1. APERIO TELEPATHOLOGY IN MALAWI; AN INNOVATIVE SOLUTION TO LACK OF PATHOLOGISTS Dr Steve Kamiza, Consultant Histopathologist and Assoc. Professor, Malawi College of Medicine.

2. Approach 1. The need for telepathology 2. Implementation process 3. Successes & Challenges 4. Other potential uses

3. APERIO TELEPATHOLOGY Defn: Telepathology – “the practice of pathology at a distance” visualizing an indirect image on a monitor screen rather than viewing a specimen slide directly through a microscope

4. APERIO TELEPATHOLOGY Can connect pathologists across geographical boundaries and enables glass slides to be digitized and securely shared with others. facilitate the transfer of image-rich pathology data for the purposes of diagnosis, education, and research

5. APERIO SYSTEM Complete slide digitization Storage on a server Internet access Imaging via a browser

6. APERIO TELEPATHOLOGY Aperio Scan scopeScreen monitor

7. APERIO TELEPATHOLOGY Aperio server & storage server

8. APERIO TELEPATHOLOGY Slide image on screen

9. APERIO TELEPATHOLOGY Why telepathology was advocated in Malawi Only one practicing pathologist in the country against a population of 14 million located in Blantyre 300km away. No on-site anatomical pathologist at Kamuzu central Hospital ( KCH). No consultation on difficult cases – sent to RSA Large turn round time, up to 3 months Specimens & reports lost in transit

10. Map of Malawi

11. APERIO TELEPATHOLOGY Implementation: Application for additional funding from MEPI UNC Malawi interest in QA for it’s research studies Both contributed to acquire the telepathology system Installed in end 2012 Lab technologist & pathologist trained Commissioned end February 2013

12. APERIO TELEPATHOLOGY How it works; Quality slides are prepared ready for routine reading Slides scanned at 20x or 40x objectives by the Aperio scan scope, and stored on the server. Up to five slides can be scanned at a time. Consulting pathologist at remote site is issued an access PIN for only files intended for viewing on the server

13. APERIO TELEPATHOLOGY This allows the consulting pathologist; to directly connect to the scan scope at remote site and see a live video feed to navigate through areas of interest and focus up and down and site staff to view the same images in real time

14. APERIO TELEPATHOLOGY Operated every fridays Good broadband internet connectivity is a must: 1.Consultations for difficult cases 2.Second opinion on unusual cases 3.Quality assurance for both cytology & histology cases ( Clinical trial – NIH/DAIDS ) UNC Hospital consulting pathologist - Dr Yuri Fedoriw

15. APERIO TELEPATHOLOGY Successes Difficult cases are resolved instantaneously More confidence to the local pathologist due to accessible second opinions from specialist pathologists Improved patient care (correct diagnosis = correct treatment) Lab quality assured (QA program implemented) No service interruption in the absence of the local pathologist

16. APERIO TELEPATHOLOGY Challenges Frequent internet outages Power outages Needs high quality slides for optical clarity Sustainability i. Equipment maintenance & service contract costs ii. Telecommunication costs

17. APERIO TELEPATHOLOGY Other potential applications in Malawi; Intra-operative diagnosis/consultations (frozen sections). Remotely conducting dynamic pathology training/teaching sessions with registrars Teleconference presentations Research data sharing with collaborators in different geographic regions

18. APERIO TELEPATHOLOGY Acknowledgements; Dr Yuri Fedoriw – UNC consulting pathologist Robert G Krysiak – UNC lab Prof George Liomba – Onsite pathologist Debbie Kamwendo – UNC lab