Using Digital Pathology in a MultiSite, Geographically Distributed Integrated Delivery Network

1
The Digital Pathology Experience at Intermountain
Healthcare

• Using Digital Pathology in a Multi-Site,
  Geographically Distributed Integrated Delivery
  Network
• Paul M Urie MD PhD

2
Intermountain Healthcare Profile

• Hospitals 20 in Utah and 1 in Idaho
• 13 Urban sites and 8 rural sites
• 2,584 licensed beds
• Medical Group - employed physicians
• 500 physicians in 150 clinics
• Affiliated Physicians 2,800 physicians
• SelectHealth 390,000 insured members
• Highly integrated Information systems and data
  network

3
Intermountain Healthcare Hospitalsin the State
of Utah
Alta View American Fork Bear River Delta
Community Dixie Regional Fillmore
Community Garfield Memorial Heber
Valley Intermountain Medical Center
LDS Hospital Logan Regional McKay-Dee
Hospital Orem Community TOSH Primary
Childrens Sanpete Valley Sevier Valley Utah
Valley Regional Valley View
4
Pathologist Distribution and Volumes

• Urban North Cassia, Logan, McKay-Dee
• 5 pathologists, 22,000 surgical cases
• Urban Central LDS, IMC, Alta View, PCMC
• 23 pathologists, 52,000 surgical cases, molecular
  pathology and flow cytometry
• Central clinical laboratory
• Urban South UVRMC, AFH, OCH, Rurals
• 5 pathologists, 22,000 surgical cases
• Southwest Dixie and Valley View
• 5 pathologists, 16,000 surgical cases

5
Pathology Service Problems

• Cases reviewed by the sub-specialty trained
  pathologists consultations
• Peer reviews for quality assurance
• Frozen section interpretations at remote
  locations
• Tumor board and conference presentations
• Review of immunohistochemistry slides from the
  central lab
• Image analysis to quantify IHC slides

6
Digital Pathology Test Hypotheses

• Pathology presentations at Tumor boards and other
  conferences
• Frozen section consultations
• Remote interpretation of immunohistochemistry
  slides performed at the central lab
• Remote consultations by pathologists within
  Intermountain Healthcare
• Remote consultations by Stanford Surgical
  Pathology Consultants
• Impact on IT resources and network

7
Digital Pathology Pilot Project at Intermountain
Healthcare

• Aperio ScanScopes and Spectrum software
• Duration of 90 days
• IMC Central lab ScanScope XT and satellite
  server
• AFH ScanScope CS and satellite server
• Dixie ScanScope CS and satellite server
• Lake Park Data Center Spectrum Server
• WAN with 100 MB links
• 4 pathologists sponsor and study directors
• 11 participating pathologists
• Approximately 12 Intermountain support personnel

8
Digital Pathology Pilot Project at Intermountain
Healthcare Data Collection

• Standard questionnaires quantitative ratings
  and comments
• Pathologists
• Tumor conference participants
• Support personnel
• Quantitative timings of functions
• IT monitors of network usage

9
Digital Pathology Project Pilot Sites
Intermountain Medical Center American Fork
Dixie Regional
10
Findings of the pilot Overview
Digital pathology can solve or at least
ameliorate some distance-related problems in a
geographically distributed health care system

• Tumor conferences overwhelmingly positive
  results in three sites
• Frozen sections 6 pathologists, 127 cases and 2
  sites demonstrated 97-100 concordance with glass
  slides
• Remote interpretation of IHC slides excellent
  scans with at least 24 hr improvement in
  turnaround time
• Remote consultations inadequate testing with
  mixed results though interest remains high

11
Tumor Conference More Efficient Preparation
Process

• This is 2 to 3 times as fast
• Time savings of at least 50...
• This is so much easierthere was less stress, it
  took less time, got me out of the zoo of taking
  photos

Average time saved 65 minutes/week (preparation
for one tumor conference)
12
Tumor Conference Better Preparation Process

• The tech scans the slides freeing me up to do
  other tasks
• I can pre-select the areas of highest interest
• I liked that the label was scanned and I could
  double-check to make sure its the right patient

13
Tumor Conference A Better Presentation

• The low power images are as good as the
  microscope
• I like being able to put up the HE and the
  immuno right next to each other
• It conveyed more information to clinicians
• You can show relationships that are hard to show
  with only a single picture

14
Tumor Conference Overall Comments

• This is a superior way of presenting a case
• It was like going down to pathology to look at
  slides with the pathologistRadiation Oncologist
• This would enable system-wide conferences
• Dr. X, though initially slow to put his trust in
  the technology, now seems to prefer it
• It would be nice to have the same level of
  technology as the radiologists

15
Frozen Sections Overall

• 2 studies, 2 sites, 6 pathologists, 127 cases
• Overall conclusions by study directors
• I would be comfortable making a frozen section
  diagnosis on a digital slide
• With the appropriate technical support and
  experience, use of the Aperio digital slides can
  effectively be used for nearly all frozen
  sections
• 97-100 concordance rate, no major discrepancies

16
Frozen Sections Learning Curve

• The diagnosis and scanning times got better as
  we got more practice
• It took a little longer to view a digital image,
  but if you factor in the time to drive to
  American Fork, it saves time

17
Frozen Sections Comments

• This could improve patient care because you can
  get consultants to look at a frozen
• Frozens are of great interest to me because Im
  the only one here
• A slightly higher deferral rate can be expected

• The possible issues include
• Added time involved in scanning slides
• Trust in non-pathologist to select and prepare
  sections
• Technical scanning problems, even minor ones, in
  this time-sensitive setting

18
Remote Viewing of Immunos, Special Stains
Promising but Not Fully Tested

• Image Quality
• Both low and high power image quality rated 4.7
  on scale of 1-5
• The digital slide was an accurate
  representation
• I could do any regular immunomore limited for a
  few microorganisms
• The quality of the scans was excellent

• Turnaround Time
• This did speed up the case
• This would save at least a day
• A day early would be great. It would be huge
  over the weekend
• This would take the wildcard of the courier out

19
Remote Second Opinions Inadequate Testing but
Interest Remains High

• A few consultations requested from Stanford
• Some consultants enthusiastic, others not
• In one case it worked the way it was supposed
  tothey called right back, suggested some
  immunos. We did those and scanned them and kept
  the billing inside
• Remote consultations within Intermountain did not
  take off, though despite these failures, they
  may be beneficial in certain circumstances
• I would use this quite a bit

20
Network Architecture
American Fork

• Slides scanned
• and stored locally
• Slides viewed
• from
• anywhere on
• the network

Image Pointers stored on central database (not
images)
IMC
Dixie
21
IT Concerns and Solutions
22
General Issues / Considerations
23
Conclusions
Primary conclusion digital pathology can solve
or at least ameliorate some distance related
problems in a geographically distributed health
care system

• Tumor conferences overwhelming positive results
  
• Frozen sections 97-100 concordance with glass
  slides
• Remote interpretation of IHC slides excellent
  scans with at least 24 hr improvement in
  turnaround time
• Remote consultations inadequate testing with
  mixed results though interest remains high

24
AcknowledgementIntermountain Healthcare Digital
Pathology Experience

• Generous and extraordinary support from Aperio
• Intermountain pathology staff and IT department
  staff
• Intermountain affiliated pathologists