Telepathology, Teledematolgy & Teledermatology

1. Telepathology, Teledematolgy & Teledermatology Dr JL Fistein MA MB BChir Barrister jfistein@hiconsultants.com February 2004

4. European Project 1996 -1999 Poor response from potential participants Technology looking for a role Wrong shape images Poor quality image display Only microscope images suitable for diagnosis

5. Overview • Telepathology • What is telepathology? • Why would we use it? • What technology is required? • Some examples • Teleradiology • Teledermatology

6. What is Telepathology? • The ability to appraise tissue biopsies (Cytology or Histology) distant to the site of the histological material

7. What is telepathology? • An evolving area so definition must be broad! • “The interpretation of transmitted digital histologic images while physically separated from the slides they were derived from” • The key to this definition is not the distance that separates the viewer from the slide, but the interpretation of histologic data visualised on a computer monitor. A pathologist may practise telepathology in another room from the original slide using the hospital intranet, he may practise it if he receives a CD-ROM with a 'virtual histologic image' or digital slide. In both of these situations, telecommunications have not played a significant role. • (ref: http://telepathologycity.com)

8. What is telepathology? • Is the preceding definition wide enough? • virtual digital slides • Education • quality assurance • image analysis (machine vision, automated diagnostic systems), • i.e. not just diagnostic consultation.

9. Overview • What is telepathology? • Why would we use it? • What technology is required? • Some examples

10. Why not? Resistance to change… • Some arguments from “Dr Dinasaur” • Image quality is too poor • It’s too slow • It’ll all be outsourced to the 3rd World • It’s too expensive

11. Why not? Resistance to change… • Image quality is too poor • For what? • Different image sizes required for different purposes • Important criterion is to have images of suitable quality to allow diagnosis • NB • equivalences between film and digital resolutions • Other components important too (e.g. optics)

12. Why not? Resistance to change… • It’s too slow • Slower than looking down a microscope if you’re sitting where the specimen is • Time required for encoding & decoding (e.g. digital radio lag) • BUT faster than sending specimens by post!

13. Why not? Resistance to change… • It’ll lead to outsourcing to the 3rd World deskilling us here • Unlikely: specialised skills required – expensive anywhere • Probably the opposite effect: will help to improve medical care by enabling the sharing of expertise

14. Why not? Resistance to change… • It’s too expensive • Digital and communications technologies are the cheapest components of the system • Most expensive are the experts and the optical devices (which are required anyway)

15. Why Use Telepathology? • Remote primary diagnosis • Already in use for remote frozen section diagnosis in Norway • Has been tested in remote cytology clinics • Requires robotic microscopy • Third world projects • Resource management: keeps experts centralized (i.e. cost-saving)

16. Why Use Telepathology? • Second opinion • Static images of histology slides • Attached to E-mail • Grabbed then interactively discussed • Remote microscopy • Controlled by sender • Robotic microscope controlled by expert

17. Why Use Telepathology? • Quality Assurance (EQA) • Static images • Robotic system • Virtual Slide • Electronic form Multiple reviews Fewer transcribing errors Audit trail

18. Why Use Telepathology? • Education • Interactive Video-conferencing • Remote teaching • Image banks / independent study (e.g. http://medlib.med.utah.edu/WebPath/webpath.html) • Consensus diagnosis for clinical trials • Quality assurance of multi-centre diagnosis for clinical trials • Consensus in type and grade of tumours for National and international studies

19. Overview • What is telepathology? • Why would we use it? • What technology is required? • Some examples

20. Laboratory (Base site) Remote Site Image Display Computer Computer Microscope Control Unit Remote Control Communication Link Communication Link Organization of Telepathology

21. Components (1) - Standard / Robotic Camera - Analogue / Digital Microscope Transfer Lens maps microscope image to camera CCD & governs field size; not WYSIWYG and may cause shading and distortion

22. Components (2) - any of the latest Pentium PC’s but: Free expansion slots Connection to peripherals Computer Graphics Performance no longer a problem

23. Components (3) - Must be of suitable quality: Colour balancing Resolution Monitor Size

24. Components (4) SOFTWARE: Dedicated telepathology software e.g. Groups images Allows annotations Maintains workflow Generic imaging / communication packages

25. Components (5) • Robotic manipulation • Motorised microscope + camera £30,000+) • Robotic stage loader

26. Remember! Determine what you need v. what you would like Will the system provide the performance you need? Is the required communication method available for all participants? Can you afford it? Can you maintain it? Systems must be set up correctly before use: microscope, colour temperature camera set up

27. Communication • In theory, the faster the better • NB large sizes of images, worst for video and live images • Need for parallel communication e.g. to manipulate a robotic stage, or to allow chat • BUT always assess the need for speed! • (NB remote locations / developing world)

28. Communication • Email - static images only • Large documents upset fire walls and internet providers. • (satellite links) - prohibitively expensive. • (microwave links) - impractical. • (mobile phone) - promising, but technology not fully developed. • .

29. Communication • “Fastest possible” = LAN line (100 Mbps) • Internet T3 (43 Mbps) • “Broadband” – up to 2 Mbps • Modems / ISDN – Kbps (NHS Net?)

30. Compression • Aims to reduce size of image file reducing transmission cost while maintaining acceptable image quality • Various industry-standard image compression and encoding standards JPEG, GIF, MPEG • Lossy (smaller) vs Lossless (best quality) • See http://www.acm.org/crossroads/xrds6-3/sahaimgcoding.html

31. Methods (This is the traditional classification, but many think it is less relevant today, because is concentrates solely on image capture techniques) • Static Imaging • Dynamic Imaging

32. STATIC IMAGING • Images selected by referring centre and transmitted to referee. • Disadvantages: • No control over image selection. • Non interactive. • Inability to conduct special tests

33. DYNAMIC IMAGING • Images generated live and transmitted using teleconferencing • software • distant operator • via robotic microscope. • Disadvantages: • Dependant on high speed Telecommunications link. • Efficiency dictated by bottlenecks. • Global time differences.

34. A better view? • A spectrum with immediate control (e.g. via robotic devices) at one end with delivery of preselected images at the other. • Where a given system is on the spectrum depends on intended use, budget, etc.

35. Ref: http://telepathologycity.com

36. Are Robotics Present? Yes Robotic Telepathology No Live or updated Microscope view? Yes Non-robotic Dynamic Telepathology No Any interaction with the images? Yes Interactive store-and-forward Telepathology No Simple store-and-forward Telepathology

37. Robotic telepathology • Images captured automatically or selected by the remote pathologist using specialised dedicated software / hardware • live - the consultation occurs in real-time, with delays being due to the method of data transmission. • NB fully-robotic vs semi-robotic. • E.g. mechanical stage but change the objectives manually / no autofocus capabilities.

38. Non-robotic Dynamic Telepathology • Images captured manually beforehand by the base pathologist. • Specialised software allows live consultation and discussion of images between base and remote station e.g. • live annotations • text/audio chat. • Remote pathologist may request additional images based upon what he/she has seen. • Implies a live video feed / regularly updated images

39. Interactive store-and-forward telepathology • The remote pathologist receives a set of preselected images either on removable media or through connecting to a server. • Specialised software is used to show the relationship between these images e.g.. a lower power image with the ability to view select higher magnification images. • The key feature is the ability to show the relationship of the individual images with the original • The remote pathologist should not be able to tell whether he is connecting to a robotic microscope live or receiving archived images.

40. Simple store-and-forward telepathology • Images captured manually by the base pathologist • No specialised telepathology software is required. • Transmission of images via email attachment, file transfer protocol (FTP), website etc. • Generic graphics viewing software used to view images

41. Overview • What is telepathology? • Why would we use it? • What technology is required? • Some examples

42. Internet based Telepathology

43. Internet Based Laboratory EQA

44. Point to Point Static Telepathology

45. Internet based Robot Microscopy

46. Virtual Microscope Slide (1)

47. Virtual Microscope Slide (2a)

48. Beyond Histopathology – the Clinical Laboratory and Telemedicine • NB usually the lab and the reporting expert are in the same location as the patient • Cf. Telehistopathology where the lab is local but the expert is remote. • So maybe only requirement is a local database to store results and allow later retrieval • NB Physical sample must get to the lab

49. Beyond Histopathology – the Clinical Laboratory and Telemedicine • Different data than histopath • Less requirement for images, etc • Patient & Sample ID plus • numerical results • Dates • Reference ranges • Brief text statments

50. Distributed Lab Services • NB may be local labs for basic test but a “send away” service for rarer, more expensive tests. • Turnaround time depends on round trip (not just speed of access to results) • Centralization may increase efficiency (less cost in setting up separate labs) but this improvement decreases as the size of the area increases (increasing transportation overheads) • Perhaps best compromise: central unit with satellite labs