1. The Laval University (Québec) virtual slide telepathology project; A structured patient-oriented network involving 21 sites Bernard Têtu MD, Medical director Christine Houde MD, Jean Boulanger Co-chairs, telehealth steering committee, Laval University Québec, Canada

2. www.ulaval.ca 2 Canada: 34, 108, 752 Québec: 7, 907, 375

3. www.ulaval.ca 3 Integrated University Health Networks 1,729,000 408,760 Km 2

4. www.ulaval.ca 4 1 2 3 7 5 30 Density of population and Distribution of pathologists on the territory

5. www.ulaval.ca 5 History of the project August 2004: Quebec MOH mandates the Integrated University Health Networks to develop telehealth in the province. Laval University prioritizes telepathology Fall 2004: Creation of telehealth steering committee Spring 2005: Survey on needs and services in the territory

6. www.ulaval.ca 6 Telepathology – clinical context Part-time pathologists available: Schedule of operations depends on the presence of a pathologist Difficulty recruiting surgeons Surgeon’s perspective

7. www.ulaval.ca 7 Telepathology – clinical context No pathology department but oncologic surgery: Two-step surgeries (sentinel lymph node) Patient transferred if frozen section expected Resection margins not available Difficulty recruiting surgeons Surgeon’s perspective

8. www.ulaval.ca 8 Telepathology – clinical context Insecurity, especially in early practice Impossibility to rapidly obtain a second opinion IHC performed in university hospitals: delays to get slides back Limited continued medical education Pathologist’s perspective

9. www.ulaval.ca 9 Telepathology – clinical context Difficulty in being absent without disturbing the organization of the surgical unit Average age of pathologists increasing and entries in residency stable: worsening of the shortage is expected Resources merely adequate, even in university hospitals Pathologist’s perspective

10. www.ulaval.ca 10 Telepathology – clinical context Creaghan Commission, New Brunswick: Recommendation #12: The Department of Health study and plan for the potential of providing pathology services for regional hospital laboratories through new technology in the field of pathology digital imaging and computer transmission… Reports of Commissions of Inquiry in Canada

11. www.ulaval.ca 11 Telepathology – clinical context Cameron Commission, Newfoundland: Recommendation #24: The Department of Health and Community Services should also ensure that adequate resources are available to fund technical resources such as telemedicine technology, particularly for pathologists who work alone, as well as new technology in the field of pathology digital imaging and computer transmission. Reports of Commissions of Inquiry in Canada

12. www.ulaval.ca 12 History of the project January 2006: Project charter accepted by the MOH and Canada Health Infoway; phase 0 Summer 2006: Extensive consultation of medical teams and professionals to better identify needs and services required January 2007: MOH authorizes the continuation of the project toward further steps 6,136,662$ covered equally by MOH and CHI

13. www.ulaval.ca 13 History of the project Summer 2008: Request for proposals October 2008: Call for tender (slide scanner, gross station/videoconferencing and viewer) April 2009: Compliancy testing of technologies (pathologists, technologists, experts in information and change management)

14. www.ulaval.ca 14 History of the project Summer 2009: Final choice of solutions Fall 2009: Contracts, agreements on physician’s fees January 2010: Deployment and validation January 2011: Expected completion of the deployment

15. www.ulaval.ca 15 Aims of the project Implement an innovative solution to provide uniform pathology services in the whole Laval University Health Network territory Main objective

16. www.ulaval.ca 16 Aims of the project Provide frozen sections anywhere, anytime Provide second opinion from a colleague or a panel of experts Allow fast return of IHC performed in university hospitals Specific objectives

17. www.ulaval.ca 17 Aims of the project 21 sites (3 additional possible sites) 6 hospitals devoid of pathology laboratory 15 sites with pathology laboratory 7 with 1 pathologist 7 with 2 or more pathologists 1 with no pathologist Deployment

18. www.ulaval.ca 18 Slide scanner: nanoZoomer RS & HT

19. www.ulaval.ca 19 Gross station (PathStand) and videoconferencing (Sony HD)

20. www.ulaval.ca 20 Viewer and image sharing solution: mScope, Aurora

21. www.ulaval.ca 21 Simplified schema of network A B

22. www.ulaval.ca 22 Health Authorities in Eastern Quebec

23. www.ulaval.ca 23

24. www.ulaval.ca 24 Expected volume of activities Over 2000 frozen sections and second opinions Over 4000 immunohistochemistries returned by telepathology

25. www.ulaval.ca 25 Governance of the project Electronic medical record, MOH Telehealth executive committee Project manager Management committee Medical director Committee of experts 6 health authorities

26. www.ulaval.ca 26 Committee of experts 18 members from university and community hospitals Mandate: Propose organizational models Develop clinical protocols Evaluate and select solutions Advise executive and management committees Advise on the deployment of the project (cohesion, respect of project charter)

27. www.ulaval.ca 27 Conclusions: strengths of the project For patients: Improved medical cares Decreased transfers to regional hospitals Faster diagnoses and treatment For pathologists: Easier access to second opinion Decreased professional isolation For organizations: Easier recruitment of surgeons and pathologists Less movement of pathologists = efficiency Easily transportable technology

28. www.ulaval.ca 28 Future direction Grant application: « Partnerships for health system improvement » Canadian Institutes of Health Research Objectives: General: evaluation of telepathology to improve the quality of cares

29. www.ulaval.ca 29 Future direction Specific objectives: Patients: Transfers prevented two step surgeries prevented Pathologists Consultations performed TAT for cases with IHC Overall satisfaction Organisations : Stability of the frozen section coverage Time saved to start treatment Retention of pathologists and surgeons

30. www.ulaval.ca 30