Technology Evolution in Pathology: The University Health Network Experience Across Ontario

1
Technology Evolution in PathologyThe University
Health Network Experience Across Ontario

• Sylvia L. Asa, MD, PhD
• Pathologist-in-Chief
• Medical Director, Laboratory Medicine Program

2
Objectives
Participants should have an understanding of

• The nature of pathology practice in Ontario
• The reason for a centralized laboratory program
• The IT requirements for success of centralized
  pathology
• The reason for using digital imaging

3
Assumptions

• A single payer, publically funded health care
  system
• A large geographic area with population
  concentration in 5 large centers
• A shortage of Pathologists

4
Initial Status

• Multiple hospitals of variable size scattered
  throughout the province
• Toronto (GTA) has 7 major teaching hospitals and
  35 other hospitals
• 5 medical schools in various cities with 1-5
  affiliated hospitals
• Other large cities with large, full-service
  hospitals
• Many small towns with hospitals of varying size
• Each hospital is operated as an independent
  entity with funding from the Ontario Ministry of
  Health and Long-term Care

5
Historical Issues

• 1990s Ontario determined that
• Health care costs were too high
• Pathology was a dying field
• There would be no need for Pathologists in the
  next century
• Training programs in Pathology were slashed
• Outcome major shortages of Pathologists emerged
  in late 1990s-2000

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Healthcare Reform 1990s

• Regional planning for healthcare (LHINs)
• Consolidation of hospitals

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The University Health Network

• A consolidation of three U f T affiliated
  teaching hospitals
• Programmatic restructuring
• TGH cardiac care transplantation advanced
  medicine and surgery
• PMH cancer care
• TWH neurosciences, musculoskeletal care,
  community health
• Laboratory consolidation

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The University Health Network
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The Challenge Lab Consolidation

• 3 physical sites
• 3 cultures
• 3 missions of the academic institution
• Complex patient care
• Education
• Research

10
Proposed Solution

• A single core department
• Electronic support for specimen tracking and
  handling at 3 sites
• Highly subspecialized expertise
• Biochemistry - Microbiology
• Hematology, Transfusion Hematopathology
• Subspecialty Anatomical Pathology
• HLA - Molecular/Genetics

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Solution Step 1

• LIS implementation goals
• Best-of-breed approach to support high volume
  complex testing
• Integration in e-chart with e-orders
• Specimen tracking and management
• Integration of lab data from all disciplines into
  a consolidated report

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Solution Step 1

• LIS implementations
• Core Lab automation and middleware
• CoPath solution for Pathology
• Transfusion Medicine LIS
• HLA Histotrack
• Upgrade existing Shire for molecular lab and
  interface with CoPath

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Solution Step 2

• Analyze workflow
  and clinical needs
• Build core labs
  and satellites
• State-of-the-art
  space and equipment
• Tubes where possible
• Rapid response labs where required
• On-site accessioning and grossing for surgical
  pathology with enhanced PA support

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Informatics Voice Recognition

• Dragon-speech integrated with LIS
• means instant reporting without
• the need for dictatyping

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Solution Step 3

• Recruit appropriate medical and technical
  expertise
• Create teams of experts who integrate with
  clinical staff in priority programs The
  Pathologist as Medical Consultant
• As is your pathology, so goes your clinical
  care.
• Sir William Osler

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Subspecialty Pathology

• All cases reported by a pathologist with
  expertise in the specific subspecialty required
• Benefits
• Better quality and faster patient care
• Fiscal responsibility 1 pathologist per case
• Pathologist satisfaction enhanced academic
  excellence
• Challenges
• Requirement for appropriate staffing in all areas
  and redundancy

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Solution Step 4

• Implement telepathology for intraoperative
  consultations and frozen sections at non-core
  sites
• Phase 1 Robotic microscopy
• Phase 2 Digital WSI

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Historical Data Telepathology

• 1973 Washington DC diagnosis of leukemia via
  satellite from Brazil
• 1986 Dr. Ronald Weinstein coins name
• 1990s Norway implements robotic microscopy to
  support frozen sections in remote hospitals
• 2003 ? Why Not UHN

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Barriers to Telepathology

• Cost cheaper than another pathologist!
• FDA approval not applicable in Canada
• Billing/CPT codes not applicable
• Turnaround time - overcome
• Pathologist issues
• learning curve/accuracy
• images are good, but not ready for prime time

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Th Philosophical Response
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Due Diligence Before Going Live

• Medical Malpractice Insurance Provider
• Canadian Medical Protective Association (CMPA)
• telepathology will not affect coverage
• UHN Medical Advisory Committee
• SOP presented for approval
• Health Canada Therapeutic Products Program
• telepathology does not involve medical devices
  (no direct contact between instrument and
  patient)
• no federal approval required
• Surgeon Education
• demonstrating the robotic microscope/slide
  scanner
• essential to get surgeon buy-in!

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The Robotic System November 2004-October 2006
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The Robotic System November 2004-October 2006
Toronto General Telepathology Work Station
Toronto Western Surgical Pathology
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Whole-Slide Imaging October 2006-Present

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Whole-Slide Imaging System Parameters
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UHN Telepathology Protocol

• System test each morning
• Pathologist reviews daily O.R. list and
  communicates game plan for the day to
  histotechnologist
• Surgeon defines tissue of interest
• Histotechnologist contacts Pathologist
• - specimen description, processing specimen
• Histotechnologist at TWH scans the slide and
  calls the Pathologist
• Pathologist speaks with the surgeon by telephone
• QA the next day

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1003 Frozen Sections from 802 Patients (Nov
2004-Sept 2008)
1003
653
350
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Performance 1003 Cases/4 Years

• Accuracy
• 98 concordance with final pathology
• Not a function of technology
• Deferral rates
• Identical to on-site rates
• NOT a function of technology
• Sometimes you just dont know for sure
• Sampling issues in the frozen section biopsy
• Turnaround times
• Well within 20 minutes required

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TAT Single Block Frozen Sections


Receipt of tissue to report of diagnosis
p lt 0.0001
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Pathologist Interpretation Time
4-fold


Receipt of image to Report of diagnosis
p lt 0.00001
Pathologists tended to go to TWH site for
multi-block cases when using the robotic
microscope not so for whole-slide imaging.
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WSI Pathologist Interpretation Time
38
32
30
Minutes/slide
70 of cases reported in lt 2 minutes after scan
is received
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Failure Mode Analysis

• PRE-CASE
• Network failure
• Moving the scanner within the surgical pathology
  lab
• static vs dynamic IP addresses
• discovered on morning test run.
• MID-CASE
• Minute/pale pieces of tissue that the scanner
  would not recognize
• Excess mounting media causing the cover slip to
  stick to the scanner objective

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Subspecialty Support for FS
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Subspecialty Model

• How do we get the two liver pathologists to read
  transplant biopsies and attend all academic
  meetings?
• Telepathology solution
• USCAP 2008 all rush biopsies read on laptops at
  the meeting

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Subspecialty Model

• How do we get the subspecialty support for
  weekend coverage?
• Telepathology solution
• Summer 2008 all weekend cases read on laptops at
  the home/cottage etc.

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Subspecialty Model

• How do we get the pituitary expert to read a
  tough biopsies when she is in Istanbul?
• Telepathology Blackberry solution

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Ontario-Wide Implementation

• Timmins and District Hospital forms an alliance
  with 9 other hospitals in North East Ontario
• Seeks Laboratory Medical Directorship
• UHN provides a suitable proposal
• Team of subspecialists to support all clinical
  needs from core in Toronto
• Initiation of a new model

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Ontario NE Cluster Implementation
422 miles
Google Maps 2008
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Configurations in NE Ontario

• Small hospitals going to POCT only
• Medium hospitals on-site labs with POCT
• Largest hospital with full lab and surgical
  pathology accessioning, grossing by PA with
  webcam support
• All smaller hospitals send AP specimens to core
  in Timmins
• Complex testing referred to UHN

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Subspecialty Model

• Requires sign-out of all cases by subspecialist
• Slides shipped to Toronto by overnight courier
• FS review by subspecialist must be available
• Ultimately no pathologist on site
• Telepathology solution

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The Ultimate Solution

• 3M grant from government to implement high
  resolution digital imaging at all sites
• All abnormal blood smears, malaria, microbiology
  gram stains, CSFs, etc
• Plan to expand FS service to hospitals that have
  not had this available
• CoPath integration of digital imaging in future
  will alleviate need for any slide transportation

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Pros and Cons of LIS Integration

• Pros
• Fast
• E-filed into right location
• Integration of gross, micro, EM, molecular
• Remote access and who has (need) access
• Cons
• Images trapped and need for export for other
  purposes

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Addition of New Clients
422 miles
Google Maps 2008
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The Future of Pathology?

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The Future of Pathology

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The Future of Pathology
The best way to predict the future is to invent
it Alan Kay
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What About Academia?

• Digital education
• Digital documentation of the biobank
• The Biobank is the current phraseology for the
  Department of Pathology
• Scanning and automated analysis of TMAs
• Scientific Advances
• Laboratories must evaluate,
  develop, and apply the genotypic and
  phenotypic analyses of specimens

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Acknowledgements

• Pathologists
• Andrew Evans
• Runjan Chetty
• Blaise Clarke
• Sidney Croul
• Bayardo Perez-Ordonez
• Rasmus Kiehl
• Surgeons
• Mark Bernstein
• Abhijit Guha
• Fred Gentili
• Chris Wallace
• Michael Fehlings
• Mojgan Hodaie
• Jaime Escallon

• Histotechnologists
• Suganthi Ilaalagan
• Sofia Aguierre
• Alfreda Antonio
• Carsen Chan
• Gordon Chin
• Norman Hew-Shue
• Pam McCartin
• Aparna Pant
• Ann Marie Scott
• Henry Wu
• IT Support
• Greg Lewis
• Karen Jaquardt

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