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Evolution of Tele-neuropathology Intra-operative Consultation at an Academic Medical Center
Jeffrey L. Fine, MD1, (finejl@upmc.edu); Craig Horbinski, M.D., Ph.D. 2, Rafael Medina-Flores, M.D. 2, Yukako Yagi1, and Clayton A. Wiley, M.D., Ph.D. 2; 1Department of Pathology, Center for Pathology Informatics, 2Division of Neuropathology, University of Pittsburgh Medical Center, Pittsburgh, PA
Content: Telepathology systems are widely available and have facilitated real-time support of multiple surgery centers by consolidated pathology groups. Neuropathology is a specialized discipline that has increasingly become concentrated into centralized practices. Telepathology has been utilized at our institution for several years by neuropathologists for intra-operative consultations from a second hospital within our academic network. We describe our experience and review diagnosis data, in the context of technological advances and lessons learned.
Technology: A teleconferencing system was first installed in 2001, which included videomicroscopy and television for viewing cases (VTEL Products Corporation, Austin, Texas, USA). From 2002 until 2003 a hybrid system featured high-resolution images or video (DN100, Nikon, Melville, New York, USA). Since late 2003 a networked, remote-controlled microscope has been utilized (Coolscope, Nikon). With these last two systems, slides were viewed remotely using a web browser and important fields were digitally photographed using the viewer software. The laboratory information system provided secure storage and access to these images (CoPathPlus, Cerner Corporation, Kansas City, Missouri, USA).
Design: Intra-operative consultation procedures are similar for local and telepathology sites, except trained pathology assistants perform manual tasks at the distant site that neuropathologists would normally perform (gross examination, smear preparation, etc.). Telephones and pagers are used for communication during the consultation. Personnel coverage and specific responsibilities are pre-arranged, including computer support personnel. All intra-operative, adult neuropathology consultations from 1999 – 2005 were reviewed. Concordance rates, deferral rates, and frozen section rates were compared between traditional and telepathology consultations; errors were analyzed for patterns.
Results: There were 1,267 intra-operative consults from 1999 – 2005. There were 242 telepathology cases (29.8% of case volume during 2002 – 2005). Preliminary analysis showed 3 telepathology errors (1%) compared with 33 errors (3%) in traditional consults. Deferral rate was higher for telepathology than traditional consults (27% vs. 15%). Cases which were discordant yet essentially correct were not scored as errors; the majority of these cases were due to tumor grade or tumor subtype, classifications most often reserved for final diagnosis. Telepathology consultations typically required more time to complete than traditional consultations.
Conclusions: Telepathology has been relied upon to provide intra-operative, subspecialty surgical pathology support within our institution for several years. Error rates are similar, but our data also shows increased rate of deferral. Although pathologists are confident in image quality, telepathology consults require more time to complete—this highlights the need for improved viewing software and faster systems.