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Telepathology for Intraoperative Consultations and Expert Opinions: The Experience of the Eastern Québec Telepathology Network [Archives of Pathology & Laboratory Medicine](Archives of Pathology & Laboratory Medicine Via Acquire Media NewsEdge) * Context.-The Eastern Québec Telepathology Network was created to provide uniform diagnostic telepathology services in a huge territory with a low population density. Objectives.-To evaluate the diagnostic concordance and turnaround times of intraoperative consultations (IOCs) and the turnaround time of expert opinions by telepathology. Design.-For the IOC part of the study, the first 104 IOC diagnoses from a single hospital were compared with those in the final pathology report. The turnaround time of the IOC was calculated from the arrival of the specimen at the pathology laboratory until the time of the call to the surgeon. For the expert opinion part of this study, the first 94 expert opinions from 5 hospitals were reviewed by comparing the time of the initial request until the time of the final report. Results.-Of the 104 cases in the IOC study, 8 diagnoses (77%) were slightly discrepant because of differences in terminology but remained in the same category of interpretation. Two cases (1.9%) were significantly discordant. Therefore, 102 cases (98.1%) were either concordant or had no clinically significant discrepancies. The average turnaround time for IOCs was 20 minutes (range, 8-43). For the expert opinion part of the study, reports were signed out within 24 hours in 64 cases (68%) and within 72 hours in 80 cases (85.1%). Conclusions.-The Eastern Québec Telepathology Network allows a rapid, high-quality IOC service to be maintained for a hospital where no pathologist was available on site. It also provides a fast, expert opinion service to pathologists working alone. (Arch Pathol Lab Med. 2014;138:1223-1228; doi: 10.5858/arpa.2013-0466-OA) Real-time telepathology allows the gross examination of specimens from a distant site, visualization of frozen sections, and case referrals or second opinions from an expert or colleague. In 2004, the Québec Ministry of Health (Ministè re de la Santéet des Services Sociaux, Quebec, Canada) and the Canada Health Infoway (Inforoute Santédu Canada, Toronto, Ontario) financially supported the creation of the Eastern Québec Telepathology Network (Réseau de Télépathologie de l'Est du Québec, Quebec, Canada). This network was aimed at providing uniform diagnostic telepathology services to pathologists and surgeons in a territory of 408 760 km2 with 1.7 million inhabitants, where the density, in certain areas, is as low as 0.4 inhabitants/km2.1 The territory covered by the Eastern Québec Telepathology Network lacked consistent pathology coverage in several smaller community hospitals. Therefore, certain surgeries were required to be postponed, several patients were transferred to regional hospitals, and 2-step surgeries had to be performed when a frozen section was needed and no pathologist was available on site. In addition, this situation proved to be a barrier in recruiting young surgeons trained in centers where access to an expert pathologist was not an issue. Furthermore, it was clear that younger pathologists in early practice felt insecure and were often reluctant to work alone because of the difficulty in rapidly obtaining an expert opinion. Practicing pathologists complained that they could hardly be absent without disturbing the surgical workflow. The Eastern Québec Telepathology Network was established to provide intraoperative consultations (IOCs) to community hospitals lacking a pathologist on site and to decrease professional isolation of pathologists working alone. The network includes 24 hospitals providing oncologic surgery; of which, 7 (29%) have no pathology laboratory, and 4 additional hospitals (17%) have a pathology laboratory but no pathologist (Figure 1). The general objective of this study was to assess the validity of telepathology to provide quality IOC diagnoses and timely expert opinions to remote communities. The first aim of the study was to evaluate the accuracy of the first series of IOCs performed by telepathology; the second objective was to assess the turnaround time required to perform the analysis, and the third objective was to assess the turnaround time required to provide expert opinions by telepathology. MATERIALS AND METHODS We performed a retrospective review of the first 104 consecutive IOCs evaluated by telepathology by a single pathologist (S.L.) practicing at the Centre Hospitalier de Baie Comeau (Baie Comeau, Québec, Canada) between March 2011 and May 2012. These IOCs were requested by surgeons practicing in a single hospital (Centre Hospitalier de Sept-îles, Sept-îles, Québec, Canada) located 233.4 km (145 miles) eastward, which had experienced a recent interruption in pathology coverage. We also performed a retrospective review of the first 94 expert-opinion reports of cases sent to a single expert in gynecologic and urologic pathology (B.T.) and originating from 5 different hospitals. The equipment used is shown in Figure 2. For the IOCs, the real-time, gross evaluation was performed using a macroscopy station (PathStand 40, Diagnostic Instruments, Sterling Heights, Michigan) and 2 videoconferencing devices (PCS-XG80DS Codec, Sony, Minato-ku, Tokyo, Japan) equipped with a drawing tablet (Bamboo CTE-450K, WACOM, Otone, Saitama, Japan). That equipment was obtained from Olympus Canada Inc (Richmond Hill, Ontario, Canada). The gross examination was performed on the macroscopy station by the technician at the distant site, with the pathologist supervising by videoconference and sketching the section needed on the screen via the drawing tablet. Complicated cases that required orientation were brought to the pathology laboratory directly by the surgeon. Once the sample was selected for the IOC, the technician processed it with cryosectioning and staining. Digital images of the slides for both the IOC and expert opinions were obtained by scanning at a 320 magnification on a Nanozoomer 2.0 RS (Hamamatsu Photonics, Hamakita City, Shizuoka Prefecture, Japan), and the images were saved on a local, dedicated tele- pathology server. The visualization had a 1680 3 1050 pixel resolution with the mScope v.3.6.1 (Aurora Interactive Ltd, Montreal, Quebec, Canada) software. Objectives The following methodology was applied to reach our 3 objectives: Concordance Study.-The diagnoses of the first 104 IOC cases obtained by telepathology and documented in the intraoperative pathology reports were compared with those of the final pathology report performed on the formalin-fixed, paraffin-embedded mate- rial of the specimen used for the IOC. Every specimen submitted for IOC was received in separate containers, even for the same patient, and was recorded independently. As proposed by others2 the concordance was assessed as follows. Concordant.-Concordance was defined as complete agreement between the intraoperative pathology report and the final pathology report. Slightly Discrepant.-Mild differences that would not have any clinical or prognostic implications (alternate nomenclature, an imprecise diagnosis that was in the same category of interpretation, a general diagnosis, such as carcinoma, instead of adenocarcinoma) were categorized as slightly discrepant. Discrepant.-Differences with clinical and/or prognostic implica- tions for the patient were labeled discrepant.Incasesofa discrepancy, as recommended,3 the reports, frozen section slides, paraffin slides, and the digitized slides were reviewed by 2 pathologists (E.P., B.T.). Turnaround Time of an IOC by Telepathology.-The time required at each step of an IOC was recorded from the moment the specimen was placed on the macroscopy table until the diagnosis was transmitted to the surgeon. Every specimen submitted for IOC in separate containers, even for the same patient, was recorded independently. Only cases that were individually reported were included in this study. Specimens were excluded in cases with incomplete time information or in cases when the pathologist did not transmit the diagnosis to the surgeon immediately after examination but waited until all the specimens coming from the operating room for the same patient were examined. Turnaround Time for Expert Opinion.-The time required to respond to a request for an opinion sent to an expert in genitourinary and gynecology pathology was assessed. The type of specimen, the date and time of the consultation request, and the date and time at which the consultation report was signed out, sent out, and received by the consulting pathologist were documented. RESULTS IOC-Concordance Study Table 1 shows a summary of the study cases and their organ of origin. The intraoperative diagnoses were com- pletely concordant with the final diagnosis in 94 cases (90.4%). Eight diagnoses (7.7%) were slightly discrepant with no clinical impact (Table 2). The diagnosis provided for such lesions remained in the same category of interpretation or used alternative nomenclature, such as lymphomatous process versus non-Hodgkin lymphoma, pulmonary carcinoma versus pulmonary adenocarcinoma,andsoforth.Two significant discordant cases (1.9%) were found (Table 3): In one case, a negative margin at the intraoperative analysis changed to a low-grade intraepithelial lesion, and in the second case, a micrometastasis (0.2 mm) was found in a lymph node. Overall, of the 104 cases, 102 cases (98.1%) were either concordant or had no clinically significant discrepancies. Therefore, the percentage of agreement between the telepathology IOC and the final diagnosis was high (98.1%). Turnaround Time of an IOC by Telepathology Of the 104 cases, 72 (69.2%) fulfilled the inclusion criteria for the turnaround time evaluation. Of which, 50 (69%) were lymph nodes from 26 patients, ranging from 1 to 6 lymph nodes per patient. Table 4 shows the time required at each step of the IOC. The average time between the arrival of the specimen and the transmission of the diagnosis by phone to the surgeon was 20:01 minutes (range, 8-43). The average turnaround time for IOC of lymph nodes was 19:37 minutes, with a median of 20 minutes, and a range of 8 to 34. The average turnaround time for the other specimens was 21:14 minutes, with a median of 19, and a range of 11 to 43. In one case, 3 lymph nodes arrived at the same time from the operating room in separate containers, and the total turnaround time for this patient was 24 minutes. Excluding the macroscopic examination step, the average time for sectioning, scanning, visualization, and interpreta- tion was 15 minutes. Overall, the slide scanning (4:46) and access to the image from the remote server (1:15) were the only additional steps required to be performed for an IOC by telepathology compared with the steps when surgeons and pathologists are at the same site. Turnaround Time for Expert Opinion Expert opinion reports were signed out within 24 hours in 64 of the 94 cases (68%) and within 72 hours in 80 cases (85%). Table 5 shows the types of cases that were sent for opinion. Table 6 summarizes the number of cases that were signed out within 24 hours, within 24 to 48 hours, within 49 to 72 hours, within 3 to 7 days, and those that took more than 7 days. Of the 14 cases that required more than 3 days, 9 (64%) were difficult cases that required obtaining the glass slides and blocks (5 of 9 cases; 56%), discussing with colleagues or reviewing appropriate literature (4 cases; 44%). Of the last 5 cases, 3 (60%) were sent while the referee was out of his office, 1 (20%) was sent before a long weekend, and no specific reason was available in 1 case (20%). COMMENT Digital pathology has been successfully implemented in many countries around the world for education, clinical pathologic conferences, and research.4 Its adoption for diagnostic purposes is increasing, but there are still few examples of structured, patient-centered networks. Canada has been a world leader in the implementation of tele- pathology, thanks to the initiative of a few leading pathologists and the financial support of provincial govern- ments and Canada Health Infoway, a federal telehealth funding agency. The relatively wide adoption of telepathol- ogy in Canada is explained in part by the large geographic size of the country, combined with its relatively small population, extreme heterogeneity in population density, and a shortage of anatomic pathologists. The Eastern Québec Telepathology Network has been created to provide services not otherwise available to remote communities. When the project was initiated, surveys demonstrated an urgent need for surgeons who practice in hospitals without a full-time, on-site pathologist to have access to more-consistent pathology coverage. Without pathologist on site, pathology cases were either being examined by part-time pathologists or were sent to remote laboratories. Surgeries requiring an IOC had to be grouped on the days when the pathologist was present, which significantly limited the flexibility of the schedule. Our survey also demonstrated that younger pathologists work- ing alone felt insecure because of the difficulty in rapidly obtaining expert opinions. Furthermore, certain community hospitals did not have enough surgical activities to justify the presence of a full-time pathologist or even of a pathology laboratory. The Eastern Québec Telepathology Network is currently the most ambitious telepathology project in Canada5 and ranks among the most important in the world in both the number of sites and its geographic coverage. Our experience in this study confirms that telepathology helps to improve the quality of health care in remote regions, particularly in oncologic surgery. The turnaround time for an IOC by telepathology compares favorably with the situation when both the surgeon and the pathologist are on site,6 and our reported average of 15 minutes without macroscopy is comparable to a reported average of 15.7 minutes by Evans et al.7 Furthermore, our concordance rate of 98.1% between the diagnosis rendered in the IOC and in the final report was comparable to that obtained for frozen sections when both the pathologist and surgeon were on the same site.3,8 Our study also confirmed the experience from different groups demonstrating an overall diagnostic accuracy ren- dered by telepathology comparable to that obtained with a conventional microscope.9 One of our discordant cases was a micrometastasis, which was missed by telepathology. In a recent study, Gifford et al10 compared the false-negative rate at searching for micrometastases by telepathology with that of a conventional light microscope. A similar false-negative rate of 12% was obtained using either telepathology or conventional microscope. Telepathology is also an important support for patholo- gists working alone and ensures their retention within their communities. Indeed, it is estimated that 10% to 20% of oncologic cases must be validated by more than one pathologist,11 and some quality assurance programs require that 10% of cases be reviewed by more than one pathologist.12 In our experience, so far, telepathology allowed the remote pathologist to obtain a report within 3 days in more than 80% of the cases, which is well within the recommended time proposed by the Association of Direc- tors of Anatomic and Surgical Pathology.13,14 Our experience in this study confirms that telepathology can provide a similar level of quality standards to that provided by microscopes. Prior studies showed that telemedicine technologies may help to attract physicians to, and retain them in, remote regions by contributing to better working conditions, such as access to expert opinions; sharing of workload and calls; and feelings of security because of reduced isolation.15-17 However, the inertia associated with the changing from a light microscope to digital technology remains significant among the pathology community. To improve the adoption of this technology, several major legal, reimbursement, and licensure issues, as well as issues relating to the efficiency of the technology have to be addressed, but, as we previously reported,1 human factors remain among the most important challeng- es. In our network, we recognized that, to be successful, telepathology requires a highly coordinated effort among medical and laboratory staff and biomedical, administrative, and information technology support teams working on different sites. Therefore, a coordination center was created centrally, and each team is visited regularly or invited to participate in follow-up videoconferences. The recently released guidelines, Validating Whole Slide Imaging for Diagnostic Purposes in Pathology, by the College of American Pathologists,18 and the Guidelines for Establishing a Tele- pathology Service for Anatomic Pathology Using Whole Slide Imaging, posted on the Web site of the Canadian Association of Pathologists,19 are among the steps bringing about a broader adoption of the technology by the pathology community. In conclusion, our study demonstrates that the diagnostic accuracy of IOC by telepathology falls well within that reported by conventional light microscopy and provides turnaround times similar to most accepted standards. The Eastern Québec Telepathology Network allows a quality IOC service to be maintained in hospitals where no pathologist is available on site and to provide fast, interinstitutional, expert opinions for pathologists working alone. It is our experience that telepathology allows greater flexibility in practice, avoids unnecessary travel, and facilitates a better organization of the work in a vast territory with a shortage of pathologists. References 1. Tetu B, Fortin JP, Gagnon MP, Louahlia S. The challenges of implementing a ''patient-oriented'' telepathology network; the Eastern Quebec telepathology project experience. Anal Cell Pathol (Amst). 2012;35(1):11-18. 2. Al-Janabi S, Huisman A, Vink A, et al. Whole slide images for primary diagnostics of gastrointestinal tract pathology: a feasibility study. Hum Pathol. 2012;43(5):702-707. 3. Gephardt GN, Zarbo RJ. Interinstitutional comparison of frozen section consultations: a college of American Pathologists Q-Probes study of 90,538 cases in 461 institutions. Arch Pathol Lab Med. 1996;120(9):804-809. 4. Pantanowitz L, Valenstein PN, Evans AJ, et al. Review of the current state of whole slide imaging in pathology [published online ahead of print August 13, 2013]. J Pathol Inform. 2011;2:36. doi:10.4103/2153-3539.83746. 5. Quebec telepathology project aims to be the largest in Canada. Can Healthc Technol. 2010;15(7):13-15. www.canhealth.com/oct10.html. 6. Novis DA, Zarbo RJ. Interinstitutional comparison of frozen section turnaround time: a College of American Pathologists Q-Probes study of 32 868 frozen sections in 700 hospitals. Arch Pathol Lab Med. 1997;121(6):559-567. 7. Evans AJ, Chetty R, Clarke BA, et al. Primary frozen section diagnosis by robotic microscopy and virtual slide telepathology: the University Health Network experience. Hum Pathol. 2009;40(8):1070-1081. 8. Novis DA, Gephardt GN, Zarbo RJ; College of American Pathologists. Interinstitutional comparison of frozen section consultation in small hospitals: a College of American Pathologists Q-Probes study of 18,532 frozen section consultation diagnoses in 233 small hospitals. Arch Pathol Lab Med. 1996; 120(12):1087-1093. 9. Bauer TW, Schoenfield L, Slaw RJ, Yerian L, Sun Z, Henricks WH. Validation of whole slide imaging for primary diagnosis in surgical pathology. Arch Pathol Lab Med. 2013;137(4):518-524. 10. Gifford AJ, Colebatch AJ, Litkouhi S, et al. Remote frozen section examination of breast sentinel lymph nodes by telepathology. ANZ J Surg. 2012;82(11):803-808. 11. Dietel M, Nguyen-Dobinsky TN, Hufnagl P; The UICC Telepathology Consultation Center; International Union Against Cancer. A global approach to improving consultation for pathologists in cancer diagnosis. Cancer. 2000;89(1): 187-191. 12. Nakhleh RE, Bekeris LG, Souers RJ, Meier FA, Tworek JA. Surgical pathology case reviews before sign-out: a College of American Pathologists Q- Probes study of 45 laboratories. Arch Pathol Lab Med. 2010;134(5):740-743. 13. Simpson PR, Tschang TP; Association of Directors of Anatomic and Surgical Pathology. ADASP recommendations: consultations in surgical pathol- ogy [comment]. Hum Pathol. 1993;24(12):1382. 14. Association of Directors of Anatomic and Surgical Pathology. Consultations in surgical pathology. Am J Clin Pathol . 1994;102(2):152-153. 15. Duplantie J, Gagnon MP, Fortin JP, Landry R. Telehealth and the recruitment and retention of physicians in rural and remote regions: a Delphi study. Can J Rural Med. 2007;12(1):30-36. 16. Gagnon MP, Duplantie J, Fortin JP, Landry R. Exploring the effects of telehealth on medical human resources supply: a qualitative case study in remote regions. BMC Health Serv Res. 2007;7(1):6-14. doi:10.1186/1472-6963-7-6, 17. Gagnon MP, Pare G, Pollender H, et al. Supporting work practices through telehealth: impact on nurses in peripheral regions. BMC Health Serv Res. 2011; 11(2):27-35. doi:10.1186/1472-6963-11-27. 18. Pantanowitz L, Sinard JH, Henricks WH, et al. Validating whole slide imaging for diagnostic purposes in pathology: guideline from the College of American Pathologists Pathology and Laboratory Quality Center [published online ahead of print May 1, 2013]. Arch Pathol Lab Med. doi:10.5858/arpa. 2013-0093-CP. 19. Têtu B; Canadian Association of Pathologists Telepathology Committee. Guidelines for Establishing a Telepathology Service for Anatomic Pathology Using Whole Slide Imaging. September 21, 2012, v.13. 21 p. http://www.cap-acp.org/ cmsUploads/CAP/File/Telepathology_Guidelines_Final_v_13.pdf. Accessed No- vember 7, 2013. Emilie Perron, MD, MSc; Said Louahlia, MD; Lyne Nadeau, RT; François Boilard, M Ing; Michè le Orain, RT; Bernard Têtu, MD Accepted for publication November 12, 2013. From the Service d'Anatomopathologie et de Cytologie, Centre Hospitalier Universitaire de Québec, Hôpital du St-Sacrement, Quebec, Quebec, Canada (Drs Perron and Têtu and Mrs Orain); the Faculty of Medicine (Drs Perron and Têtu and Mrs Orain) and the Centre de Service et de Coordination en Télésanté, Réseau Universitaire Intégréen Santé(MrBoilard),UniversitéLaval, Québec, Canada; the Department of Pathology, Centre Hospitalier Régional de Rimouski, Rimouski, Québec, Canada (Dr Louahlia); and the Department of Pathology, Centre Hospitalier de Sept-Îles, Sept-Îles, Québec, Canada (Mrs Nadeau). The authors have no relevant financial interest in the products or companies described in this article. Presented in part at the annual meeting of the United States and Canadian Academy of Pathology; March 6, 2013; Baltimore, Maryland. Reprints: Bernard Têtu, MD, Service d'Anatomopathologie et de Cytologie, Centre Hospitalier Universitaire de Québec, Hôpital du St-Sacrement, 1050 Chemin Ste-Foy, Québec, PQ G1S 4L8, Canada (e-mail: [email protected]). (c) 2014 College of American Pathologists |