telepathology and the future of pathology (or why did we change our practice model) jagdish butany,...
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Telepathologyand
The Future of Pathology(or Why did we change our Practice Model)
Jagdish Butany, MBBS, MS, FRCPC
Consultant Cardiovascular Pathologist/Director Autopsy Services Co-Editor-in-Chief, Cardiovascular Pathology
Professor, University of Toronto &Dir.Divn.of Pathology ,Dept. of Laboratory Medicine and Pathobiology, Sectty/treasurer WASPaLM(2009--)
University Health Network / Laboratory Medicine Program Toronto General Hospital , 200 Elizabeth Street, E11-444
Toronto, Ontario M5G 2C4,Canada. Tel: 416-340-3003 Fax: 416-586-9901 e-mail: [email protected]
2 Feb 2011, Birmingham, UK.
I HAVE NO CONFLICT OF INTEREST WITH ANY Equipment/Supplier!
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(a)Why did we implement telepathology (WSI) at UHN?
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Imagine
1.Cover 3 sites2.No new staff available3.Increasing workload
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• TGH, PMH, TWH
• No on-site TWH pathologist
• 2-10 frozen sections
per week (mostly
neurosurgery)
• Sept. 2004 – no NP
University Health Network
~ 1 mile
X
X
X
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UHN
IMAGINE 2!
Research
S S
S
S= Service
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UHN
IMAGINE3: 3 Departments of Pathology! # Q S Sites
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Medical Laboratories
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The Perfect Storm---!
Right Circumstances
Right Leadership Right Tools!! Available!
Problem!!
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TWH Frozen Sections: The Problems to Be Solved
• Single pathologist traveling to TWH– Inefficient process - traveling time and waiting
– Disruptive to regular workflow – 99% of departmental activity occurs at TGH
• delays in regular sign-out affecting other UHN patients
– No possibility for consultation on difficult cases – possibly affecting TWH surgical patients.
• Compromised diagnostic accuracy• Unnecessary deferred diagnoses
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The Robotic System: November 2004-October 2006
• 350 frozen sections
• accurate
• deferral rate < 10%
• slow (~ 10 minutes/slide)
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Toronto GeneralTelepathology Work Station(not a pathologist’s office)
Toronto Western
The Robotic System
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Whole-Slide Imaging: October 2006-Present
• > 1800 frozen sections/1500 patients
• 90% from neurosurgery
• 98.5-100% accuracy (month to month)
• 14-16 minute turnaround time
• 5% deferral rate
- 2 pathologists review all deferrals
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Telepathology Was A Viable Solution
• > 90% of the cases are single block• Surgeons select the tissue of interest
– no need for gross assessment by pathologist– surgeon-defined margins – submit in toto for frozen section/smear
• Robotic microscopy (2004-2006)– most intense development and validation
• Transition to WSI (late 2006- present)
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• Easy consultation with colleagues – better for patient care
• WSI had essentially no learning curve (compared to robotic microscope)
Whole-Slide Imaging: Architecture
This was TGH/UHN
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Pathology 2000-2010Pathology 2000-2010
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Future of Pathology
Frontiers in Laboratory Medicine
Feb 1-2, 2011, Birmingham UK.
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• Volume – aging population – higher sensitivity for early disease
• Demand– Sophisticated knowledgeable population– Culture of “instant gratification”
• New technologies– genomics– proteomics– informatics– robotics ‘tissue soup’ instead of tissue
Challenges for 2020Challenges for 2020
MONEY??
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The Challenge for 2020 The Challenge for 2020
• Faster• Better
– Higher quality– Personalized
• Cheaper
• Innovative
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The New Paradigm: The New Paradigm: FasterFaster
• Pathology must be faster
– “Same Day” diagnosis
– Automation
– 24/7 labs
FasterFaster
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The New Paradigm: FasterThe New Paradigm: Faster
• Speech-recognition integrated with LIS
means instant reporting without
the need for dictatyping
CHEAPER
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Technologic Advances: “omics”Technologic Advances: “omics”
HT-SequencingDNA
MicroarrayExpressionProfiling
RNA
Mass SpectrometryProtein
Metabolomics
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What is “Correct”?• Objective classification by
– mRNA expression– DNA sequencing– Response to therapy
The New Paradigm: BetterThe New Paradigm: Better
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• Synoptic Reporting– Complete
• Standardized formats (CAP checklists)
– Adaptable and flexible• No more verbose reports that no one reads!
– Database technology• Statistics collection• Administrative tracking• QA monitoring• Academic data mining
The New Paradigm: BetterThe New Paradigm: Better
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The New Paradigm: BetterThe New Paradigm: Better(A Bit Controversial-(A Bit Controversial-still !!still !!))
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 Built in redundancy
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Requirements for Full Adoption Requirements for Full Adoption • Workflow integration
– From the lab to the pathologist
• LIS integration– Barcodes– Slide tracking and retrieval
CHEAPER
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Digital Pathology EnablesDigital Pathology Enables• Remote access
• Multiple viewers
• Immediate access to the right pathologist at the right time
BETTER
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Computer-Assisted DiagnosticsComputer-Assisted Diagnostics• Automated analysis of:
– Measurement– Mitoses– Ki67 LI – Other IHC
• intensity• distribution
– Her2 FISH– Hematology
• Cellavision
– More?
• QA of technical quality– Section thickness– Stain quality
? Need for Westgard rules in AP?
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Epigenetic Control: Epigenetic Control: Can it Override the Genotype?Can it Override the Genotype?
N Engl J Med. 2007 Feb 15;356(7):731-3
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What Is Anatomical Pathology?What Is Anatomical Pathology?• Integrative
morphology based interpretation
• Consultant’s ReportGross Morphology
Chemistry on a glass slide
Immunoassay on a glass slide
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The Virtual AutopsyThe Virtual Autopsy
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After “The Anatomy Lecture of Dr. Nicolaes Tulp” – Rembrandt, 1632(Courtesy of Dr. Carlos Cordón, New York, USA)
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• Patient-Centred Care
• Individualized diagnostics
• Targeted therapies
All based on “omics”
Will “omics” replace pathology?
The New Paradigm: PersonalizedThe New Paradigm: Personalized
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The Future of Pathology?The Future of Pathology?
$15.00 each $1000.00 each$15.00 each $1000.00 each
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2020 Pathology2020 PathologyDigital radiology
Digital cardiology
Digital genetics
Biomarkers & CAD
ClinicalPathology
Gross Pathology
History, Physical,Family History
Digital EMR
QA
Labs/
Pathology:
the center
of
Personalized
Medicine !!Endoscopy
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• Comprehensive & Integrated Pathology reports– Incorporation and integration of radiologic,
biochemical, morphologic , molecular, cytogenetic and epigenetic data
The 2020 ParadigmThe 2020 Paradigm
The Pathologist’s Cockpit
Gross Pathology
BiomarkersRadiology
Biochemistry
MolecularPathology
Histopathology
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• To provide the right diagnosis
• To provide the right material
• To provide the right leads
• To provide the right experiments
• To evaluate the consequences of genetic manipulation
• To PROVIDE An INTELLIGIBLE, COMPREHENSIVE REPORT!!
The Expanding Role of Lab MedicineThe Expanding Role of Lab Medicine
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2020 2020
2020 2020 THE THE Pathologist !!Pathologist !!
The Pathologist and the Patient!!
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2020 2020 PathologistPathologist
Pathologist and Patient!“The Diagnosis is----, and the prognosis is----.”
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“AS IS YOUR PATHOLOGYSO IS YOUR MEDICINE.”
Sir William OslerMcGill Univ, Hopkins, London (UK)
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IMAGINE!!
X
X
XX
KuwaitX
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The Future of PathologyThe Future of Pathology
The best way to predict the future is to invent it
Alan Kay