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TELEPATHOLOGY: REMOTE INTRAOPERATIVE CONSULTATION
Experience at Ketchikan General Hospital, Ketchikan, Alaska
Berle Stratton, MD, FCAP
Northwest Pathology, PS
Bellingham, Washington
Mission: Stewardship of Community, Hospital, Medical Staff and Pathology Laboratory• Quality & Safety
• Strategic
• Financial
Incentives: Engage Hospital Administrationand Medical Staff
• Improve patient outcomes: Quality and Safety
• Reduce hassles and wasted time
• Understand the organization’s culture
• Understand the legal opportunities and barriers
Engaging Physicians in a Shared Quality Agenda. Innovations Series 2007, Institute for Healthcare Improvement.
• Access anywhere, anytime– WSI on computer monitor
simulates microscope
– Global access via internet
– Primary diagnosis, quantitative comparison, case sharing and collaboration, image analysis, remote intraoperative consults, data mining for decision support, personalized medicine.
– Redefining the standard of care
Tecotzky, R: Benefits of digital pathology. Laboratory, 2008 August;7(8):40.Singh, A: Big picture, big rewards—how to think about digital. CAP Today, October 2009.
Gross Examination
Microscopic Examination
Low, medium, high power resolution
Images by Alex Milne
Low, medium, high power resolution
Resources
• Hospital IT department
• Personnel– Histotechnologist
• Gross examination
• Frozen section
• Smear preparation
• Stain
• Scan
– Available 40 hours per week
• Equipment– Telepathology system
– Gross examination system
– Pathologist computer system
Implementation: Training and Validation
• Gross telepathology
• Microscopic telepathology– Scanning technique
– Software i.e. image browser
• Validation– 20 cases in each of six
specimen categories; 120 cases total
– Require 90% concordance with known assessments
– Specimens for diagnosis• Frozen sections
• Sentinel lymph node smears
• Blood smears
• Body fluids
– Specimens for adequacy• CT and US-guided needle
biopsy imprints
• FNA
Management: Quality Assurance
• Quality Assurance Programs– Concordance of intraoperative vs. final diagnosis
• “Practice” with other programs– Scan/interpret proficiency programs i.e. CAP PIP program
– Conferences i.e. tumor board
Legal: Physician State Licensure
“Pathologist Could Be Held Liable for Remote Review of Biopsy”1
• State license may be required to “practice in the state” from which biopsy originated.
– Washington State pathologist rendered a medical diagnosis for an Idaho resident without holding a license to practice medicine in Idaho.
– [Idaho resident] v. [Washington State Laboratory], W.D. Wash.2, No. C09-1662, 12/30/10
– “ Under Washington law, there are no limits on the practice of an out-of-state physician, provided [the pathologist] does not open an office in Washington.”
– “On the other hand, Idaho has created an aggressive statute to prevent unlicensed out-of-state doctors from practicing on Idaho residents.”
1 G2 Reports, March, 20112 U.S. District Court for the Western District of Washington
Conclusion
• Future of Digital Pathology– Not if, but when
• Your laboratory– Partial vs. complete solution
TELEPATHOLOGY: REMOTE INTRAOPERATIVE CONSULTATION
Experience at Ketchikan General Hospital, Ketchikan, Alaska