Telepathology in Milwaukee -“Veterans Integrated Service Network”

[Source: Almagro, 1996; Dunn, 1997/(1); Dunn, 1997/(2); Dunn, 1996;

http://www.va.gov/telemed/user/remoteDesc.idc; http://path.upmc.edu/index.html; con-tact: Bruce.Dunn@med.va.gov].

Participants

Expert: The consultant is located at the Clement J. Zablocki VAMC in Milwaukee, Wisconsin, a 888-bed facility with 5 staff pathologists and approximately 80 medical technologists and technicians in the two laboratories. It offers many academic programs and is famous for its strong technology transfer programs.

2nd Expert: The Hines VAMC, a medical center near Chicago, IL, offers second opin-ion diagnoses.

Client: The client is at the Iron Mountain Veterans Affairs Medical Center located in the Upper Penisula of Michigan, 220 miles north of Milwaukee.

There are close cooperation with telepathology users in Pittsburgh and Arizona.

Background

The Iron Mountain Veterans Affairs Medical Center is one of the smaller hospitals (120 beds) in the Veterans Affairs system. It is located at an area which is periodically inacces-sible by commercial airlines during the winter months. The hospital offers active surgery

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service that generates approximately 1000 surgical pathology cases annually [Dunn,

1996/(2), p. 463; Kayser 1999, p. 155]. The majority of the specimens at Iron Mountain are biopsies (prostate, urinary bladder, gastrointestinal tract, skin) and ordinary specimens (hernia sacs, lipomas, etc.). Only 5 % of specimens require a pathologist’s direct tele-supervision for dissection [Dunn, 1997/(1), p. 2 ]. Using telepathology, these types of specimens require a team approach for gross examination, since the affected tumors need to be thoroughly examined for adequacy of margins and lymph node involvement, to ensure that adequate numbers of tissue blocks are obtained [Almagro, 1996]. The gross examinations for telepathology and the microscopical settings are performed by two full-time employees, a senior medical technologist and a histo-technician. Both are well quali-fied in terms of educational background and very interested in telepathology [Almagro, 1996, pp. 470, 472].

The project in Milwaukee was introduced in March 1996 between the Clement J. Zablocki VAMC in Milwaukee and the Iron Mountain VAMC. After a period of test examinations, the system now is used for daily surgical pathology cases since August 1996. It is planned that the whole pathology case workload of the Iron Mountain VAMC should be performed by telepathology. Doing so, the amount of frozen section examinations, which is actually rarely performed, should be increased. The surgical pathology workload is approximately 1.000 cases per year.

The overall objective of the telepathology project at Milwaukee is the establishment of a network between the 171 Veterans Affairs hospitals for sharing resources and expertise.

The so called ‘Veterans Integrated Service Network’ is planned to be introduction at three additional VAMC hospitals at Milwaukee [Dunn, 1997/(1), p. 8]. Since VAMC hospitals are located all over the USA, it is to assume that the experience of the Milwaukee’s telepathology project will have a major impact on the development of telepathology sys-tems all over the USA!

Pathological Services

Milwaukee is rendering accurate and timely diagnoses in both - surgical pathology and clinical pathology (peripheral blood smears, body fluids, gram stains, etc.). Since July 1996, the dynamic-robotic telepathology application is used for routine, real-time diagno-ses in surgical pathology [Dunn, 1996/(2), p. 463]. From April 1996 to November 1996 already 440 surgical pathology cases at the Iron Mountain VAMC have been examined by Milwaukee’s pathologists.

Hines VAMC offers second opinion consultations for the Iron Mountain VAMC. Non-robotically controlled microscopes and cameras that are controlled at sending stations, allow to do bi-directional second opinion consultations between the Milwaukee and Hines facilities. In this way a ‘virtual’ net of 13 pathologists is available, which may improve the efficiency of the pathological workflow [Dunn, 1997/(2), p. 9].

Equipment

The used equipment is a component of the Apollo-Corabi hybrid dynamic-robotic/static-image telepathology system (Apollo Systems, Alexandria, VA, USA) [Dunn, 1997/(1), p. 9]. It integrates a video teleconsultation grossing workstation and a separate video microscopy unit. The grossing teleconsultation module enables bi-directional audio and video conferencing. It uses a readily adjustable camera (Sony VID-P100 camera) to view

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gross specimens and employs graphical annotation features to direct dissections precisely.

The telemicroscopy unit at Iron Mountain consists of a Sony DKC-5000 video camera (Montvale, NJ) mounted on a fully motorized and robotically controlled Nikon Optiphot-2 microscope (Meville, NY), equipped with five objectives (4x, 10x, 20x, 40x, and 100x; oil-free, coverslip-corrected). These devices are connected by Cybex PC Companion Plus and Extron ADA 380 to the Pentium computer which controls the entire system [Dunn,

1996/(1), p. 467]. Pentium computers are employed at both sides. In Iron Mountain the used monitor is a 19-inch video monitor, consisting of a Sony Trinitron Multiscan 20 [Almagro, 1996, p. 470]. At the client’s side the whole system is located in the main Iron Mountain VAMC’s telepathology room. For real-time videoconferencing, the staff at Iron Mountain uses a headset, HelloSet Cordless 100 (Hello Direct, San Joes, CA, USA), instead of speakers. This allows to minimize extraneous noise and ensure optimal audio connections with the pathologists at the receiving host’s station.

At the Milwaukee site, the workstation incorporates a Sony SE 20-inch video monitor that is used for all modules - for viewing gross specimens and microscopy images, and for face-to-face video conferencing. Codec is used for gross and microscopic specimen imaging.

Diagnostic sessions are performed by bi-directional video conferencing. Video

conferencing and specimen imaging take place simultaneously in separate windows on the monitor.

Communication

Initially linkage for network access between Milwaukee and Iron Mountain was achieved by using a dedicated T-1 line with a rate of 1.54 Mbps. This connection has been switched to simulate transmission over an inverted multiplex (IMUX) of four ISDN lines, transmit-ting at 512 kilobits per second. Finally static images are transmitted at 128 kbps, and full-motion video data have proved to be sufficient with ISDN at a rate of 512 kbps.

The Hines VAMC’s workstation is identical to the one at the Milwaukee VAMC. The Iron Mountain and Hines VAMC are linked by dial-up telecommunication connections using an inverted multiplex of 4 ISDN-BRI lines. Communication costs are much lower with this multiplexer compared to the T-1 line. For the future a high-speed, high bandwidth wide area network (WAN) is in development. This WAN enables the VAMC to facilitate its telemedicine applications and to reduce telecommunication costs [Dunn, 1996/(2), pp. 464-465].

The system operates with Microsoft Windows (Microsoft Corp. Redmond, WA). The Apollo system includes Micromapper software. The hybrid dynamic-robotic / static-image store-and-forward system runs by a Corabi control module (Corabi International Telemet-rics, Inc., Alexandria, VA) [Almagro, 1998, p. 1161].

Process

In Iron Mountain the medical technologist precisely mounts the glass slide on the specimen stage of the robotic microscope. Then the telepathology system in Milwaukee enables the expert to do global mapping of tissue sections on glass slides for microscopy. The host-site computer has functions that control microscope stage movements, focus, and magnifica-tion. The expert can position the microscope’s objective lens over specific target areas in tissue sections during telemicroscopy sessions. The system can operate in a dynamic mode for real-time viewing or in a static-imaging mode for higher-resolution imaging. The

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robotic microscope is used for all cases with no on-site pathologist at the remote station.

For the discussion of pathology specimens teleconferencing is used between the two sites.

At a test in 1997, resolution in the dynamic mode was 352 x 288 x 24-bit color, whereas for the static digitized images resolution was first 786 x 486 x 16-bit color, which was later upgraded to 1.520 x 1.144 x 24-bit color [Almagro, 1998, p. 1161]. Dynamic live images were viewed in a 6 x 4³/4 -inch window on the 20-inch monitor (approx. 17 % of screen).

The 0.45x lens adapter attaching the video camera to the microscope body displays appro-ximately 40% of the viewing fields in comparison to the observation directly through the microscope eye piece [Dunn, 1997/(2), p. 3]. Most of the diagnoses at Milwaukee are rendered on the basis of dynamic images. However high-resolution static images, viewed in an 11³/4 -inch x 8¹/2 -inch window proved to be valuable for examining fine details of specimen structures (e.g. to identify the cell types in an inflammatory infiltrate). Altogether the static feature was only used at 10-20% of the cases, and this mostly with low resolution to reduce transmission time [Dunn, 1997/(1), p. 10; Dunn, 1997/(2), pp. 6, 8].

Currently pathologists rarely use static images for documentation, since glass slides as the ultimate pathology record of Iron Mountain cases are stored in Milwaukee after each case is signed out. For an improved documentation of pathological cases in the future, medical records with digitized images from surgical pathology, clinical pathology and autopsy pathology cases will be stored in a decentralized hospital computer system, which is the hospital information system used in most VA facilities. Case data of Iron Mountain is accessible or can be printed out from both sides. The final objective is that the telepathol-ogy system should be fully integrated into the electronically health care systems of VAMC.

Economical Efficiency of Telepathology

In 1996 an Apollo-Corabi telepathology system costed US-$ 110.000 for the remote-site robotic station, and US-$ 30.000 for the hub-site workstation. Connection costs are dependent on the employed network (T1 or ISDN-BRI) and duration of the connection.

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