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Telepathology

Telepathology. and The Future of Pathology (or Why did we change our Practice Model) Jagdish Butany, MBBS, MS, FRCPC

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Telepathology

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  1. Telepathology and 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: jagdish.butany@uhn.on.ca 2 Feb 2011, Birmingham, UK. I HAVE NO CONFLICT OF INTEREST WITH ANY Equipment/Supplier!

  2. (a)Why did we implement telepathology (WSI) at UHN?

  3. Imagine 1.Cover 3 sites 2.No new staff available 3.Increasing workload

  4. University Health Network • TGH, PMH, TWH • No on-site TWH pathologist • 2-10 frozen sections • per week (mostly • neurosurgery) • Sept. 2004 – no NP X X ~ 1 mile X

  5. UHN S S IMAGINE 2! S Research S= Service

  6. UHN IMAGINE3: 3 Departments of Pathology! # Q S Sites

  7. Medical Laboratories

  8. “-----and sometimes u get lucky!!”

  9. Right Circumstances Problem!! The Perfect Storm---! Right Tools!! Available! Right Leadership

  10. 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

  11. The Robotic System: November 2004-October 2006 • 350 frozen sections • accurate • deferral rate < 10% • slow (~ 10 minutes/slide)

  12. The Robotic System Toronto Western Toronto General Telepathology Work Station (not a pathologist’s office)

  13. 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

  14. 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)

  15. Whole-Slide Imaging: Architecture • Easy consultation with colleagues – better for patient care • WSI had essentially no learning curve (compared to robotic microscope) This was TGH/UHN

  16. Pathology 2000-2010

  17. Future of Pathology Frontiers in Laboratory Medicine Feb 1-2, 2011, Birmingham UK.

  18. 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 2020 MONEY?? 18

  19. The Challenge for 2020 • Faster • Better • Higher quality • Personalized • Cheaper • Innovative

  20. The New Paradigm: Faster Pathology must be faster “Same Day” diagnosis Automation 24/7 labs Faster

  21. The New Paradigm: Faster Speech-recognition integrated with LIS means instant reporting without the need for dictatyping CHEAPER 21

  22. Technologic Advances: “omics” DNA HT-Sequencing RNA Metabolomics Mass Spectrometry Protein Microarray Expression Profiling

  23. What is “Correct”? The New Paradigm: Better • Objective classification by • mRNA expression • DNA sequencing • Response to therapy

  24. The New Paradigm: Better • 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

  25. The New Paradigm: Better(A Bit Controversial-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 25

  26. Requirements for Full Adoption CHEAPER • Workflow integration • From the lab to the pathologist • LIS integration • Barcodes • Slide tracking and retrieval

  27. Digital Pathology Enables • Remote access • Multiple viewers • Immediate access to the right pathologist at the right time BETTER 27

  28. Computer-Assisted Diagnostics Automated analysis of: Measurement Mitoses Ki67 LI Other IHC intensity distribution Her2 FISH Hematology Cellavision More? ? Need for Westgard rules in AP? • QA of technical quality • Section thickness • Stain quality

  29. Epigenetic Control: Can it Override the Genotype? N Engl J Med. 2007 Feb 15;356(7):731-3

  30. What Is Anatomical Pathology? Chemistry on a glass slide Gross Morphology Immunoassay on a glass slide Integrative morphology based interpretation Consultant’s Report

  31. The Virtual Autopsy

  32. After “The Anatomy Lecture of Dr. Nicolaes Tulp” – Rembrandt, 1632 (Courtesy of Dr. Carlos Cordón, New York, USA)

  33. Patient-Centred Care Individualized diagnostics Targeted therapies All based on “omics” Will “omics” replace pathology? The New Paradigm: Personalized 33

  34. The Future of Pathology? $15.00 each $1000.00 each $15.00 each $1000.00 each

  35. 2020 Pathology Digital radiology Digital genetics History, Physical, Family History Digital EMR Labs/ Pathology: the center of Personalized Medicine!! Clinical Pathology Gross Pathology Biomarkers & CAD QA Digital cardiology Endoscopy

  36. Comprehensive & Integrated Pathology reports Incorporation and integration of radiologic, biochemical, morphologic , molecular, cytogenetic and epigenetic data The 2020 Paradigm Biochemistry Biomarkers Histopathology Gross Pathology Molecular Pathology Radiology The Pathologist’s Cockpit

  37. The Expanding Role of Lab Medicine • 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!! 37

  38. 2020 2020 THE Pathologist !! The Pathologist and the Patient!!

  39. 2020 Pathologist Pathologist and Patient! “The Diagnosis is----, and the prognosis is----.”

  40. “AS IS YOUR PATHOLOGYSO IS YOUR MEDICINE.” Sir William Osler McGill Univ, Hopkins, London (UK)

  41. IMAGINE!! X X X X X Kuwait

  42. The Future of Pathology The best way to predict the future is to invent it Alan Kay 42

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