostic quality [Marsan, 1995, p. 342]. Volume reconstruction are generated through section pil-ing, and computer-aided diagnosis and statistics are created by 3D applications [Allaert, 1999]. Such technical procedures were introduced to gain a more detailed or specific diag-nostic statement. Procedures such as immunohistology, DNA analysis, ligandohistochem-istry or PCR are summarized under the term ‘technical diagnostic pathology’ [Kayser, 1996, p. 476].

As soon as images get a digital format on the computer, morphometric information can be extracted on a distance and diagnostic accuracy can be improved by ‘telequantifica-tion’ of images [Phillips, 1995, pp. 288 ff.; Phillips, 1996, pp. 231 ff.]. For this, images are sent for quantitative DNA-cytometry analysis or quantitative immunohistochemisty to specialized centers. ‘Analytic or quantitative cytology is already widely employed to measure ploidy on Feulgen-stained specimens or to assay clinically tumor markers, such as estrogen receptor protein on immunohistochemically stained specimens. If such standard-ized quantitative measures are online available, specimen evaluation, diagnosis and reporting will be improved [O’Brien, 1998, p. 153; Kunze, 1998, p. 141; Kunze, 2000].

Institutions which do not have experience or the necessary equipment and manpower can submit images of their case slides to others who are willing to perform the measurement [Kayser, 1993/(1), pp. 332, 333]. This is already practiced in Dresden (Germany) and in Tenerife (Spain) [Woziwodzki, 2000; Ferrer-Roca, 1995/(2), pp. 154 ff.].

Quality Assurance

Diagnosis validation (to which second opinion consultations belong to), quality assurance activities, and personal performance tests are compulsory for several specialties in pathol-ogy. By this quality assurance is defined as

”... a procedure that ensures a constancy of high-quality diagnosis or therapy in space and time ... it should assist all involved partners to reach the best and most reliable diagnosis within a limited period. Telepathology can be considered a technical procedure to assist assurance and maintenance of high standards in diagnostic pathology.” [Kayser, 1996, p. 477].

Quality assurance tests are often performed during post-university continuous education, or during various meetings and congresses. Currently such tests are organized by national and international specialized pathology associations like the CAP (College of American

Pathologists), the RCP (Royal College of Pathology), or the AFAQAP in France [Allaert, 1999; Della Mea, 1995, p. 237]. The CAP for example developed criteria for the assess-ment of continuous quality improveassess-ment and investigated the degree of accuracy of pathol-ogy services. These criteria already helped to confirm an error rate in surgical patholpathol-ogy diagnoses of less than 1% for its non-telepathology practice [Bhattacharyya, 1995, p. 12].

With telepathology such quality assurance activities could be expanded, standardized, and simplified. For example, test tissue samples which had to be mailed in the past, could be distributed as a digital image together with a question/answer file to evaluate the examina-tion quality of pathologists. Post-graduate training with proficiency tests could also be exe-cuted online [Martin, 1995, p. 192; McGee, 2000; Slodkowska, 2000].

Description of Telepathology in General Page: 51

Science

As soon as cases are diagnosed and coded by thesaurus (e.g. SNOMED, ICD, ADICAP, RESINTEL) and stored in telepathology databases, statistical output through data sort is immediately available for epidemiology studies [Allaert, 1999; Flandrin, 1997/(1), p. 97;

Flandrin, 1997/(2), p. 104]. To easily retrieve data from local databases, again it is

important to speed up the standardization of pathological medical records. Such records or images of a scientific archive can easily be used for quantitative research analysis of images, for documentation of diagnostic findings at clinical conferences, as well as for the creation of shared teaching materials.

6.3.4 On Call Services

Another interesting effect of telepathology services is the creation of ‘on call’ cooperation between pathologists, e.g. for weekend services, or even for the establishment of ‘on call’

service centers, offering 24-hours pathological consultation services. Such centers also could be contacted, if second opinion examination is needed. And as a vision, they could help to optimize medical resources between diagnosis provider countries (Europe, USA) and diagnosis requester countries (third world, medically emerging countries such as India, Africa).

An example for such a service center is the AFIP in Washington/DC. A similar service was created in Arizona - the Arizona-International Telemedicine Network (AITN), or in Berlin - the UICC (see chapters nine, 9.1.1.1 and 9.4.3). Cases are tracked through this network to subspecialists, who will help the referring pathologist [Bhattacharyya, 1995, pp. 9 ff.;

Weinstein 1995].