Systems of Client in Samedan
9.4 International Projects
9.4.1 AFIP - Armed Forces Institute of Pathology
[Source: Mullick, 1996, pp. 187-193; Mun, 1995, p. 160; Yatsenko, 2000;
http://www.afip.org/telepathology/].
Participants
Expert: Armed Forces Institute of Pathology, 6825 Sixteenth Street, N.W., Washington, D.C. 20306-6000
Client: All over the world Background
The Armed Forces Institute of Pathology (AFIP49) had been created by the U.S. military health care support services of the Department of Defense. Already starting in 1862 with the objective to improve medicine of the U.S. Army, three national medical resources arose:
a) the National Library of Medicine, b) the Walter Reed Army Institute of Research, and c) the Army Institute of Pathology, later renamed to Armed Forces Institute of Pathology - a joint agency of the Army, Navy, and Air Force. The AFIP had put a lot of effort in the evaluation and distributed deployment of emerging telecommunications technologies within the Institute’s environment. It sees its mission in medical consultation, education and research50.
The AFIP’s experience with telepathology began with a pilot project that extended from 1991 to 1993. Telepathology services in the form of diagnostic consultations were provided to remotely located Army, Navy and Air Force pathological laboratories. Since diagnostic results were satisfying, the practice of sending both, digital images and glass slides was discontinued soon. Soon the transmission of glass slides was no longer necessary, due to the improvement of image acquisition technologies which provide high resolution images.
Since 1993, the AFIP’s telepathology services are also offered to civilian laboratories and pathologists globally [Mullick, 1996, p. 187]. First the AFIP furnished three pathology laboratories in the states of South Carolina, Tennessee and Ohio with telepathology units.
These units provided brief on-site technical training and established access to structured formal anatomic pathology diagnostic consultations. A further telepathology service unit was built in the Commonwealth of Puerto Rico (V A Medical Department, Puerto Rico Health Sciences Center, University del Caribe). It serves the U.S. Navy, as well as local private laboratories with tele-consultation and tele-education services. Interestingly, the minimal communication requirement between the AFIP and case referring laboratories was as modest as a conventional telephone line and an Internet access.
Telephone lines are judged as sufficient because the AFIP employs static imaging systems where transmission speed is less important. The AFIP’s activities in consultation are
49 http://www.afip.org; contact address: T. J. O’Leary, Department of Cellular Pathology, Armed Forces Institute of Pathology, Washington, DC 20306-600 [Becker, 1993, p. 909].
50 http://www.radpath.org/history/body.html
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mostly focused and organized on single organ systems, such as dermatopathology, genitou-rinary pathology, or GYN/breast pathology. Several other disciplines are organized on larger, more encompassing areas like infectious and parasitic diseases, veterinary pathol-ogy, or medical and molecular genetics. Since 1996 the AFIP has also started to employ real-time system options for specific pathological needs. In 1995, already 200 cases had been successfully referred for diagnostic consultation.
Parallel to the tele-consultation services, the AFIP started to conduct the first electronic slide seminars through telepathology. Soon the AFIP began to offer courses and teaching programs world-wide on the WWW51 . International pathologists got access to Internet-based conferences where criteria of difficult and rare diagnoses were discussed. Further the AFIP’s Wednesday Department Slide conference, which previously reached 135 institu-tions every week by mail, started to enjoy a world-wide audience on the department’s WWW site [Mullick, 1996, p. 191].
In 1996 the AFIP already grew to a total staff number of 825 employees. Over 540 civilian and military staff were employed in 22 specialized pathology departments in consultation, education, and research. Remaining 285 employees are working in ancillary or support services. Each year, the AFIP responds to more than 48.000 surgical pathology and autopsy consultation requests from all over the world, including investigations of military and civilian aircraft accidents and other national disasters. The AFIP claims to get relevant patient information and clinical history in advance of a consultation session, to be able to do a proper interpretation of images,. The fee is approximately US-$ 50 (overview about fees, please see appendix IV). The AFIP is known for rapid turnaround times. In general final diagnoses are faxed to the contributor within 2 to 4 hours after receiving the images (average of 3 hours) [Mullick, 1996, pp. 187 ff.].
Pathological Services
The AFIP offers consultation services, education classes, and runs various research activi-ties all over the world.
Equipment
Case consultations can be sent either by file transfer protocol on the Internet, by modem, using the Roche Image Manager system (Roche Image Analysis Systems, Elon College, NC), or through the Internet, using Silicon Graphics (Silicon Graphics, Inc., Mountain View, CA.).
The cameras used by the AFIP are able to magnify in the ranges of 2x, 4x, 10x, 20x, 40x.
The following cameras are employed52: Kontron Electronic (resolution: 1024 x 768 pixels), Pixera (resolution: 1024 x 768 pixels), Polaroid DMC (resolution: 1600 x 1200 pixels), Sony DKC 5000 (resolution: 1500 x 1144 pixels), Sony DXC-760 MD (resolution: 768 x 500 pixels).
The AFIP telepathology service can handle multiple-image formats. The most common ones are JPEG compressed files. Images are viewed by using Adobe Photoshop 3.0
51 http://www/afip.mil
Extensive information: http://www.afip.org; contact: Director Bruce H. Williams, telepath@afip.osd.mil or consultation@tele8.afip.org
52 Source: http://www.afip.org/telepathology/cameras/webpages/40x.htr
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(Mountain View, CA) or Mediaconvert, a graphics tool in Irix 5.3 System 5 (Silicon Graphics).
9.4.2 Telepathology Network in Arizona - the AITN
[Source: Bhyttacharyya, 1995, pp. 9-17; Weinstein, 1995, pp. 219-226; Halliday, 1997, pp. 17-21; Nelson, 1997, p. 176A; Kayser, 1999, p. 153;
http://www.ahsc.arizona.edu/telemed; contact: ranaldw@u.arizona.edu].
Participants of the Arizona-International Telemedicine Network
Expert: University of Arizona, College of Medicine, located in Tucson, Arizona.
Client: Four hospitals in USA, (Phoenix / Mesa, Cottonwood, Kingman, Yuma), one in Mexico (Hermosillo), and one in the People’s Republic of China (Hangzhou).
Two of these hospitals have a single pathologist in solo practice employed, at each of the other sites three to eight pathologists work together as a team of colleagues.
Background
A similar service as the one of the AFIP had been created in Arizona - the Arizona-Inter-national Telemedicine Network (AITN) within the Arizona Telemedicine Program (ATP).
The ATP is a rural telemedicine network that serves rural communities in Arizona with multi-specialty telemedicine services. Cases are tracked through this network to sub-spe-cialists, who will give diagnostic advises to the referring pathologists.
The AITN became operational in June 1993, with ‘pathologist-to-pathologist consultations’
as its first service. It linked referral sites in three countries to the ‘Central Telepathology Laboratory’ at the University of Arizona, College of Medicine, located in Tucson, Arizona.
The AITN does not set any limitations on the types of cases that would be accepted for consultation. Eleven pathologists are employed by the Central Telepathology Laboratory of the AITN.
The AITN mainly works with static image telepathology systems. It tries to create a model, where general pathologists operate as triage telepathologists, and where telepathology workforce could be organized with sub-specialty pathologists utilized on an ad hoc basis.
The triage model may be suited to pathology practices that incorporate general pathologists into their customary work flow. Cases are distributed and tracked by a central office of the network. The network’s objective is to increase collegiality to improve the quality of diag-noses, and to reduce the need for subspecialists at remote sites. Subspecialists are readily available 24 hours a day as consultants for general pathologists. Approximately 30 cases per month are transmitted within this network. So far, second opinion consultations have been executed for over 300 cases and many telemedicine training programs have been offered. Since the services were found to be valuable they already gained high acceptance.
Pathological Services
The AITN’s network has been established for primary diagnostic services, second opinion consultations, and quality assurance programs. That is that the AITN provides ‘telepre-sence’ services for cases for which a referring pathologist requests assistance in rendering a primary diagnosis, and it offers ‘telediagnostic’ services for cases for which a referring pathologist had already rendered a diagnosis and now asks for verification.
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Equipment
The camera (Kontron ProgRes 3012) operates at 1024 x 774 pixels and at 24 bits of color.
Images are compressed by JPEG to a ration of 6.5:1. The frame grabber has resolution options of various pixel combinations. The finally used resolution is 768 x 580 pixels or lower for specimen orientation images, and 1024 x 774 x 8 pixels images for diagnoses. A Zeiss microscope (Oberkochen, Germany) with a 10x eyepieces and 2x, 4x, 10x, 20x, and 40x objectives is used. Data are stored in a reference case database (Paradox, Boreland International, Inc. Scotts Valley, CA).
The aim of the AITN is to offer consultation services, accessible by using ordinary tele-phone lines. All sites are connected by standard teletele-phone lines using error-correcting 14.400 bps modems. Average images are compressed via a lossless algorithm (JPEG) to approximately 300 KB.
The AITN uses the Roche Image Analysis System (RIAS-ImageManger, Roche Image Analysis Systems, Inc., Elon College, NC). It works with a Microsoft Windows platform (Microsoft corporation, Redmond, WA) and uses PC computers.
9.4.3 ICIT - International Consortium for Internet Telepathology
The idea to build up an International Consortium for Internet Telepathology53 (ICIT) was formed in 1995. The original participants were the Oxford University (Oxford, England, Dr. McGee), the Armed Forces Institute of Pathology (Washington, DC, USA, Dr.
Fontelo), the Wright Patterson Medical Center (Dayton, OH, USA, Dr. Elsayed, who also initiated the static image telepathology at the AFIP), the Japan National Cancer Center in Tokyo and Chiba, Japan (Dr. Mukai and Dr. Matsuno), and the Georgetown University Medical Center together with the Imaging Science and Information Systems Center, both located in Washington, DC, USA (Dr. Azumi, Mr. Yagi and Dr. Mun). The ICIT is
designed to be an open forum for international telepathologists - a so called ‘telepathology system for the masses’. The Internet is used as communication medium for a rapid and frequent exchange of opinions, ideas, cases and consultation services among international pathologists.
The ICIT is based on static telepathology systems, because such systems are cheaper, not as complex as robotic systems, and hard- and software can almost be bought off-the-shelf.
Compatibility between systems is easy to achieve by using almost existing hardware, soft-ware, image, and communication standards [Azumi, 1996, pp. 447, 448, 451]. The idea is to create an easy to access and easy to use telepathology network at an affordable price.
This network should be used for the everyday pathological practice. It should help to improve the communication, consultation and education of pathologists. Interesting cases can be posted to the ICIT’s web site and used for educational purposes. ICIT may lead to a quick evolution and adaptation of new entities and classifications among international pathologists.
53 Web site: http://gomyan.basic-sci.georgetown.edu and FTP server: ftp://gomyan.basic-sci.georgetown.edu; contact person: Mr.
Norio Azumi, Department of Pathology, Georgetown University Medical Center, 3900 Reservoir Road, N.W., Washington, DC 20007, USA.
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9.4.4 UICC Telepathology Consultation Center - TPCC
[Source: Conceptual paper, UICC meeting on telepathology. Charité University Hospital of Berlin, Institute of Pathology, 16.-19. July 1999, M. Bodó, S. Hufnagl, not published;
Hufnagl, 2000/(2); Dietel, 2000].
The TPCC54 is an actual approach to offer international consultation services. It is compa-rable with the activities of the AFIP in Washington, USA, with which a cooperation is intended. The consultation center will be located at the Charité University Hospital, Insti-tute of Pathology (Rudolf-Virchow-Haus) in Berlin, Germany, since this institution offers with about 40 pathologists a sufficient background. It has the necessary capacity and com-munication infrastructures, as well as the pathological and computer know-how at hand.
The objective of the TPCC is the improvement of the histological and cytological diagnos-tic quality in tumor pathology, and an enhancement of pathological communication. The TPCC provides a time-saving and easy access to high-quality pathological consultations independent of the client’s location. Particularly attention will be given to TPCC’s access by developing countries and smaller institutes of pathology in Eastern Europe, Asia, and Africa.
Requesting Pathologist International Experts
Internet E-mail
Telemicroscopy
Reference DB